28 May 2026 Lacey Carole Anne HEATH · Prevention of Future Deaths report Essex
View report summary
Concerns raised 13 Inadequate clinical records of the patient’s presentation, INR results and medication dose View source Lack of General Practitioner funding for at-home anticoagulation testing supplies View source Unavailability of at-home anticoagulation monitoring for daily readings and individualised dosing View source Failure to apply for funding for at-home anticoagulation monitoring View source Failure to clarify the nature and clinical impact of reported illness in records View source Use of alternative anticoagulation medication associated with high INR readings and bleeding risk View source Insufficient trial of Warfarin View source Failure to provide medical review or haematology referral for prolonged non-therapeutic INR View source Failure to consider learning difficulties when providing anticoagulation care View source Unaffordability of at-home anticoagulation monitoring View source Failure to achieve a therapeutic INR for a prolonged period View source Failure to explain available funding to the patient View source Failure of alternative anticoagulation regimes to maintain a therapeutic range View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 10
Action
Establish a home INR monitoring process with suitability assessment, training, equipment, support, governance, follow-up and documented decisions discussed with patients and families or carers where possible.
Stated plannedThe respondent said that this action was planned when they made their response on 6 August 2026. View source
Action
Introduce the trust-wide electronic patient record to integrate clinical information and make observations and electronic notes visible across encounters and hospital sites.
Stated in progressThe respondent said that this action was in progress when they made their response on 6 August 2026. View source
Action
Introduce documented senior-clinician and, where appropriate, haematology review requirements, an updated operating procedure, staff communication and governance audits for complex anticoagulation cases.
Stated plannedThe respondent said that this action was planned when they made their response on 6 August 2026. View source
Action
Complete a review of the anticoagulation service escalation process for complex patients under hospital care.
Stated plannedThe respondent said that this action was planned when they made their response on 6 August 2026. View source
Action
Review documentation standards within the anticoagulation service.
Stated in progressThe respondent said that this action was in progress when they made their response on 6 August 2026. View source
Action
Implement a structured clinical note template covering presentation, symptoms, risks, advice, escalation decisions and follow-up, with staff briefing and documentation audits.
Stated plannedThe respondent said that this action was planned when they made their response on 6 August 2026. View source
Action
Introduce a pathway prompt for communication support, family or carer involvement, reasonable adjustments and advocacy for vulnerable patients, with staff briefing and documentation audits.
Stated plannedThe respondent said that this action was planned when they made their response on 6 August 2026. View source
Action
Implement a high-risk anticoagulation pathway with senior review criteria, INR monitoring, escalation thresholds, documentation requirements and governance audits.
Stated in progressThe respondent said that this action was in progress when they made their response on 6 August 2026. View source
Action
Establish an escalation process for clinically required anticoagulation monitoring equipment or consumables when financial barriers arise, including funding guidance, staff communication and application audits.
Stated plannedThe respondent said that this action was planned when they made their response on 6 August 2026. View source
Action
Set referral and escalation triggers for prolonged poor INR control, missed appointments or persistent instability, supported by documented rationale, referral logging, record audits and governance review.
Stated plannedThe respondent said that this action was planned when they made their response on 6 August 2026. View source See 7 more actions
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AI-generated summary
Lacey Carole Anne HEATH · 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
Lacey Carole Anne HEATH died on 16 February 2025 after collapsing at home and suffering cardiac arrest en route to hospital. The death followed thrombosis and complete stenosis of her mechanical aortic valve in the context of sub-therapeutic anticoagulation. Concerns included difficulty maintaining therapeutic anticoagulation, lack of access to affordable at-home monitoring, absence of a funding application, insufficient medical review or haematology referral, and inadequate clinical records.
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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate clinical records of the patient’s presentation, INR results and medication dose
Wider context from the report “7. There was an absence of appropriate medical records recorded for Ms Heath to understand her clinical presentation other than very basic information on the INR platform on INR results and medication dose . Evidence was these records are not compliant with the requirements of healthcare regulators and led to a lack of appreciation of Ms Heath’s concerns and complexity of her case. One entry stated Ms Heath had been “unwell” with no clarification or further information on what the problem was and/or how this may have impacted on her condition.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of General Practitioner funding for at-home anticoagulation testing supplies
Wider context from the report “4. Ms Heath could not afford to fund the at home monitor as this was financially prohibitive for her being on a low income. The monitor was expensive and there is no obligation for General Practitioners to fund the testing strips and incidentals required to facilitate testing . As this would be a lifelong commitment for a woman who was only 34 years-old, Ms Heath was not able to take the advice of her expert clinical team and was compelled to have alternative prescribing that was not successful in keeping her INR within therapeutic range.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of at-home anticoagulation monitoring for daily readings and individualised dosing
Wider context from the report “3. Ms Heath’s experienced clinical team did not consider that there had been a sufficient trial of Warfarin and recommended at-home monitoring to permit daily readings to be taken to manage the significant risks associated with anticoagulation and to find an individualised dose for Ms Heath. Clinicians were not concerned about medication non-compliance and that the difficulties were clinical.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to apply for funding for at-home anticoagulation monitoring
Wider context from the report “5. No application for funding was made on behalf of Ms Heath by the Trust nor was this explained to Ms Heath who a very quiet, shy lady who always relied on her very loving family to assist her with appointments and could not advocate for herself. There was no consideration if Ms Heath had any learning difficulties and it was noted that there was a developmental delay in her medical records. Evidence at the inquest was Ms Heath experienced this as clinicians not caring about her and she became very despondent about the failure to achieve a therapeutic range.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clarify the nature and clinical impact of reported illness in records
Wider context from the report “7. There was an absence of appropriate medical records recorded for Ms Heath to understand her clinical presentation other than very basic information on the INR platform on INR results and medication dose. Evidence was these records are not compliant with the requirements of healthcare regulators and led to a lack of appreciation of Ms Heath’s concerns and complexity of her case. One entry stated Ms Heath had been “unwell” with no clarification or further information on what the problem was and/or how this may have impacted on her condition .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Use of alternative anticoagulation medication associated with high INR readings and bleeding risk
Wider context from the report “2. Due to the complexity of her case, Ms Heath’s anticoagulation was under the care of the acute hospital team. Alternative anticoagulation medication had resulted in high INR readings and significant risks associated with bleeding .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient trial of Warfarin
Wider context from the report “3. Ms Heath’s experienced clinical team did not consider that there had been a sufficient trial of Warfarin and recommended at-home monitoring to permit daily readings to be taken to manage the significant risks associated with anticoagulation and to find an individualised dose for Ms Heath. Clinicians were not concerned about medication non-compliance and that the difficulties were clinical.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide medical review or haematology referral for prolonged non-therapeutic INR
Wider context from the report “6. Ms Heath did not manage to achieve a therapeutic INR for a protracted period of time putting her at increased risk of developing complications and did have a medical review or a haematology 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider learning difficulties when providing anticoagulation care
Wider context from the report “5. No application for funding was made on behalf of Ms Heath by the Trust nor was this explained to Ms Heath who a very quiet, shy lady who always relied on her very loving family to assist her with appointments and could not advocate for herself. There was no consideration if Ms Heath had any learning difficulties and it was noted that there was a developmental delay in her medical records. Evidence at the inquest was Ms Heath experienced this as clinicians not caring about her and she became very despondent about the failure to achieve a therapeutic range.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unaffordability of at-home anticoagulation monitoring
Wider context from the report “4. Ms Heath could not afford to fund the at home monitor as this was financially prohibitive for her being on a low income. The monitor was expensive and there is no obligation for General Practitioners to fund the testing strips and incidentals required to facilitate testing. As this would be a lifelong commitment for a woman who was only 34 years-old, Ms Heath was not able to take the advice of her expert clinical team and was compelled to have alternative prescribing that was not successful in keeping her INR within therapeutic range.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to achieve a therapeutic INR for a prolonged period
Wider context from the report “6. Ms Heath did not manage to achieve a therapeutic INR for a protracted period of time putting her at increased risk of developing complications and did have a medical review or a haematology 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to explain available funding to the patient
Wider context from the report “5. No application for funding was made on behalf of Ms Heath by the Trust nor was this explained to Ms Heath who a very quiet, shy lady who always relied on her very loving family to assist her with appointments and could not advocate for herself. There was no consideration if Ms Heath had any learning difficulties and it was noted that there was a developmental delay in her medical records. Evidence at the inquest was Ms Heath experienced this as clinicians not caring about her and she became very despondent about the failure to achieve a therapeutic range.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of alternative anticoagulation regimes to maintain a therapeutic range
Wider context from the report “1. Ms Heath was noted to be warfarin resistant and alternative medication regimes were not successful in keeping Ms Heath within a therapeutic range for her required lifelong requirement to have anticoagulation to prevent a significant risk of death. The GP and hospital clinicians trailed different combinations of appropriate therapy which included additional injections when required. This was not considered to be clinically appropriate long-term.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a home INR monitoring process with suitability assessment, training, equipment, support, governance, follow-up and documented decisions discussed with patients and families or carers where possible.
Verbatim wording from the response “By the end of September 2026, a robust process for home INR monitoring will be in place. Prior to home monitoring proceeding, we will conduct a detailed assessment of patient suitability, any training needs, equipment requirement, general support and governance, and follow-up arrangements as necessary. This new process will ensure that decisions to recommend, decline or defer self-testing are clearly recorded with the rationale, and always discussed with the patient and, if possible, their family or carers.” Source location Response from Mid & South Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce the trust-wide electronic patient record to integrate clinical information and make observations and electronic notes visible across encounters and hospital sites.
Verbatim wording from the response “We are currently in the process of introducing a new single electronic patient record (“EPR”) system across our trust. This EPR will replace/integrate with current systems services in all areas and will be for all our hospital sites.” Source location Response from Mid & South Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce documented senior-clinician and, where appropriate, haematology review requirements, an updated operating procedure, staff communication and governance audits for complex anticoagulation cases.
Verbatim wording from the response “We plan to introduce a documented requirement for complex cases including high INR readings, bleeding risk, recurrent instability or failed alternative regimes to be reviewed by a senior clinician and, where appropriate, haematology. This will establish a clear escalation route for complex anticoagulation patients.” Source location Response from Mid & South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a review of the anticoagulation service escalation process for complex patients under hospital care.
Verbatim wording from the response “By the end of August 2026, we will have conducted a complete review of the anticoagulation service escalation process for complex patients under hospital care.” Source location Response from Mid & South Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review documentation standards within the anticoagulation service.
Verbatim wording from the response “We are reviewing documentation standards within the anticoagulation service, and we will implement a structured clinical note template for contacts, missed appointments, patient-reported symptoms such as “unwell”, risk discussions, escalation decisions, advice given and follow-up plan by the end of October 2026. This will explore system functionality for persistent alerts or pinned critical risk information.” Source location Response from Mid & South Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a structured clinical note template covering presentation, symptoms, risks, advice, escalation decisions and follow-up, with staff briefing and documentation audits.
Verbatim wording from the response “We are reviewing documentation standards within the anticoagulation service, and we will implement a structured clinical note template for contacts, missed appointments, patient-reported symptoms such as “unwell”, risk discussions, escalation decisions, advice given and follow-up plan by the end of October 2026. This will explore system functionality for persistent alerts or pinned critical risk information.” Source location Response from Mid & South Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a pathway prompt for communication support, family or carer involvement, reasonable adjustments and advocacy for vulnerable patients, with staff briefing and documentation audits.
Verbatim wording from the response “By the end of October 2026, we plan to introduce a prompt within the high-risk anticoagulation pathway requiring clinicians to consider whether the patient may need additional communication support, family/carer involvement, reasonable adjustments or advocacy where records or presentation suggest vulnerability, developmental delay, difficulty self-advocating or reduced understanding of risk.” Source location Response from Mid & South Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a high-risk anticoagulation pathway with senior review criteria, INR monitoring, escalation thresholds, documentation requirements and governance audits.
Verbatim wording from the response “We recognise the importance of clinically appropriate plans being in place for our patients. Therefore, we are implementing a high-risk anticoagulation pathway for patients with persistent sub-therapeutic INR, suspected warfarin resistance, complex anticoagulation requirements or repeated instability despite appropriate dose adjustment.” Source location Response from Mid & South Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish an escalation process for clinically required anticoagulation monitoring equipment or consumables when financial barriers arise, including funding guidance, staff communication and application audits.
Verbatim wording from the response “By the end of September 2026 we will have a process for escalating cases where recommended anticoagulation monitoring equipment or consumables may be clinically required but financial barriers are identified. This will include signposting to available funding routes, individual funding consideration, charitable support or commissioner discussion where applicable.” Source location Response from Mid & South Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Set referral and escalation triggers for prolonged poor INR control, missed appointments or persistent instability, supported by documented rationale, referral logging, record audits and governance review.
Verbatim wording from the response “A defined trigger will be set for medical review and/or haematology referral when a patient INR remains outside therapeutic range for a prolonged period; when repeated appointments are not attended during a high-risk period; or when treatment instability persists despite appropriate intervention. This will include a requirement for documented clinical rationale where referral is not made.” Source location Response from Mid & South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Long-term additional injections were not clinically appropriate after alternative anticoagulation regimens had been trialled.
Verbatim wording from the response “1. Ms Heath was noted to be warfarin resistant and alternative medication regimes were not successful in keeping Ms Heath within a therapeutic range for her required lifelong requirement to have anticoagulation to prevent a significant risk of death. The GP and hospital clinicians trialled different combinations of appropriate therapy which included additional injections when required. This was not considered to be clinically appropriate long-term.” Source location Response from Mid & South Essex NHS Foundation Trust
Open published response
27 May 2026 Abigail Louise SMITH · Prevention of Future Deaths report Essex
View report summary
Concerns raised 8 Failure to prevent access to ligature materials View source Lack of appropriate care plans and risk assessments for known self-harm risk View source Use of inappropriate or untrained staff for enhanced observation View source Lack of communication adjustments and plans for autistic patients with learning difficulties View source Use of an unsuitable hospital setting for a patient actively attempting suicide View source Failure to maintain required supervision when staff attend to other patients View source Failure to incorporate relevant previous restraint and trauma history into admission care View source Insufficient trained staffing for enhanced observations of patients at risk of severe self-harm View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Abigail Louise SMITH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Abigail Louise Smith was found at Braintree Recreation Ground on 15 February 2022 after attempting to suspend herself; resuscitation was unsuccessful and she was pronounced deceased at 00:08 on 16 February 2022. The report identifies concerns about inadequate trained staffing and observation, unsuitable care arrangements, access to ligature materials, insufficient risk assessments and care plans, communication adjustments for autism and learning disability, and an unsafe discharge from hospital.
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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent access to ligature materials
Wider context from the report “3. Abbi at times had to be physically and chemically restrained due to the level of distress and harm to herself. During her admissions Abbi was able to access ligature material that she tied around her neck on multiple occasions over multiple days including her socks, cords from her clothing and pull cords in the bathroom . There were no appropriate care plan and risk assessments to mitigate a significant known risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate care plans and risk assessments for known self-harm risk
Wider context from the report “3. Abbi at times had to be physically and chemically restrained due to the level of distress and harm to herself. During her admissions Abbi was able to access ligature material that she tied around her neck on multiple occasions over multiple days including her socks, cords from her clothing and pull cords in the bathroom. There were no appropriate care plan and risk assessments to mitigate a significant known risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Use of inappropriate or untrained staff for enhanced observation
Wider context from the report “2. For a period of time Abbi was left under the observation of staff that were security personnel and were not appropriate or trained to undertake this work . Male security staff were informed that Abbi should use a commode due to her presenting risks and there were not sufficient trained female staff available . There had been a previous incident where actions taken to restrain Abbi by security personnel caused her trauma and there had been an allegation of assault, this was not considered in this admission.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of communication adjustments and plans for autistic patients with learning difficulties
Wider context from the report “6. No adjustments or plans were made for communication for Abbi as a patient with Autism and learning difficulty
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Use of an unsuitable hospital setting for a patient actively attempting suicide
Wider context from the report “4. Abbi was a complex mental health patient awaiting assessment under the Mental Health Act and was being cared for in a part of the hospital that was not suitable for a patient who was actively attempting to take her life .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain required supervision when staff attend to other patients
Wider context from the report “5. Staff left Abbi unsupervised during the admission to attend to other patients that permitted her to tie ligatures .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate relevant previous restraint and trauma history into admission care
Wider context from the report “2. For a period of time Abbi was left under the observation of staff that were security personnel and were not appropriate or trained to undertake this work. Male security staff were informed that Abbi should use a commode due to her presenting risks and there were not sufficient trained female staff available. There had been a previous incident where actions taken to restrain Abbi by security personnel caused her trauma and there had been an allegation of assault, this was not considered in this admission .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient trained staffing for enhanced observations of patients at risk of severe self-harm
Wider context from the report “1. There were not sufficient trained staff to conduct the enhanced observations required to monitor Abbi with her known risk of severe self-harm whilst she was awaiting assessment under the Mental Health Act and actively attempting to take her own life.
” 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 Include enhanced supervision in mandatory training for staff providing enhanced supervision to patients.
Verbatim wording from the response “Enhanced Supervision is part of mandatory training for all staff who are involved with providing enhanced supervision to patients.” Source location Response from Mid & South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide specialist Learning Disability Team and Autism Lead support to clinical teams developing individual care plans and making reasonable adjustments.
Verbatim wording from the response “Our specialist Learning Disabilities (‘LD’) Team is trained to support and advise staff on patient communication needs; any sensory needs or sensitivities; pain recognition; interaction with medical history and any medication regimens; and to ensure reasonable adjustments are considered in line with the Equality Act 2010 and the Mental Capacity Act 2005. For example, this may be facilitating a patient being placed in a quiet area away from populated waiting rooms and information being given that is free of jargon and medical terminology.” Source location Response from Mid & South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Perform environmental risk assessments for clinical and non-clinical areas before placing potentially at-risk patients there.
Verbatim wording from the response “Our Policy for Ligature and Self Harm Awareness require environmental risk assessments to be performed in regard to clinical and non-clinical areas. These risk assessments are considered by staff before placing a potentially at-risk patient within the area.” Source location Response from Mid & South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use Learning Disability and Autism Health Passports to identify communication and sensory needs and guide reasonable adjustments.
Verbatim wording from the response “For patients with Learning Disabilities, a Hospital Passport should be completed which includes questions such as ‘How I communicate and how you communicate with me’ and any sensory issues which may impact communication.” Source location Response from Mid & South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require ligature risk assessments, including consideration of clothing as ligature material, with documented rationale and mitigating actions where items remain.
Verbatim wording from the response “I am aware that the Court has been provided with an updated copy of the Trust’s Policy for Ligature and Self Harm Awareness.” Source location Response from Mid & South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement enhanced supervision and engagement policy with risk-level assessment, staffing escalation, supervision handovers, daily review and family or carer involvement.
Verbatim wording from the response “I understand that the Court has been provided with an updated copy of the Trust’s Policy for Enhanced Supervision and Engagement. This policy strengthens our assessment and guidance for patients requiring enhanced supervision as per the attached tool.” Source location Response from Mid & South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No evidence was identified that Trust-employed security staff were allocated to patients that night, as would usually have been documented.
Verbatim wording from the response “We acknowledge the concerns of HM Coroner that lack of staffing led to the provision of a security guard in order to support the Mental Health Team. We have not identified any evidence of a Trust-employed security staff being allocated to patients that night, as would usually be documented. In any event, we are not able to comment on staffing of the mental health team or how that fell within the remit of Essex Partnership University Foundation Trust (EPUT).” Source location Response from Mid & South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for mental health team staffing falls within Essex Partnership University Foundation Trust's remit, not this Trust's.
Verbatim wording from the response “We acknowledge the concerns of HM Coroner that lack of staffing led to the provision of a security guard in order to support the Mental Health Team. We have not identified any evidence of a Trust-employed security staff being allocated to patients that night, as would usually be documented. In any event, we are not able to comment on staffing of the mental health team or how that fell within the remit of Essex Partnership University Foundation Trust (EPUT).” Source location Response from Mid & South Essex NHS Foundation Trust
Open published response
4 Mar 2026 Viviana-Ray Winnie Elsie Wendy Butnaru · Prevention of Future Deaths report Essex
View report summary
Concerns raised 6 Lack of awareness of the difference between metabolic and respiratory acidosis View source Failure to fully explore underlying causes of metabolic acidosis View source Delays in official radiologist reporting of chest X-rays showing cardiomegaly View source Lack of guidelines for identifying and investigating possible heart-related issues in accident and emergency and paediatric settings View source Incomplete recording of medical-team handovers View source Incomplete documentation of nursing observations and escalations View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Viviana-Ray Winnie Elsie Wendy Butnaru · 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
Viviana-Ray Winnie Elsie Wendy Butnaru attended the Children’s Emergency Department on 24 October 2024 and died at Basildon Hospital on 25 October 2024 after cardiac arrest. The stated cause of death was myocarditis caused by Parvovirus, contributed to by bronchiolitis and bronchopneumonia. Concerns included delayed reporting of chest X-rays showing cardiomegaly, incomplete exploration of metabolic acidosis, failures in escalation and review processes, and incomplete documentation and handovers.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of the difference between metabolic and respiratory acidosis
Wider context from the report “(4) Underlying causes for metabolic acidosis were not fully explored. Greater awareness of the difference between metabolic and respiratory acidosis is required .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to fully explore underlying causes of metabolic acidosis
Wider context from the report “(4) Underlying causes for metabolic acidosis were not fully explored . Greater awareness of the difference between metabolic and respiratory acidosis is required.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in official radiologist reporting of chest X-rays showing cardiomegaly
Wider context from the report “(3) Chest X rays which showed cardiomegaly were not reported officially by a radiologist until several days later .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidelines for identifying and investigating possible heart-related issues in accident and emergency and paediatric settings
Wider context from the report “(1) There appears to be a lack of local or national guidelines assisting those assessing patients in an accident and emergency and paediatric environment to assess the correct pathway for identifying and investigating those who may present with heart related issues such as myocarditis .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete recording of medical-team handovers
Wider context from the report “(5) Incomplete documentation to be addressed to include all updates from nursing staff in relation to observations and escalations; and handovers from the medical team to one another to be clearly recorded .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete documentation of nursing observations and escalations
Wider context from the report “(5) Incomplete documentation to be addressed to include all updates from nursing staff in relation to observations and escalations ; and handovers from the medical team to one another to be clearly recorded.
” 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 Share the updated radiology escalation guidance with paediatric teams and publish it on the Trust intranet.
Verbatim wording from the response “As a result of these guideline changes, targeted sharing of the changes will be undertaken with the Paediatric teams across our sites within MSEFT, alongside the updated guideline being available on the Trust's intranet page, which is accessible for all staff.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver blood-gas interpretation and escalation education, supported by prompts for recognising abnormal results and deteriorating trends.
Verbatim wording from the response “Response: Both the Clinical Lead for Paediatrics and the Associate Director of Nursing for Paediatrics have confirmed the service identified these issues during the initial review of the incident, and a specific action was implemented to address concerns relating to blood gas interpretation and documentation, particularly where results were inconsistent with the working diagnosis.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate learning about metabolic acidosis and associated safety actions through multidisciplinary forums, teaching, simulation and a staff safety bulletin.
Verbatim wording from the response “Viviana-Ray’s case has been discussed at various trust forums, to share learning and the associated actions that have been taken. The case was presented at Basildon’s site Mortality and Morbidity (M&M) meeting in March 2026, which is attended by consultants, tier 1 and 2 doctors and clinical nurse facilitators. Her case has also been discussed at the cross-site Grand Round in January 2026, during this meeting the case was discussed with learnings and differential for metabolic acidosis including cardiac and attended by consultants, tier 1 and 2 doctors and Associate Directors of Nursing. A safety bulletin has also been circulated to all staff in February 2026.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete and formalise the radiology policy review to document how clinical teams can expedite imaging reports for clinical concerns.
Verbatim wording from the response “The Radiology Department identified that guidance for clinical teams on how to expedite an imaging report due to clinical concern was not documented in Trust radiology policies and procedures. As such, the Director of Nursing has confirmed that a review of the Trust’s policy, Guide for making the best use of a Radiology Department (MSEGL23134) will be completed by 1 June 2026 to ensure an updated version is formalised to include this guidance going forward. The Trust will be able to share a copy of this updated policy with you in due course if it is of assistance.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver CEWT refresher training emphasizing documentation of nursing observations, escalations and responses.
Verbatim wording from the response “The paediatric service recognises that there were gaps in fully documenting nursing observations and escalation actions. In response, Children’s Early Warning Tool (CEWT) refresher training has been delivered to all relevant nursing and support staff, with specific emphasis on clear documentation of escalations made and responses received.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue monthly documentation audits across Children’s ED and inpatient wards, with feedback and reminders addressing identified documentation deficiencies.
Verbatim wording from the response “In addition, monthly documentation audits continue across both Children’s ED and the inpatient wards. Documentation compliance in Children’s ED remained above 95% between October 2025 and March 2026. On the inpatient wards, compliance ranged between 75% and 95% during the same period. Reduced compliance identified in December 2025 related to illegible handwriting, unsigned amendments, and incomplete nursing documentation. Feedback was provided directly to staff, with reminders regarding documentation standards and their importance for patient safety and medico-legal assurance. Subsequent audits have demonstrated improved compliance, indicating that learning has been embedded.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the National Paediatric Early Warning System across paediatric services, including revised escalation criteria and dedicated escalation records.
Verbatim wording from the response “In parallel, the Trust is implementing the National Paediatric Early Warning System (nPEWS) across paediatric services. Robust governance arrangements are in place, including a weekly task-and-finish group to oversee delivery and provide assurance. A comprehensive 12-week education and training programme started on 13 April 2026 for the planned June 2026 go-live, ensuring staff are prepared and supported.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
26 Nov 2025 Evie Gladys Muir · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2 Failure to widely share hospital reviews of unusual cardiac deaths with clinicians and relevant specialist disciplines View source Failure to adequately assess cardiac patients with HLA B27 positivity or rheumatological conditions for associated risks including vasculitis View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Evie Gladys Muir · 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
Evie Gladys Muir, aged 17, died after suffering a cardiac arrest on 19 February, less than two weeks after a hospital admission for cardiac problems and treatment for axial spondylarthritis. The concerns were that reviews of unusual cardiac deaths may not be widely shared with clinicians involved in a patient’s care, and that patients with cardiac problems who are HLA B27 positive or have rheumatological conditions may not be adequately assessed for related risks, including vasculitis.
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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to widely share hospital reviews of unusual cardiac deaths with clinicians and relevant specialist disciplines
Wider context from the report “(1) That hospital reviews into unusual cardiac deaths such as this one are not more widely shared with other clinicians involved with a patient’s care, and other disciplines, such as, in this case, rheumatology specialists . This means that the full clinical picture of how a patient died may not be sufficiently widely understood.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately assess cardiac patients with HLA B27 positivity or rheumatological conditions for associated risks including vasculitis
Wider context from the report “(2) patients with cardiac problems known to be HLA B27 positive or otherwise known to present rheumatological conditions being adequately assessed for the risks which those rheumatological problems might present, include vasculitis .
” 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 Implement a quality improvement programme and new process for sharing learning from deaths across clinical teams and hospital sites.
Verbatim wording from the response “We are currently undertaking a quality improvement programme to improve our processes for learning from deaths in line with our new operating model and clinical governance structure. The new process will allow sharing of learning between teams and across hospital sites.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue increasing awareness of comparable cases among allied rheumatology healthcare professionals.
Verbatim wording from the response “We have therefore agreed a wider learning exercise to raise awareness of cases such as this is required. Our Rheumatology team have confirmed that they will present Miss Muir’s case at the Essex Rheumatology meeting, which is a regional meeting. They will also continue to increase awareness among allied rheumatology health care professionals.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invite Cardiology colleagues to Rheumatology departmental meetings to improve education on coronary vasculitis and myopericarditis.
Verbatim wording from the response “The Rheumatology team have confirmed that they will in future invite Cardiology colleagues to their departmental meetings to improve education of coronary vasculitis and myopericarditis. I understand that the Rheumatology team are working hard to improve awareness and management of cases such as Miss Muir’s.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a review of the Learning From Deaths process, including assessing M&M meeting effectiveness and identifying opportunities for cross-specialty learning.
Verbatim wording from the response “We plan to complete a full review of our Learning From Death’s process this year with the aim of ensuring that it is robust and effective. As part of this work, we will be looking at the effectiveness of M&M meetings and identifying opportunities to elevate their use, with a focus on opportunities for cross-speciality learning.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Present Miss Muir’s case at the regional Essex Rheumatology meeting.
Verbatim wording from the response “We have therefore agreed a wider learning exercise to raise awareness of cases such as this is required. Our Rheumatology team have confirmed that they will present Miss Muir’s case at the Essex Rheumatology meeting, which is a regional meeting. They will also continue to increase awareness among allied rheumatology health care professionals.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
21 Feb 2025 Lady Lola Kay Crouch · Prevention of Future Deaths report Essex
View report summary
Concerns raised 5 Failure to trigger a Medical Emergency call when elevated NEWS scores require medical review View source Delays in medical review due to doctor staffing levels View source Failure to follow up potential malignancy findings View source Failure to include relevant diagnostic findings in the patient history View source Failure to inform patients of potential malignancy findings View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lady Lola Kay Crouch · 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
Lady Lola Kay Crouch died at Broomfield Hospital on 26 February 2023 from multi-organ failure due to small bowel obstruction associated with leiomyosarcoma of the small intestine and abdominal adhesions. A December 2022 CT finding suggestive of malignancy was not followed up or communicated to her, and it was not included in her later hospital history. The report also identifies delayed medical review overnight because of doctor staffing levels.
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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to trigger a Medical Emergency call when elevated NEWS scores require medical review
Wider context from the report “(2) Staffing levels – A Medical Emergency call was not triggered overnight on the surgical ward when elevated NEWS scores required medical review that was escalated but delayed due to doctor staffing levels.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in medical review due to doctor staffing levels
Wider context from the report “(2) Staffing levels – A Medical Emergency call was not triggered overnight on the surgical ward when elevated NEWS scores required medical review that was escalated but delayed due to doctor staffing levels .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up potential malignancy findings
Wider context from the report “(1) Lady Lola was not informed of the findings of potential malignancy from a CT scan in December 2022. This was not followed up and was then not given as part of the history when Lady Lola attended hospital in February 2023.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include relevant diagnostic findings in the patient history
Wider context from the report “(1) Lady Lola was not informed of the findings of potential malignancy from a CT scan in December 2022. This was not followed up and was then not given as part of the history when Lady Lola attended hospital in February 2023.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform patients of potential malignancy findings
Wider context from the report “(1) Lady Lola was not informed of the findings of potential malignancy from a CT scan in December 2022. This was not followed up and was then not given as part of the history when Lady Lola attended hospital in February 2023.
” 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 Establish a hospital out-of-hours service in the surgical department to provide a more robust response and senior support to surgical wards.
Verbatim wording from the response “Since Lady Lola’s case we have established the hospital out of hours service in the surgical department to provide a more robust response to the surgical wards. This process has been in place for other specialties previously and we know it works very well.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reiterate NEWS and local clinical escalation processes to new surgical residents during standard induction.
Verbatim wording from the response “Along with the hospital wide trigger response team and hospital out of hours service, this provides the surgical team, with senior nursing support who can provide the more junior surgical resident with clinical support, vascular access, resuscitative support, and escalation prompting. We have further reiterated the NEWS and local clinical escalation process to the new residents as part of our standard induction process.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide patients with copies of their radiology reports through the NHS App, including summaries of clinical findings.
Verbatim wording from the response “As part of our digital improvement innovation project, we have signed up to the ‘NHS App’ radiology reporting service whereby patients now receive a copy of their own imaging reports to their personal NHS App. The reports include a summary of clinical findings that can be read by patients to improve communication and understanding of their own health record.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning from the case and reinforce NEWS2 escalation, trigger-response-team and local escalation requirements with surgical staff.
Verbatim wording from the response “Our ‘NEWS2’ escalation policy was in place at the time of Lady Lola’s attendances. The outcome of Lady Lola’s case was communicated at both our July 2024 and August 2024 general surgical audit meetings to share learning. During the meetings we highlighted the importance of compliance with the NEWS2 escalation policy again and reminded the surgical staff about the role of the trigger response team, and our local departmental escalation process. The trigger response and hospital out of hours team are automatically notified by the electronic observation system, NEWS escalations and attend the unwell patient.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement changes and processes to ensure patients are properly informed of their imaging results.
Verbatim wording from the response “We have implemented the necessary changes to ensure that patients are properly informed of their imaging results, and embedded new processes within our surgical teams to make sure surgical colleagues are well supported overnight for urgent cases and when required the Consultants act down as per policy.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The referring clinician is responsible for delivering requested radiology results and communicating significant findings to patients.
Verbatim wording from the response “Our policy ‘Communication of time critical or unexpected significant findings during diagnostic reporting’ MSEPO-21240’ makes clear that the referring clinician is responsible for delivery of any radiology they request. Where radiological imaging reports detect an unexpected, significant or time sensitive finding, our policy provides that a radiology alert is sent to the responsible consultant with the full report so that prompt action can be taken, including communication with the patient.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NEWS2 escalation, trigger response, out-of-hours support and consultant acting-down arrangements provide sufficient staffing safeguards for urgent surgical cases.
Verbatim wording from the response “Our ‘NEWS2’ escalation policy was in place at the time of Lady Lola’s attendances. The outcome of Lady Lola’s case was communicated at both our July 2024 and August 2024 general surgical audit meetings to share learning. During the meetings we highlighted the importance of compliance with the NEWS2 escalation policy again and reminded the surgical staff about the role of the trigger response team, and our local departmental escalation process. The trigger response and hospital out of hours team are automatically notified by the electronic observation system, NEWS escalations and attend the unwell patient.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing radiology alerts, communication procedures and annual audits provide sufficient arrangements for timely review and patient communication of significant findings.
Verbatim wording from the response “Our policy ‘Communication of time critical or unexpected significant findings during diagnostic reporting’ MSEPO-21240’ makes clear that the referring clinician is responsible for delivery of any radiology they request. Where radiological imaging reports detect an unexpected, significant or time sensitive finding, our policy provides that a radiology alert is sent to the responsible consultant with the full report so that prompt action can be taken, including communication with the patient.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The presentation and symptom resolution were more consistent with adhesive than malignant small bowel obstruction, making malignancy an unexpected outcome.
Verbatim wording from the response “I am advised by my surgical colleagues that presentations to the Emergency Department (ED) with signs and symptoms of bowel obstruction, particularly small bowel obstruction, have a variety of differential diagnoses. As in Lady Lola’s case, with a background of multiple previous complex open operations, adhesions are the leading cause of small bowel obstruction.” Source location Response from Mid & South Essex NHS Trust
Open published response
17 Feb 2025 DAVID WAYNE BENNETT · Prevention of Future Deaths report Essex
View report summary
Concerns raised 9 Failure of mental health liaison to undertake the mental health risk assessment View source Failure to identify and escalate unrequested antipsychotic medication View source Lack of appropriate access by mental health crisis staff to primary care mental health records View source Unclear and implementation-inconsistent mental health urgent care pathways View source Failure to share all available information with the acute Trust nurse View source Failure to escalate urgent medication review requests to an appropriate clinician View source Failure to accurately record contact and suicidal ideation in mental health records View source Lack of acute Trust nurse access to mental health and GP records View source Failure to share vital mental health information View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
DAVID WAYNE BENNETT · 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 Wayne Bennett died by hanging on 13 June 2023 after being found suspended by a ligature, with cocaine and alcohol ingestion. He had a history of drug-induced psychosis and had sought help for deteriorating mental health, psychosis and lack of sleep before his death. Concerns included inadequate sharing and recording of mental-health and primary-care information, unclear urgent-care pathways, failures to escalate requests for urgent medication review, and insufficient mental-health assessment and liaison at hospital.
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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of mental health liaison to undertake the mental health risk assessment
Wider context from the report “(7) The mental health liaison nurse asked the acute Trust nurse to undertake the risk assessment for Mr Bennett’s mental health . This is the role and purpose of mental health liaison .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and escalate unrequested antipsychotic medication
Wider context from the report “(5) Mr Bennett had an open prescription for antipsychotic medication on his GP record that was not being requested and the primary care mental health nurse did not ask about this and the nurse did not inform the GP or seek any advice from her line manager who was a nurse prescriber .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate access by mental health crisis staff to primary care mental health records
Wider context from the report “(1) Evidence was heard that the mental health crisis staff do not appear to have appropriate access to the primary care mental health System One records and there is a risk that vital information is not being shared.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear and implementation-inconsistent mental health urgent care pathways
Wider context from the report “(2) The Operational Policy Mental Health Urgent Care Department pathways Appendices are not clear and do not appear to accord with the implementation .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share all available information with the acute Trust nurse
Wider context from the report “(6) Mr Bennett attended the acute hospital Trust for his deteriorating mental health. The acute Trust hospital nurse sought advice from the mental health liaison nurse. The acute Trust nurse did not have access to the mental health or GP records and not all available information was shared with the acute Trust nurse .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate urgent medication review requests to an appropriate clinician
Wider context from the report “(4) Mr Bennett requested a GP appointment; a telephone appointment was made with the primary care mental health nurse. The primary care mental health nurse on 1ˢᵗ June did not escalate Mr Bennett to the GP or Community Psychiatrist when Mr Bennett was adamant he wanted to see a doctor and required an urgent medication review for his deteriorating mental health.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record contact and suicidal ideation in mental health records
Wider context from the report “(3) Recent contact with the primary care mental health records did not appear to be accurately recorded in the System One Records with suicidal ideation not recorded .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of acute Trust nurse access to mental health and GP records
Wider context from the report “(6) Mr Bennett attended the acute hospital Trust for his deteriorating mental health. The acute Trust hospital nurse sought advice from the mental health liaison nurse. The acute Trust nurse did not have access to the mental health or GP records and not all available information was shared with the acute Trust nurse.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share vital mental health information
Wider context from the report “(1) Evidence was heard that the mental health crisis staff do not appear to have appropriate access to the primary care mental health System One records and there is a risk that vital information is not being shared .
” 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 Devise an action plan to deliver improvements to the Mental Health Liaison service.
Verbatim wording from the response “Independent Mental Health Liaison Safety Review
In addition to the steps taken above, we have commissioned an independent review of the MHLT adult services supplied to us by EPUT. The review was finalised in January 2025 and several recommendations were made to improve the MHLT service.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a multi-agency Mental Health Working Group to develop emergency department treatment pathways for mental health patients.
Verbatim wording from the response “Mental Health Working Group
We recognise that patients in mental health crisis must find our services accessible and to achieve this we have established a Mental Health working group to develop specific ED treatment pathways for mental health patients.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission and complete an independent safety review of the Mental Health Liaison service.
Verbatim wording from the response “Independent Mental Health Liaison Safety Review
In addition to the steps taken above, we have commissioned an independent review of the MHLT adult services supplied to us by EPUT. The review was finalised in January 2025 and several recommendations were made to improve the MHLT service.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and expand the Shared Care Record to provide unified access to patient information across partner services.
Verbatim wording from the response “Access to medical records- Shared Care Record
We have several projects under development to improve the sharing of patient information between us, primary care, social care, and NHS colleagues.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the NOVA unified electronic patient record across acute, community and mental health services.
Verbatim wording from the response “Unified Electronic Patient Record- NOVA
The Nova programme is our long-term plan working to implement a unified electronic patient record (EPR) utilising the Oracle Health platform. This will be a joint platform across acute, community and mental health, enabling a more streamlined, transparent approach to patient care. It will link in with our shared care record (Orion) to allow GPs visibility of information and vice versa, as well as some information being sent to the patient portal, for example discharge letters, results, and questionnaires.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a Mental Health Liaison service across all hospitals in partnership with the Integrated Care Board and EPUT.
Verbatim wording from the response “We are working in partnership with the Mid and South Essex Integrated Care Board and EPUT to develop a Mental Health Liaison service in all of our hospitals that meets the needs of patients in mental health crisis whilst they await care and treatment in the appropriate mental health care setting.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate Shared Care Record notifications, guidance and videos to emergency department clinical staff during rollout.
Verbatim wording from the response “Notification, training guidance and videos about the Shared Care Record are currently being disseminated to our ED clinical staff as part of the rollout programme. Once the Shared Care Record is embedded, our clinical colleagues will have access to patient records from other agencies themselves, via ACP, enabling them to have a fuller picture of the patient’s clinical background. Staff will have the potential to be alerted to previous mental health interactions or concerns outside of the acute setting, without relying on the patient’s own disclosure. The types of records currently available are set out in the graphic below.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Finalise, obtain governance approval for, and roll out mental health emergency department pathways with staff training.
Verbatim wording from the response “The pathways are in the final stages of drafting, for review and approval by all involved agency’s governance structures. The final stage of the plan will include a rollout programme and training for ED staff prior to launch.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Concerns about care before 6 June 2023 do not relate to the respondent, so it has identified no action concerning them.
Verbatim wording from the response “I understand from my colleagues in attendance at the Inquest hearing, that these matters of concern; points 1 – 5, do not relate to Mid and South Essex NHS Foundation Trust (MSEFT), and we have not identified any action to be taken in respect of these.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No action was identified because the acute Trust nurse appropriately sought advice from the mental health liaison team for the risk assessment.
Verbatim wording from the response “(7) The mental health liaison nurse asked the acute Trust nurse to undertake the risk assessment for Mr Bennett’s mental health. This is the role and purpose of mental health liaison.” Source location Response from Mid & South Essex NHS Trust
Open published response
12 Jan 2025 Mr Warren James Green · Prevention of Future Deaths report Essex
View report summary
Concerns raised 4 Lack of Consultant Psychiatrist oversight for vulnerable patients View source Failure to complete appropriate risk assessments before high-risk patients leave the acute ward View source Failure to ensure hospital staff know when high-risk patients leave the acute ward View source Lack of clear mechanisms and criteria for escalation to a Consultant Psychiatrist View source See 1 more concern
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
Mr Warren James Green · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Warren James Green, who was receiving care in an acute hospital following a serious attempt on his life, died on 20 August 2024 after jumping through a gap in a four-storey stairwell and sustaining a skull fracture and traumatic subdural haemorrhage. The concerns identified included delays in securing a psychiatric bed, inadequate supervision and safeguarding for a patient at high risk of self-harm, patients being able to leave the acute ward without appropriate assessment or staff awareness, and unclear escalation to consultant psychiatric oversight.
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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of Consultant Psychiatrist oversight for vulnerable patients
Wider context from the report “(1) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without appropriate risk assessment
(2) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without the knowledge of the hospital staff
The above shows a lacuna in terms of patients’ safety and safeguarding.
(3) The evidence showed that the Mental Health Liaison Service relies on nurses to conduct initial assessments and follow up reviews of patients suffering with mental health issues and the mechanism by which escalation to a Consultants Psychiatric is decided and the factors to be taken into account for escalation are not at all clear. This leads to lack of Consultants oversight for these vulnerable patients.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete appropriate risk assessments before high-risk patients leave the acute ward
Wider context from the report “(1) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without appropriate risk assessment
(2) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without the knowledge of the hospital staff
The above shows a lacuna in terms of patients’ safety and safeguarding.
(3) The evidence showed that the Mental Health Liaison Service relies on nurses to conduct initial assessments and follow up reviews of patients suffering with mental health issues and the mechanism by which escalation to a Consultants Psychiatric is decided and the factors to be taken into account for escalation are not at all clear. This leads to lack of Consultants oversight for these vulnerable patients.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure hospital staff know when high-risk patients leave the acute ward
Wider context from the report “(1) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without appropriate risk assessment
(2) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without the knowledge of the hospital staff
The above shows a lacuna in terms of patients’ safety and safeguarding.
(3) The evidence showed that the Mental Health Liaison Service relies on nurses to conduct initial assessments and follow up reviews of patients suffering with mental health issues and the mechanism by which escalation to a Consultants Psychiatric is decided and the factors to be taken into account for escalation are not at all clear. This leads to lack of Consultants oversight for these vulnerable patients.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear mechanisms and criteria for escalation to a Consultant Psychiatrist
Wider context from the report “(1) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without appropriate risk assessment
(2) The evidence identified a risk of patients at high risk of self-harm being able to leave the acute ward without the knowledge of the hospital staff
The above shows a lacuna in terms of patients’ safety and safeguarding.
(3) The evidence showed that the Mental Health Liaison Service relies on nurses to conduct initial assessments and follow up reviews of patients suffering with mental health issues and the mechanism by which escalation to a Consultants Psychiatric is decided and the factors to be taken into account for escalation are not at all clear . This leads to lack of Consultants oversight for these vulnerable patients.
” 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 Include Section 5(2) Mental Health Act guidance in the Trust’s Mental Health policy for high-risk patients attempting or intending to leave the ward.
Verbatim wording from the response “Mental Health Policy
I am also including a copy of the staff guidance regarding Section 5(2) Mental Health Act which has now been included in the Trust’s Mental Health policy. This legal framework is an option for ward clinicians to use in situations where a patient has been assessed as high risk and attempts to leave the ward, or voices intent to leave the ward.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update policies and flowcharts guiding risk assessment and supervision of inpatients at high risk of self-harm.
Verbatim wording from the response “Response: The Trust has reviewed an updated relevant policies and flowcharts to assist clinical staff with guidance and processes when managing high risk of self-harm patients in an inpatient setting, to ensure the appropriate risk assessments and supervision are put in place to maintain their safety and minimise their ability to leave a ward without staff knowledge or appropriate supervision.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver Section 5(2) Mental Health Act training to FY2 doctors every six months during induction.
Verbatim wording from the response “I can confirm the Trust’s Mental Health Lead and Prevent Lead Nurse is undertaking a programme to raise awareness of this updated staff guidance at the Nurses' Grand Rounds. A training session is also delivered every 6 months to the FY2 doctors as part of their induction, in which this topic around Section 5(2) assessment of the Mental Health Act is covered. In addition, this has now been added into the Trust’s Mental Health Act training that is delivered each month online.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add Section 5(2) Mental Health Act assessment to the Trust’s monthly online Mental Health Act training.
Verbatim wording from the response “I can confirm the Trust’s Mental Health Lead and Prevent Lead Nurse is undertaking a programme to raise awareness of this updated staff guidance at the Nurses' Grand Rounds. A training session is also delivered every 6 months to the FY2 doctors as part of their induction, in which this topic around Section 5(2) assessment of the Mental Health Act is covered. In addition, this has now been added into the Trust’s Mental Health Act training that is delivered each month online.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise awareness of the updated Section 5(2) guidance through the Nurses’ Grand Rounds programme.
Verbatim wording from the response “I can confirm the Trust’s Mental Health Lead and Prevent Lead Nurse is undertaking a programme to raise awareness of this updated staff guidance at the Nurses' Grand Rounds. A training session is also delivered every 6 months to the FY2 doctors as part of their induction, in which this topic around Section 5(2) assessment of the Mental Health Act is covered. In addition, this has now been added into the Trust’s Mental Health Act training that is delivered each month online.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
23 Dec 2024 William Charles Hare (Bill) · Prevention of Future Deaths report Essex
View report summary
Concerns raised 13 Delays in progressing treatment while patients remain eligible for surgery View source Failure to appropriately prioritise referrals or requests View source Delays in reaching diagnosis and implementing treatment plans View source Lack of a specialist renal consultant at the MDT View source Delays in making CT scan results available View source Disjointed inter-hospital coordination delaying treatment progression View source Delays in Consultant appointments following MDT referral View source Delays in taking first biopsies View source Failures to organise and coordinate inter-hospital transport View source Delays in MDT consideration of CT scan results and treatment plans View source Ineffective interaction between people and systems across Southend and Basildon Hospitals View source Fragmented computer systems controlling clinical referral processes View source Clinically consequential referral processes controlled by non-medically trained staff View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
William Charles Hare (Bill) · 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
William Charles Hare (Bill) presented with abdominal and left loin pain in November 2022 and was subsequently diagnosed with metastatic urothelial cancer. He died in a hospice on 23 January 2024 after delays in diagnosis and treatment, including delays in biopsy, specialist review, MDT consideration, hospital transfer and scan results. The report identified systemic and procedural errors and ineffective coordination between Basildon and Southend Hospitals as substantive concerns.
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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in progressing treatment while patients remain eligible for surgery
Wider context from the report “v. A further delay occurred from 4 September , as Bill had been assessed as unfit for surgery due to his HBA1c reading . Whilst this is unlikely to have been relevant by the cancer, there was likely to have been an opportunity, had his case been progressed earlier, at which his HBA1c was at an acceptable level for the procedure to be carried out .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately prioritise referrals or requests
Wider context from the report “viii. Among the delays, and potentially contributing to them, were a series of systemic and procedural errors largely related to processes controlled by isolated computer systems or people who are not medically trained. One example is the default of a referral or request to “routine”.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in reaching diagnosis and implementing treatment plans
Wider context from the report “i. There was an overall delay in reaching any diagnosis in Bill’s case and, therefore, any treatment plan being implemented .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a specialist renal consultant at the MDT
Wider context from the report “ix. The lack of a specialist renal consultant at the MDT and lack of effective interaction between the people and systems at Southend and Basildon Hospitals prevented quick and effective decision making and, therefore, progress of Bill’s diagnosis and 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in making CT scan results available
Wider context from the report “vii. A final delay occurred in the results of a CT scan , the results of which were not available until 15 January . By this time, the cancer had spread throughout Bill’s body and became untreatable.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Disjointed inter-hospital coordination delaying treatment progression
Wider context from the report “vi. In his last admission to Basildon Hospital between November 2023 and January 2024 there were delays in progressing his treatment due to the disjointed nature of the inter-relationship between Basildon and Southend Hospitals as well as delays in transporting him to Southend Hospital which included failures to organise transport and properly coordinate his transfer.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in Consultant appointments following MDT referral
Wider context from the report “iii. There was a delay from the MDT referring the case to the Consultant, to an appointment taking place in May 2023.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in taking first biopsies
Wider context from the report “ii. There was a delay in the first biopsy being taken which ultimately took place well outside the national guideline of 31 days .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failures to organise and coordinate inter-hospital transport
Wider context from the report “vi. In his last admission to Basildon Hospital between November 2023 and January 2024 there were delays in progressing his treatment due to the disjointed nature of the inter-relationship between Basildon and Southend Hospitals as well as delays in transporting him to Southend Hospital which included failures to organise transport and properly coordinate his transfer .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in MDT consideration of CT scan results and treatment plans
Wider context from the report “iv. There was an additional delay between the further CT scan ordered by the Consultant , which took place on 5 June, and the MDT which considered the results and treatment plan on 29 August , notwithstanding the fact that the MDT meet weekly and Bill’s case could have been considered at any of those meetings.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective interaction between people and systems across Southend and Basildon Hospitals
Wider context from the report “ix. The lack of a specialist renal consultant at the MDT and lack of effective interaction between the people and systems at Southend and Basildon Hospitals prevented quick and effective decision making and, therefore, progress of Bill’s diagnosis and 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Fragmented computer systems controlling clinical referral processes
Wider context from the report “viii. Among the delays, and potentially contributing to them, were a series of systemic and procedural errors largely related to processes controlled by isolated computer systems or people who are not medically trained. One example is the default of a referral or request to “routine”.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Clinically consequential referral processes controlled by non-medically trained staff
Wider context from the report “viii. Among the delays, and potentially contributing to them, were a series of systemic and procedural errors largely related to processes controlled by isolated computer systems or people who are not medically trained . One example is the default of a referral or request to “routine”.
” 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 Operate a focused weekly kidney and upper-tract urological cancer MDT reviewing relevant recent scans with specialist multidisciplinary participation across hospital sites.
Verbatim wording from the response “A further key development is the creation of a focused weekly kidney/upper tract urological cancers MDT (multi-disciplinary team) meeting. By separating this MDT from the general pelvic MDT, patients with suspected upper tract urological cancers are reviewed in a very timely manner and it is our routine practice to review all relevant patient scans taken within the past 7 days.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use one comprehensive patient-tracking system across hospital sites to monitor cancer pathways, diagnostic reporting, timescales and required escalations.
Verbatim wording from the response “We now have one comprehensive patient tracking system for all hospital sites providing a centralised monitoring for all cancer patients and their progress through the cancer pathway.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase diagnostic clinic capacity and provide designated consultant presence at all clinics.
Verbatim wording from the response “We have reflected on Mr Hare’s experience and carefully considered how the patient pathway and treatment timescales could be improved.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide consultant-led pre-operative support, including early identification, specialist review, endocrinology support and monitoring for patients with poorly controlled HBA1c.
Verbatim wording from the response “We have improved the quality of care delivered at our pre-assessment clinics. Specialist staff are now reviewing clinic lists for patients such as Mr Hare, where HBA1c is poorly controlled and would benefit from early support from the hospital. We know that hospital led support yields the best outcomes for these patients, and so we have increased clinical capacity in this area. In doing so we monitor any deterioration of HBA1c control and work closely with our patients to counsel them on the impact this may have on the future treatments we can offer.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The transfer delay did not affect the clinical outcome because appropriate care was provided at Basildon Hospital.
Verbatim wording from the response “We acknowledge that there were issues with inter hospital transfers and delays, however in this case transferring from Basildon to Southend had no bearing on the clinical outcome as Mr Hare was receiving appropriate care in Basildon HDU. However, we appreciate there should have been better communication at this time with the patient and his family. Should a patient require urgent transfer for specific treatment this is prioritised by the Trust and the East of England ambulance service.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Urgent transfers are prioritised by the Trust and East of England ambulance service.
Verbatim wording from the response “We acknowledge that there were issues with inter hospital transfers and delays, however in this case transferring from Basildon to Southend had no bearing on the clinical outcome as Mr Hare was receiving appropriate care in Basildon HDU. However, we appreciate there should have been better communication at this time with the patient and his family. Should a patient require urgent transfer for specific treatment this is prioritised by the Trust and the East of England ambulance service.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust found no evidence that computer systems downgraded urgent requests to routine.
Verbatim wording from the response “Following the Inquest, we have investigated the concerns raised about the computer systems. I would like to assure you that we have not observed any issues as described at Inquest where requests are downgraded to routine when raised as urgent.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation By 5 January, disease progression had made the condition inoperable, so surgery would not have been appropriate treatment.
Verbatim wording from the response “On review of Mr Hare’s MRI scan taken on 5th January 2024 and his clinical presentation at that time, regrettably the disease progression had made his condition inoperable, and surgery would not have been the appropriate treatment.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Weekly specialist MDT meetings and centralised tracking are considered sufficient to prevent delays in scan review and treatment planning.
Verbatim wording from the response “We are not experiencing any delays between scans and the MDT review and patient clinics to review results are happening, and within the timescale prescribed within the cancer pathway.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Earlier progression would not establish that surgery was feasible because HbA1c was never optimal and surgical complication risks remained high.
Verbatim wording from the response “My colleagues advise me that Mr Hare’s HBA1c control was unfortunately in decline since his first presentation at the preassessment clinic on 4th September 2023. We cannot speculate that Mr Hare would have been a suitable candidate for the procedure at an earlier date as his HBA1c was never optimal for surgery and he was at high risk of complications including stroke. Poorly controlled HBA1c places patients at risk of death from such procedures and these risks were explained to Mr Hare when the clinical decision was that he was at too high a risk for surgery at that time. He was referred to his GP for HBA1c optimisation.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Specialist renal consultant participation and cross-site hybrid MDT working are considered to have addressed concerns about decision-making and hospital interaction.
Verbatim wording from the response “We are confident that these concerns have been addressed by the development of our kidney/upper tract urological cancer specific MDT meetings which take place following the general MDT each week.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
17 Dec 2024 MARY MARGARET WHITLOCK · Prevention of Future Deaths report Essex
View report summary
Concerns raised 5 Failure to provide safety-netting advice to care homes View source Failure to prevent administration of morphine to patients with recorded opioid allergies View source Failure to review medication safety incidents and raise safeguards View source Failure to provide discharge summaries to care homes View source Understaffing of Notley Ward View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
MARY MARGARET WHITLOCK · 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
Mary Margaret Whitlock died at Broomfield Hospital on 23 August 2023 after sustaining cervical fractures in a fall and subsequently suffering aspiration following assisted feeding while experiencing swallowing difficulties. The report identified concerns about delayed provision of a recommended collar, inadequate planning and communication regarding swallowing and oral intake, medication administration despite recorded opioid allergies, understaffing, and the absence of discharge and safety-netting advice to her care home.
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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide safety-netting advice to care homes
Wider context from the report “(3) No Discharge Summary or Safety Netting advice was provided by the Trust to the care home for a patient with dementia who was discharged from Accident & Emergency at night where she had undergone investigations for traumatic head injury
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent administration of morphine to patients with recorded opioid allergies
Wider context from the report “(1) Morphine in the form of 5mg Oramorph and then 2.5mg Intravenous morphine was administered for a patient where the medication record noted allergy to Tramadol, Codeine and Buprenorphine . Naloxone was required to reverse the effect. Whilst this did not cause or contribute to this death this matter was not part of the Trust review, and no safeguards was raised.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review medication safety incidents and raise safeguards
Wider context from the report “(1) Morphine in the form of 5mg Oramorph and then 2.5mg Intravenous morphine was administered for a patient where the medication record noted allergy to Tramadol, Codeine and Buprenorphine. Naloxone was required to reverse the effect. Whilst this did not cause or contribute to this death this matter was not part of the Trust review , and no safeguards was raised .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide discharge summaries to care homes
Wider context from the report “(3) No Discharge Summary or Safety Netting advice was provided by the Trust to the care home for a patient with dementia who was discharged from Accident & Emergency at night where she had undergone investigations for traumatic head injury
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Understaffing of Notley Ward
Wider context from the report “(2) Evidence of clinical witnesses is that Notley Ward was (at the time of this death) and remains understaffed despite escalation within Trust
” 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 Monitor discharge-summary issuance through the 2025 trust-wide corporate audit programme and use findings to determine further action.
Verbatim wording from the response “We plan to monitor our performance with issuing discharge summaries within our 2025 trust-wide corporate audit programme to assure ourselves with compliance and use the results to take action as appropriate.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide weekday duty Matron cover and embed escalation routes for approving additional bank or agency staffing.
Verbatim wording from the response “We have a duty Matron on site weekdays until 20:00PM to manage any staffing concerns and we have embedded clear escalation processes to the Director and Deputy Director of Nursing who can approve requests to increase staffing by sourcing bank staff/ agency support.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind nursing staff to verify discharge-summary completion before patients leave the department.
Verbatim wording from the response “Nursing colleagues have also been reminded to check that this has been completed prior to the patient leaving the department upon discharge.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete inpatient ward Funded Staff Rota reviews and adjust nursing establishments to acuity and safe nurse-to-patient ratios.
Verbatim wording from the response “Funded Staff Rota (FSR) reviews are completed on every inpatient ward and our nursing establishments are altered to meet nursing acuity and safe nurse to patient ratios. The FSR’s are signed-off at Director of Nursing level.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning from the opioid analgesia incident with Emergency Department colleagues to inform future practice.
Verbatim wording from the response “In retrospect, the clinicians consider that a smaller dose than 2.5mg, of 1mg increments of opiate would have been more appropriate given her noted allergies. Learning from this case has been shared with Emergency Department colleagues accordingly for future practise.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish learning from the case in the January 2025 all-staff patient safety bulletin, emphasising complete and accurate discharge summaries at discharge.
Verbatim wording from the response “We have included the learning from Mrs Whitlock’s case within our all-staff patient safety bulletin for January 2025 emphasising the importance of a full and accurate discharge summary being completed at the point of discharge.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct daily site-wide staffing huddles and provide daily Matron oversight to identify staffing risks and arrange immediate redeployment or mitigation.
Verbatim wording from the response “To ensure that safe staffing levels are maintained across all wards, we have implemented a daily staffing huddle which takes place at 08:15AM Monday-Friday. The huddle review the staffing position across the site and senior colleagues make immediate redeployment/mitigation plans as required. At the weekend, we have a daily duty Matron on site to complete the same function.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind Emergency Medicine clinicians to complete discharge summaries for every patient, including those discharged somewhere other than home.
Verbatim wording from the response “Following Mrs Whitlock’s experience, all our Emergency Medicine clinicians have been reminded of the requirement to complete a discharge summary to all patients in every case. We have highlighted the importance of these being available to patients who are not being discharged to their own home.” Source location Response from Mid & South Essex NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit to all vacant Registered Nurse posts on Notley Ward, bringing the ward to full establishment.
Verbatim wording from the response “Our Deputy Director of Nursing for Broomfield Hospital has reviewed the staffing position on Notley Ward and confirmed that we have recruited to all vacant Registered Nurse posts, and the ward is at full establishment with no current nursing vacancies.” Source location Response from Mid & South Essex NHS Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust disputes that Notley Ward currently remains understaffed, stating that all vacant Registered Nurse posts are filled.
Verbatim wording from the response “Our Deputy Director of Nursing for Broomfield Hospital has reviewed the staffing position on Notley Ward and confirmed that we have recruited to all vacant Registered Nurse posts, and the ward is at full establishment with no current nursing vacancies.” Source location Response from Mid & South Essex NHS Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Opioid analgesia was within acceptable clinical decision-making, so further review or safeguarding was not considered necessary.
Verbatim wording from the response “The choice of analgesia was not included as a term of reference for our review as it was within an acceptable range of clinical decision making, and a safeguarding was not triggered or indicated for this event. The use of opioid analgesia was made on a balance of risk basis and the risks of allergy were carefully managed.” Source location Response from Mid & South Essex NHS Trust
Open published response
13 Dec 2024 LAURA-JANE KIRSTEN NICOLE SEAMAN · Prevention of Future Deaths report Essex
View report summary
Concerns raised 16 Lack of compliance with national guidance and training View source Delays in escalating deteriorating maternity patients for senior and critical care review View source Failure to maintain contemporaneous and accurate Labour Ward medication records View source Failure to obtain accounts from Haematology and blood laboratory staff after a massive haemorrhage View source Insufficient experienced doctor skill mix on the Labour Ward View source Omission of covert bleeding from the Trust Drills & Skills Booklet View source Failure to obtain consultant obstetric input, medical review and imaging before therapeutic anticoagulation View source Failure to communicate and share clinical information between Trust staff View source Failure to record Labour Ward vital signs on required MEOWS charts View source Failure to obtain critical care review after Labour Ward administration of Metaraminol View source Failure to trigger the major haemorrhage protocol View source Failure to recognise covert bleeding causing hypovolaemia View source Failure to obtain and retain contemporaneous blood testing results for high-risk or deteriorating patients View source Failure to communicate key information during staff handovers View source Failure to escalate obstetric emergencies to an obstetric consultant View source Failure to consider bleeding as a cause of maternal deterioration View source See 13 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 14
Action
Embed deterioration recognition, concealed-bleeding assessment and escalation training in PROMPT, induction, local teaching, drills and written staff communications.
Stated completedThe respondent said that this action was complete when they made their response on 18 December 2024. View source
Action
Audit obstetric bleeding-strategy compliance and review postpartum-haemorrhage cases to feed learning to governance and national study teams.
Stated in progressThe respondent said that this action was in progress when they made their response on 18 December 2024. View source
Action
Address major-haemorrhage protocol compliance through education, training, amended guidance and monthly monitoring.
Stated completedThe respondent said that this action was complete when they made their response on 18 December 2024. View source
Action
Upload patient notes digitally before multidisciplinary meetings so attendees can scrutinise records across meeting formats.
Stated completedThe respondent said that this action was complete when they made their response on 18 December 2024. View source
Action
Teach and practise SBAR escalation during annual multidisciplinary PROMPT training.
Stated completedThe respondent said that this action was complete when they made their response on 18 December 2024. View source
Action
Strengthen collaboration with haematology, critical care and anaesthetics, including regular specialty attendance and dedicated ICU consultant input for complex maternal-care reviews.
Stated completedThe respondent said that this action was complete when they made their response on 18 December 2024. View source
Action
Use electronic prescribing and medication administration records for medications across all Trust sites, except unsupported variable-rate infusions.
Stated completedThe respondent said that this action was complete when they made their response on 18 December 2024. View source
Action
Train staff on MEWS charts and eliminate photocopied versions to support accurate scoring and escalation.
Stated completedThe respondent said that this action was complete when they made their response on 18 December 2024. View source
Action
Renew MNSI investigation processes so all involved staff receive draft reports and can provide comments through multidisciplinary factual-accuracy review.
Stated completedThe respondent said that this action was complete when they made their response on 18 December 2024. View source
Action
Implement the national MEWS observation package and escalation policy, including trigger-team referral and mandatory maternity-inpatient use.
Stated completedThe respondent said that this action was complete when they made their response on 18 December 2024. View source
Action
Continue escalation work and audit compliance with expected communication standards.
Stated in progressThe respondent said that this action was in progress when they made their response on 18 December 2024. View source
Action
Implement the OBS UK obstetric bleeding care bundle covering risk assessment, quantitative blood-loss measurement, escalation, and rapid clotting tests.
Stated in progressThe respondent said that this action was in progress when they made their response on 18 December 2024. View source
Action
Launch the RCOG escalation toolkit, including AID language, conflict-resolution teaching and team-of-shift handover practices.
Stated plannedThe respondent said that this action was planned when they made their response on 18 December 2024. View source
Action
Adopt a rota requiring junior registrars to pair with senior registrars and establish supervision and risk-mitigation arrangements when the intended skill mix is unavailable.
Stated completedThe respondent said that this action was complete when they made their response on 18 December 2024. View source See 11 more actions
×
AI-generated summary
LAURA-JANE KIRSTEN NICOLE SEAMAN · 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
Laura-Jane Seaman died at Broomfield Hospital on 23 December 2022 following a massive intra-abdominal haemorrhage after a recent vaginal delivery, with subsequent disseminated intravascular coagulation. The principal concerns were failures to recognise and escalate maternal collapse and hypovolaemia, obtain and record vital signs and blood-test results, examine for covert bleeding, activate the major haemorrhage protocol, and provide appropriate senior review. The inquest concluded that her death was avoidable and contributed to by neglect.
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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of compliance with national guidance and training
Wider context from the report “(1) The acute Trust 72-hour investigation did not identify:
a. The absence of a contemporaneous Labour Ward medication chart for a patient that was administered medications on the ward
b. Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023
c. Vital signs for patients on the labour ward being annotated on a piece of cardiotocograph paper and the absence of required MEOWS charts
d. Communication issues with Trust staff and sharing of information
e. Lack of compliance with national guidance and training
f. Absence of contemporaneous blood testing results for Laura-Jane as a patient at high risk of post-partum haemorrhage in labour taken at
i. 00:40 hours for cross matching, and
ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient
g. Lack of compliance with the triggering of the major haemorrhage protocol
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in escalating deteriorating maternity patients for senior and critical care review
Wider context from the report “(2) Laura-Jane was not escalated for hours as a deteriorating patient in accordance with training and national guidance including PROMPT training, or the Royal College of Obstetricians and Gynaecologists Maternal Collapse in Pregnancy and Puerperium (RCOG)Green-top Guideline No.56. The maternal collapse was categorised as a “Faint” by Trust staff and Laura-Jane was treated for potential dehydration (with no apparent risk factors) and administered medication that had only a transient effect.
(3) The administration of Metaraminol on the labour ward is rare for a mother who had an uneventful delivery and did not prompt a critical care review with a background of deranged vital signs.
(4) There was a focus by midwifery staff on per vaginal bleeding and the hypovolemia was not recognised. The PROMPT training guidance contains illustrations by way of photographs to assist with the assessment of blood loss that focuses on per vaginal bleeding. Covert bleeding is referred to in the context of hypovolemia in a separate place on one line. Covert bleeding is not referred to in the Trust Drills & Skills Booklet.
(5) Laura-Jane informed clinical professionals she thought she was haemorrhaging and that she was going to die in a background picture of maternal collapse and prolonged deranged vital signs. This did not trigger Consultant obstetric review, 2222 alert or referral to the critical care outreach 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain contemporaneous and accurate Labour Ward medication records
Wider context from the report “(1) The acute Trust 72-hour investigation did not identify:
a. The absence of a contemporaneous Labour Ward medication chart for a patient that was administered medications on the ward
b. Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023
c. Vital signs for patients on the labour ward being annotated on a piece of cardiotocograph paper and the absence of required MEOWS charts
d. Communication issues with Trust staff and sharing of information
e. Lack of compliance with national guidance and training
f. Absence of contemporaneous blood testing results for Laura-Jane as a patient at high risk of post-partum haemorrhage in labour taken at
i. 00:40 hours for cross matching, and
ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient
g. Lack of compliance with the triggering of the major haemorrhage protocol
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain accounts from Haematology and blood laboratory staff after a massive haemorrhage
Wider context from the report “(12) No accounts were taken from Haematology, or the blood lab team involved with this massive haemorrhage by the Trust or the HSIB (who investigated this case) where massive amounts of blood products were prepared, dispensed and then administered where the timings and sharing of information were important to understand.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient experienced doctor skill mix on the Labour Ward
Wider context from the report “(9) Staff skill mix for doctors on the Labour Ward for the night of 20/21 December was staffed with a junior obstetric registrar with a newly qualified colleague in his first week and a junior anaesthetist, all with limited experience of working on the Labour Ward .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Omission of covert bleeding from the Trust Drills & Skills Booklet
Wider context from the report “(2) Laura-Jane was not escalated for hours as a deteriorating patient in accordance with training and national guidance including PROMPT training, or the Royal College of Obstetricians and Gynaecologists Maternal Collapse in Pregnancy and Puerperium (RCOG)Green-top Guideline No.56. The maternal collapse was categorised as a “Faint” by Trust staff and Laura-Jane was treated for potential dehydration (with no apparent risk factors) and administered medication that had only a transient effect.
(3) The administration of Metaraminol on the labour ward is rare for a mother who had an uneventful delivery and did not prompt a critical care review with a background of deranged vital signs.
(4) There was a focus by midwifery staff on per vaginal bleeding and the hypovolemia was not recognised. The PROMPT training guidance contains illustrations by way of photographs to assist with the assessment of blood loss that focuses on per vaginal bleeding. Covert bleeding is referred to in the context of hypovolemia in a separate place on one line. Covert bleeding is not referred to in the Trust Drills & Skills Booklet .
(5) Laura-Jane informed clinical professionals she thought she was haemorrhaging and that she was going to die in a background picture of maternal collapse and prolonged deranged vital signs. This did not trigger Consultant obstetric review, 2222 alert or referral to the critical care outreach 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain consultant obstetric input, medical review and imaging before therapeutic anticoagulation
Wider context from the report “(11) Therapeutic anticoagulation was administered without consultant obstetric input, further medical review or imaging where there had been hours of deranged vital signs that were inconsistent potential complications for pulmonary embolism.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate and share clinical information between Trust staff
Wider context from the report “(1) The acute Trust 72-hour investigation did not identify:
a. The absence of a contemporaneous Labour Ward medication chart for a patient that was administered medications on the ward
b. Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023
c. Vital signs for patients on the labour ward being annotated on a piece of cardiotocograph paper and the absence of required MEOWS charts
d. Communication issues with Trust staff and sharing of information
e. Lack of compliance with national guidance and training
f. Absence of contemporaneous blood testing results for Laura-Jane as a patient at high risk of post-partum haemorrhage in labour taken at
i. 00:40 hours for cross matching, and
ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient
g. Lack of compliance with the triggering of the major haemorrhage protocol
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record Labour Ward vital signs on required MEOWS charts
Wider context from the report “(1) The acute Trust 72-hour investigation did not identify:
a. The absence of a contemporaneous Labour Ward medication chart for a patient that was administered medications on the ward
b. Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023
c. Vital signs for patients on the labour ward being annotated on a piece of cardiotocograph paper and the absence of required MEOWS charts
d. Communication issues with Trust staff and sharing of information
e. Lack of compliance with national guidance and training
f. Absence of contemporaneous blood testing results for Laura-Jane as a patient at high risk of post-partum haemorrhage in labour taken at
i. 00:40 hours for cross matching, and
ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient
g. Lack of compliance with the triggering of the major haemorrhage protocol
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain critical care review after Labour Ward administration of Metaraminol
Wider context from the report “(2) Laura-Jane was not escalated for hours as a deteriorating patient in accordance with training and national guidance including PROMPT training, or the Royal College of Obstetricians and Gynaecologists Maternal Collapse in Pregnancy and Puerperium (RCOG)Green-top Guideline No.56. The maternal collapse was categorised as a “Faint” by Trust staff and Laura-Jane was treated for potential dehydration (with no apparent risk factors) and administered medication that had only a transient effect.
(3) The administration of Metaraminol on the labour ward is rare for a mother who had an uneventful delivery and did not prompt a critical care review with a background of deranged vital signs .
(4) There was a focus by midwifery staff on per vaginal bleeding and the hypovolemia was not recognised. The PROMPT training guidance contains illustrations by way of photographs to assist with the assessment of blood loss that focuses on per vaginal bleeding. Covert bleeding is referred to in the context of hypovolemia in a separate place on one line. Covert bleeding is not referred to in the Trust Drills & Skills Booklet.
(5) Laura-Jane informed clinical professionals she thought she was haemorrhaging and that she was going to die in a background picture of maternal collapse and prolonged deranged vital signs. This did not trigger Consultant obstetric review, 2222 alert or referral to the critical care outreach 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to trigger the major haemorrhage protocol
Wider context from the report “(1) The acute Trust 72-hour investigation did not identify:
a. The absence of a contemporaneous Labour Ward medication chart for a patient that was administered medications on the ward
b. Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023
c. Vital signs for patients on the labour ward being annotated on a piece of cardiotocograph paper and the absence of required MEOWS charts
d. Communication issues with Trust staff and sharing of information
e. Lack of compliance with national guidance and training
f. Absence of contemporaneous blood testing results for Laura-Jane as a patient at high risk of post-partum haemorrhage in labour taken at
i. 00:40 hours for cross matching, and
ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient
g. Lack of compliance with the triggering of the major haemorrhage protocol
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise covert bleeding causing hypovolaemia
Wider context from the report “(2) Laura-Jane was not escalated for hours as a deteriorating patient in accordance with training and national guidance including PROMPT training, or the Royal College of Obstetricians and Gynaecologists Maternal Collapse in Pregnancy and Puerperium (RCOG)Green-top Guideline No.56. The maternal collapse was categorised as a “Faint” by Trust staff and Laura-Jane was treated for potential dehydration (with no apparent risk factors) and administered medication that had only a transient effect.
(3) The administration of Metaraminol on the labour ward is rare for a mother who had an uneventful delivery and did not prompt a critical care review with a background of deranged vital signs.
(4) There was a focus by midwifery staff on per vaginal bleeding and the hypovolemia was not recognised . The PROMPT training guidance contains illustrations by way of photographs to assist with the assessment of blood loss that focuses on per vaginal bleeding. Covert bleeding is referred to in the context of hypovolemia in a separate place on one line. Covert bleeding is not referred to in the Trust Drills & Skills Booklet .
(5) Laura-Jane informed clinical professionals she thought she was haemorrhaging and that she was going to die in a background picture of maternal collapse and prolonged deranged vital signs. This did not trigger Consultant obstetric review, 2222 alert or referral to the critical care outreach 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and retain contemporaneous blood testing results for high-risk or deteriorating patients
Wider context from the report “(1) The acute Trust 72-hour investigation did not identify:
a. The absence of a contemporaneous Labour Ward medication chart for a patient that was administered medications on the ward
b. Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023
c. Vital signs for patients on the labour ward being annotated on a piece of cardiotocograph paper and the absence of required MEOWS charts
d. Communication issues with Trust staff and sharing of information
e. Lack of compliance with national guidance and training
f. Absence of contemporaneous blood testing results for Laura-Jane as a patient at high risk of post-partum haemorrhage in labour taken at
i. 00:40 hours for cross matching , and
ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient
g. Lack of compliance with the triggering of the major haemorrhage protocol
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate key information during staff handovers
Wider context from the report “(10) Quality of communication and handovers between Trust staff key information was omitted in handovers between staff at all levels including when Laura-Jane was taken to theatre as a medical emergency.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate obstetric emergencies to an obstetric consultant
Wider context from the report “(6) The Trust Executive Review Group (“ERG”) Report was not shared with the Trust Director of Midwifery or the Head of Midwifery at Broomfield Hospital who did not agree with the ERG conclusions that:
‘The absence of escalation to an obstetric consultant was discussed and noted that the team escalated to an anaesthetist, which is usual practice in an obstetric emergency (putting out a call to the medical emergency team would not be common practice).’
‘The possible reasons why the bleeding was not identified were discussed and it was noted that in maternity cases the absence of vaginal bleeding and with no signs of uterine rupture it would be unlikely that the team would have considered bleeding as a cause of deterioration.’
and gave evidence that this is not in accordance with good clinical practice or national guidelines and training .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider bleeding as a cause of maternal deterioration
Wider context from the report “(6) The Trust Executive Review Group (“ERG”) Report was not shared with the Trust Director of Midwifery or the Head of Midwifery at Broomfield Hospital who did not agree with the ERG conclusions that:
‘The absence of escalation to an obstetric consultant was discussed and noted that the team escalated to an anaesthetist, which is usual practice in an obstetric emergency (putting out a call to the medical emergency team would not be common practice).’
‘The possible reasons why the bleeding was not identified were discussed and it was noted that in maternity cases the absence of vaginal bleeding and with no signs of uterine rupture it would be unlikely that the team would have considered bleeding as a cause of deterioration.’
and gave evidence that this is not in accordance with good clinical practice or national guidelines and training .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed deterioration recognition, concealed-bleeding assessment and escalation training in PROMPT, induction, local teaching, drills and written staff communications.
Verbatim wording from the response “7) An ‘unwell woman’s’ simulation based on antepartum and postpartum haemorrhage including uterine rupture, abruption, and Vasa Previa, as well as a separate simulation on an anaphylaxis scenario was included in the 2023 PROMPT maternity training for all staff in addition to Human factors training, teamwork, situational awareness, and escalation.” Source location Response from Mid & South Essex NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit obstetric bleeding-strategy compliance and review postpartum-haemorrhage cases to feed learning to governance and national study teams.
Verbatim wording from the response “To date, we have 91% training compliance of our target group of clinicians which is being reassessed after a new rotation of staff to ensure we remain above 90%. To assess our compliance of the strategy audits (first 30 consecutive births) and case note reviews (first ten consecutive births with 1 litre loss or more) are undertaken at month one, four, seven and ten after the start of the study. Due to training of staff and development of a standard operating procedure (attached) taking a number of months the strategy did not commence till 21st November 2024 with the last few months taken to drive the uptake of the bundle. To reflect this, the service undertook an additional audit in January which showed a 75% compliance across the board for risk assessments, measured blood loss and appropriate TEG testing.” Source location Response from Mid & South Essex NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Address major-haemorrhage protocol compliance through education, training, amended guidance and monthly monitoring.
Verbatim wording from the response “Although this concern was not specifically drawn out in the initial Rapid Review, the HSIB report highlighted this as a safety action which has now been addressed through education, training, and the amendment of local guidance.” Source location Response from Mid & South Essex NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Upload patient notes digitally before multidisciplinary meetings so attendees can scrutinise records across meeting formats.
Verbatim wording from the response “The division acknowledges that the use of multiple medication charts was not included as a specific line of inquiry at the Rapid Review stage, and it should have been. We have reflected on the MDT meeting undertaken for Laura-Jane’s incident and we have made improvements to our processes. We now ensure that patient notes are uploaded as a digital copy in readiness for all MDT meetings so that whether meetings take place in person, online or hybrid, all staff attending have access to review and scrutinise the patient’s notes. Therefore, minimising the risk that important factors such as accuracy and quality record keeping are missed.” Source location Response from Mid & South Essex NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Teach and practise SBAR escalation during annual multidisciplinary PROMPT training.
Verbatim wording from the response “The obstetric, midwifery and anaesthetic teams have yearly Practical Obstetric Multi Professional Training (PROMPT) training sessions as an MDT where they role play emergency scenarios. Since Laura-Jane’s death, during PROMPT, the teams are taught about the SBAR tool, (Situation, Background, Assessment, Recommendation). Escalation via the use of the SBAR tool is practiced teaching the quality and effectiveness of good communication. SBAR is an easy to remember mechanism to use to frame communications or conversations. It is a structured way of communicating information that requires a response from the receiver. As such, SBAR can be used very effectively to escalate a clinical problem that requires immediate attention, or to facilitate efficient handover of patients between clinicians or clinical teams.” Source location Response from Mid & South Essex NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen collaboration with haematology, critical care and anaesthetics, including regular specialty attendance and dedicated ICU consultant input for complex maternal-care reviews.
Verbatim wording from the response “The service now has an improved working relationship with haematology, critical care, and anaesthetics with regular attendance from these specialties where indicated. The Risk and Governance team now have a dedicated ICU consultant involved in reviewing any complex maternal care.” Source location Response from Mid & South Essex NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use electronic prescribing and medication administration records for medications across all Trust sites, except unsupported variable-rate infusions.
Verbatim wording from the response “All Mid and South Essex Hospital NHS Foundation Trust (‘MSE’) sites have now adopted an electronic prescribing and medication administration (EPMA) platform. EPMA facilitates team members across specialties to record accurately and contemporaneously in one place. The system allows all registered users to clearly see what other medications have been administered and by whom. Staff details are visible against the record so that each interaction is name and date stamped within the patient record. This aides staff communication as it is clear who has been involved in the prescription of medications, and any queries or escalations can be quickly actioned. A new ‘e-chart’ is automatically started when there is a new patient admission which limits the risk of drug errors and allows for re-evaluation of a patient’s medication.” Source location Response from Mid & South Essex NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train staff on MEWS charts and eliminate photocopied versions to support accurate scoring and escalation.
Verbatim wording from the response “Our Rapid Review identified this issue, and several immediate actions were taken including urgent training delivered to staff to increase awareness and improve knowledge of MEWS charts.” Source location Response from Mid & South Essex NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Renew MNSI investigation processes so all involved staff receive draft reports and can provide comments through multidisciplinary factual-accuracy review.
Verbatim wording from the response “We have now renewed and improved our processes regarding MNSI investigations. The revised processes ensures that all staff involved in the incident are shared the draft report to facilitate the opportunity to comment for factual accuracy and for these comments to be shared with MNSI.” Source location Response from Mid & South Essex NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the national MEWS observation package and escalation policy, including trigger-team referral and mandatory maternity-inpatient use.
Verbatim wording from the response “The service identified these issues in the initial review of the incident. Since Laura-Jane’s death there has been an implementation of a new MEWS package with escalation policy. This includes the trigger response/medical emergency team once a score of 7 or above is reached.” Source location Response from Mid & South Essex NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue escalation work and audit compliance with expected communication standards.
Verbatim wording from the response “We will continue with this work and monitor compliance with the expected standards by audit.” Source location Response from Mid & South Essex NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the OBS UK obstetric bleeding care bundle covering risk assessment, quantitative blood-loss measurement, escalation, and rapid clotting tests.
Verbatim wording from the response “Since August 2024, the maternity unit at Broomfield hospital has begun the implementation of a new obstetric bleeding strategy. The strategy works alongside current PROMPT recommendations of managing a postpartum haemorrhage already in place at the maternity unit.” Source location Response from Mid & South Essex NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch the RCOG escalation toolkit, including AID language, conflict-resolution teaching and team-of-shift handover practices.
Verbatim wording from the response “As part of the Each Baby Counts initiative, the maternity service is launching the Royal College of Obstetricians and Gynaecologists’ (RCOG) ‘Escalation Toolkit’ in February 2025. This toolkit is designed to enhance escalation and improve patient safety and consists of three key components:” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt a rota requiring junior registrars to pair with senior registrars and establish supervision and risk-mitigation arrangements when the intended skill mix is unavailable.
Verbatim wording from the response “We now have a new rota system in place where the required staffing establishment must include a junior registrar paired with a senior registrar. The junior then has a point of escalation to ensure that any MEWS score of four or above is escalated to the senior registrar and onto the Consultant.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Metaraminol administration is appropriate for hypotension and does not necessarily indicate severe illness; repeated use should trigger senior anaesthetic or intensive-care review.
Verbatim wording from the response “The administration of Metaraminol is an appropriate treatment given to someone who is hypotensive. It is not necessarily a marker of how unwell a patient is - a patient may transiently become hypotensive for example following a regional anaesthetic technique (epidural for example) or rapid infusion of IV paracetamol. Its repeated use (because of transient response to the medication) would indicate a problem that needs further investigation and definitive treatment. Therefore, Metaraminol's repeated use should trigger a review by a senior anaesthetic and/or intensive care doctor.” Source location Response from Mid & South Essex NHS Trust
Open published response
12 Dec 2024 THOMAS ADRIAN BURROUGHS · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2 Failure to promptly remove an unused Hickman catheter View source Failure to report a split Hickman catheter through the required incident-reporting process View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
THOMAS ADRIAN BURROUGHS · 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
Thomas Burroughs was a 35-year-old learning disabled man with cerebral palsy, scoliosis, pressure ulcers and PEG feeding who died in hospital on 22 February 2024 after recurrent aspiration pneumonia and prolonged admissions. Concerns included a split Hickman Catheter that was not reported through the required Datix process, remained in situ after advice that it should be removed, and was later surgically removed on 30 January 2024; he also developed tachycardia and a raised temperature while it remained in place.
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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly remove an unused Hickman catheter
Wider context from the report “(3) Mr Burroughs had a jejunal extension to his PEG on 15 January 2024. Advice was received that the Hickman Catheter should be removed as soon as possible if it was not being used .
(4) Mr Burroughs was tachycardic and spiked a temperature on 19 January 2024 with no apparent symptoms of recurrent aspiration and the Hickman Line remained in situ .
(5) The Hickman Catheter was surgically removed on 30 January 2024 .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to report a split Hickman catheter through the required incident-reporting process
Wider context from the report “(2) The incident was escalated for urgent medical review due to the significant risk of infection, however no Datix was raised for the split Hickman Catheter as required by the acute Trust protocol .
” 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 Report the delay in Hickman line removal retrospectively to identify issues and necessary preventive action.
Verbatim wording from the response “We recognise that Mr Burroughs case identified non-adherence/awareness of the CVAD policy by clinicians across specialties, and specifically at the resident surgeon level. We have retrospectively raised an incident for the delay in removal of the line so that we can identify the issues and take the necessary action to avoid recurrence.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a Patient Safety update highlighting incident-reporting requirements and incident-record management.
Verbatim wording from the response “In addition to this, the Patient Safety team issued an ‘MSE Patient Safety update’ during the week commencing 13th January 2024, highlighting the importance of reporting incidents, and our expectations on how the incident record should be managed.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use senior-leader briefings to disseminate incident-reporting expectations, including reporting equipment failures, near misses and no-harm incidents.
Verbatim wording from the response “Each month we hold in-person Senior Leader’s briefing sessions on all our acute hospital sites. The purpose of these briefings is to share key messages to senior colleagues, and the expectation is for these messages to be cascaded to all teams across all trust sites.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Cascade immediate and reflective learning from the catheter incident to involved, ward, medical and surgical staff.
Verbatim wording from the response “We acknowledge regrettably on this occasion there was a failure by staff to raise an incident when the event occurred on the trust’s Datix incident reporting system (DCIQ) for the split Hickman line. A retrospective incident has since been reported with immediate learning identified and cascaded to all staff. We have also retrospectively reported the incident to the Medicines and Healthcare Products Regulatory Agency (MHRA). In events where implants or prosthesis has failed/malfunctioned or broken, the correct process is for the clinical team raise an incident and report it to the MHRA. Reflective learning has been taken by the individual staff involved, as well as the nursing staff from Edith Cavell Ward, and the wider medical and surgical wards.” Source location Response from Mid & South Essex NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Report the split Hickman catheter incident retrospectively through the Trust’s electronic incident-reporting system.
Verbatim wording from the response “We acknowledge regrettably on this occasion there was a failure by staff to raise an incident when the event occurred on the trust’s Datix incident reporting system (DCIQ) for the split Hickman line. A retrospective incident has since been reported with immediate learning identified and cascaded to all staff. We have also retrospectively reported the incident to the Medicines and Healthcare Products Regulatory Agency (MHRA). In events where implants or prosthesis has failed/malfunctioned or broken, the correct process is for the clinical team raise an incident and report it to the MHRA. Reflective learning has been taken by the individual staff involved, as well as the nursing staff from Edith Cavell Ward, and the wider medical and surgical wards.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce incident-reporting requirements through ward meetings and Elevate training or refresher training for staff.
Verbatim wording from the response “On 23 December 2024 and 29th January 2025 staff meetings were held on Edith Cavell Ward, (the location of the split Hickman line incident), to discuss Mr Burrough’s experience in detail and identify learning opportunities. All staff were reminded of the Trust’s expectations around incident reporting, and the requirement to complete their incident reporting training on the Trusts electronic training platform, ‘Elevate’. Staff who were already compliant were directed to complete refresher training on incident reporting where required.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Present the Hickman line case to the vascular governance team and reinforce timely removal and compliance with the central venous access policy.
Verbatim wording from the response “On 16 January 2025, the Clinical Director for Vascular Services, ████████ presented Mr Burroughs’ case to the vascular governance team meeting and discussed the need to remove indwelling lines as soon as possible, (within the limitations of theatre access and emergency case prioritisation). Attention was drawn to the CVAD policy and the importance of compliance to ensure patient safety.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind inpatient adult wards to access the central venous access policy and remove Hickman lines promptly.
Verbatim wording from the response “Communications have also been sent to all inpatient adult wards reminding staff to access the CVAD policy reiterating the importance of the timely removal of Hickman lines.” Source location Response from Mid & South Essex NHS Trust
Open published response
19 Jun 2024 Aaron James DEELEY · Prevention of Future Deaths report Essex
View report summary
Concerns raised 5 Confusing and incomplete policy for placing patients awaiting Mental Health Act assessment under 1:1 observation View source Lack of a joint protocol for working between the two Trusts on Mental Health Act assessment referrals View source Lack of Responsible Clinician allocation for vulnerable patients held pending Mental Health Act assessment View source Lack of specialist mental health training among acute care healthcare professionals for mental health assessment View source Failure of Mental Health Liaison to attend acute wards and assess presenting self-harm risks during the assessment waiting period View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Aaron James DEELEY · 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
Aaron James Deeley died after deliberately exiting a defective second-floor hospital window on 14 January 2022, sustaining multiple traumatic injuries. The report identified concerns about safeguarding and the removal of 1:1 observation, as well as gaps and confusion in arrangements for patients awaiting a Mental Health Act assessment while receiving physical healthcare.
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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Confusing and incomplete policy for placing patients awaiting Mental Health Act assessment under 1:1 observation
Wider context from the report “While a patient is admitted to an acute Trust ward for treatment for physical health treatment and is being held under section 5 (2) Mental Health Act for a Mental Health Act assessment due to concerns the patient presents a risk to themselves or others with a mental disorder, it permits the patient to be held for a maximum period of 72 hours.
a. Patients admitted into the Accident & Emergency department detained under various sections of the Mental Health Act have a Responsible Clinician allocated. Patients who are not under section have access to the Mental Health Liaison Team.
b. Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental health Act.
c. During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm.
d. The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm.
e. There was confusion at the acute Trust as to what regime was required to ensure that a patient awaiting Mental Health Act assessment could be put under 1:1 observation. The Trust policy was confusing and did not cover patients like Aaron Deeley.
f. There is no joint protocol to cover the working between the two Trusts on this issue as the referral for Mental Health Act assessment goes outside of both organisations.
There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a joint protocol for working between the two Trusts on Mental Health Act assessment referrals
Wider context from the report “While a patient is admitted to an acute Trust ward for treatment for physical health treatment and is being held under section 5 (2) Mental Health Act for a Mental Health Act assessment due to concerns the patient presents a risk to themselves or others with a mental disorder, it permits the patient to be held for a maximum period of 72 hours.
a. Patients admitted into the Accident & Emergency department detained under various sections of the Mental Health Act have a Responsible Clinician allocated. Patients who are not under section have access to the Mental Health Liaison Team.
b. Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental health Act.
c. During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm.
d. The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm.
e. There was confusion at the acute Trust as to what regime was required to ensure that a patient awaiting Mental Health Act assessment could be put under 1:1 observation. The Trust policy was confusing and did not cover patients like Aaron Deeley.
f. There is no joint protocol to cover the working between the two Trusts on this issue as the referral for Mental Health Act assessment goes outside of both organisations.
There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of Responsible Clinician allocation for vulnerable patients held pending Mental Health Act assessment
Wider context from the report “While a patient is admitted to an acute Trust ward for treatment for physical health treatment and is being held under section 5 (2) Mental Health Act for a Mental Health Act assessment due to concerns the patient presents a risk to themselves or others with a mental disorder, it permits the patient to be held for a maximum period of 72 hours.
a. Patients admitted into the Accident & Emergency department detained under various sections of the Mental Health Act have a Responsible Clinician allocated. Patients who are not under section have access to the Mental Health Liaison Team.
b. Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental health Act .
c. During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm.
d. The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm.
e. There was confusion at the acute Trust as to what regime was required to ensure that a patient awaiting Mental Health Act assessment could be put under 1:1 observation. The Trust policy was confusing and did not cover patients like Aaron Deeley.
f. There is no joint protocol to cover the working between the two Trusts on this issue as the referral for Mental Health Act assessment goes outside of both organisations.
There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of specialist mental health training among acute care healthcare professionals for mental health assessment
Wider context from the report “While a patient is admitted to an acute Trust ward for treatment for physical health treatment and is being held under section 5 (2) Mental Health Act for a Mental Health Act assessment due to concerns the patient presents a risk to themselves or others with a mental disorder, it permits the patient to be held for a maximum period of 72 hours.
a. Patients admitted into the Accident & Emergency department detained under various sections of the Mental Health Act have a Responsible Clinician allocated. Patients who are not under section have access to the Mental Health Liaison Team.
b. Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental health Act.
c. During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm.
d. The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm.
e. There was confusion at the acute Trust as to what regime was required to ensure that a patient awaiting Mental Health Act assessment could be put under 1:1 observation. The Trust policy was confusing and did not cover patients like Aaron Deeley.
f. There is no joint protocol to cover the working between the two Trusts on this issue as the referral for Mental Health Act assessment goes outside of both organisations.
There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Mental Health Liaison to attend acute wards and assess presenting self-harm risks during the assessment waiting period
Wider context from the report “While a patient is admitted to an acute Trust ward for treatment for physical health treatment and is being held under section 5 (2) Mental Health Act for a Mental Health Act assessment due to concerns the patient presents a risk to themselves or others with a mental disorder, it permits the patient to be held for a maximum period of 72 hours.
a. Patients admitted into the Accident & Emergency department detained under various sections of the Mental Health Act have a Responsible Clinician allocated. Patients who are not under section have access to the Mental Health Liaison Team.
b. Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental health Act.
c. During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm.
d. The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm.
e. There was confusion at the acute Trust as to what regime was required to ensure that a patient awaiting Mental Health Act assessment could be put under 1:1 observation. The Trust policy was confusing and did not cover patients like Aaron Deeley.
f. There is no joint protocol to cover the working between the two Trusts on this issue as the referral for Mental Health Act assessment goes outside of both organisations.
There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver nursing training on the updated supervision policy and record-keeping standards for supervision documentation.
Verbatim wording from the response “A key management tool for staff caring for acute patients with mental health needs is our ‘MSEPO-21228 Policy for Enhanced Supervision and Engagement’. We have therefore made several improvements to this policy to provide more practical guidance and support for staff during this important time while patients await assessment. We have also delivered training to nursing colleagues in relation to the updated policy and refreshers on record keeping standards so that staff are appropriately skilled in how to complete the supervision paperwork correctly.” Source location Response from Mid and South Essex 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 acute hospital mental health admission policy with practical guidance on accessing and escalating to the Mental Health Liaison Team.
Verbatim wording from the response “We have recently reviewed our policy ‘MSEPO-21231 Admission & Treatment of Patients with a Mental Health Disorder in an Acute Hospital Setting’ which reinforces the mental health support available to patients whilst in ED and inpatient wards.” Source location Response from Mid and South Essex 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 Rewrite enhanced-supervision criteria to clarify when patients awaiting assessment should receive enhanced supervision.
Verbatim wording from the response “Section 5 of our Policy for Enhanced Supervision and Engagement has been re-written in collaboration with the Mental Health Lead Nurse to clearly set out the criteria that should be met for a patient to trigger for enhanced supervision.” Source location Response from Mid and South Essex 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 Develop a joint protocol with EPUT covering assessment sequencing, referral expectations, and staff roles and responsibilities.
Verbatim wording from the response “The joint working group will meet for the first time on 23 September 2024, and senior colleagues will set out terms of reference including the sequencing of assessments for patients with both a mental and physical health need; a written service level agreement so that staff are clear on when to ask for support, and when to expect it; a document setting out clear roles and responsibilities for staff at both trusts.” Source location Response from Mid and South Essex 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 Improve the enhanced supervision policy with practical guidance for safely supporting patients awaiting Mental Health Act assessment.
Verbatim wording from the response “A key management tool for staff caring for acute patients with mental health needs is our ‘MSEPO-21228 Policy for Enhanced Supervision and Engagement’. We have therefore made several improvements to this policy to provide more practical guidance and support for staff during this important time while patients await assessment. We have also delivered training to nursing colleagues in relation to the updated policy and refreshers on record keeping standards so that staff are appropriately skilled in how to complete the supervision paperwork correctly.” Source location Response from Mid and South Essex 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 Deliver ongoing mental health training for MSE staff covering enhanced supervision, engagement, de-escalation, risk assessment and risk management.
Verbatim wording from the response “We have also recently developed a rolling training programme with EPUT so that our staff can learn from the experts, and develop their skills and confidence delivering de-escalation techniques, therapeutic engagement, risk assessment, awareness of warning signs, triggers and environmental hazards and risk management.” Source location Response from Mid and South Essex NHS
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Comprehensive mental-health and associated risk assessments are provided by EPUT; acute-trust staff are expected to identify when assessments are needed.
Verbatim wording from the response “As an acute trust we cannot expect all staff to be able to conduct comprehensive mental health assessments and associated risk assessments, this is a service that EPUT are contracted to provide. However, staff must be trained to identify when mental health assessments are required, and all staff should know when a patient is at risk of harm, to themselves or others.” Source location Response from Mid and South Essex NHS
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mental Health Liaison Team provision is commissioned by the ICB under contract with EPUT, requiring those bodies' involvement in service arrangements.
Verbatim wording from the response “We have listened to this concern, and we feel this is a key topic for us to take forward with EPUT in our future working arrangements. As you will be aware, the MHLT service is commissioned by our local Integrated Care Board (ICB), and there exists a contractual arrangement between the ICB and Essex Partnership University Trust (EPUT).” Source location Response from Mid and South Essex NHS
Open published response
19 Jun 2024 Selina Samarina · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1 Insufficient doctor staffing for Emergency Department and Paediatrics Department View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Selina Samarina · 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
Selina Samarina, aged 2, was brought to hospital with fever, a rash and irritability, and the sepsis protocol was triggered. She was assessed initially by a very junior doctor, with no differential diagnosis addressing possible sepsis or pneumonia, and was discharged before a suitably senior doctor could review her. The principal concerns were the sufficiency of staffing arrangements and the availability of only 60% of the doctors for the relevant 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient doctor staffing for Emergency Department and Paediatrics Department
Wider context from the report “(1) I was told in evidence that the Trust has now consolidated the staffing rotas for the Emergency Department and Paediatrics Department, so that it is now easier to see any deficit as one deficit across two departments. That does not however, address the situation of how and why a situation in which only 60% of the doctors are available for these important services .
(2) I am concerned about the overall sufficiency of the staffing arrangements .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop governance and management processes to identify, escalate and mitigate Emergency Department staffing risks before shifts commence.
Verbatim wording from the response “The Trust has now improved how paediatric shifts are allocated to the Emergency Department to ensure that it is adequately staffed. We have developed the governance and management around staffing the Emergency Department so that we can promptly escalate staffing issues before a shift commences, and appropriately manage and mitigate any potential staffing concerns.” Source location Response from Mid and South Essex 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 Transfer responsibility for allocating paediatric Emergency Department shifts to the Emergency Department team, with care-group approval and paediatric input for specialist cover.
Verbatim wording from the response “The Trust has now improved how paediatric shifts are allocated to the Emergency Department to ensure that it is adequately staffed. We have developed the governance and management around staffing the Emergency Department so that we can promptly escalate staffing issues before a shift commences, and appropriately manage and mitigate any potential staffing concerns.” Source location Response from Mid and South Essex 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 Monitor Emergency Department staffing through the ongoing audit programme and collate audit data to assess staffing coverage.
Verbatim wording from the response “As a comparison, and for assurance of the improvements we have made since this tragic case, I have attached our audit data collated for the Easter period in 2024, names of the staff members have been redacted. The data shows that very few shifts were unfilled during this period, despite this often being a challenging time to cover shifts, and middle grade and Consultant rotas were well filled. Senior doctor cover was as planned especially on the late shifts going into the evening and overnight.” Source location Response from Mid and South Essex 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 Check Emergency Department staffing throughout each day, conduct weekend multidisciplinary planning, and escalate unfilled shifts for mitigation or bank and agency cover.
Verbatim wording from the response “The Emergency Department team are of course better placed to review the staffing arrangements as they possess the knowledge of staff competencies within their teams and can ensure that a safe staffing skill mix is met for each shift. This extends to not only the medical teams, but also the wider staff groups including for example allied professions and Advanced Nurse Practitioners.” Source location Response from Mid and South Essex NHS
Open published response
28 Feb 2024 Chloe Anne Tapp · Prevention of Future Deaths report Essex
View report summary
Concerns raised 15 Failure to implement identified actions addressing unsafe neurology practice View source Delays and unsafe processes in investigation reporting and results access View source Provision of medication tapering instructions based on incorrect doses View source Chronic staffing shortages across neurology doctors, nurses and administrative staff View source Failure to establish medication doses and apply appropriate conversion factors View source Unsafe backlogs for neurology first and follow-up appointments View source Failure to deliver medication tapering information through a valid and timely communication channel View source Failure to make timely referrals to adult neurology services View source Worsening unsafe condition of the neurology department View source Failure to provide visual assessment when clinically required View source Failure to respond to patient communications requiring medication clarification View source Insufficient national neurologist capacity relative to demand View source Failure to answer patient and carer communications in a timely manner View source Failure to record medication tapering regimes in clinical notes View source Unsafe practice in the neurology department View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Chloe Anne Tapp · 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
Chloe Anne Tapp, a 20-year-old with epilepsy and other medical conditions, suffered seizures and respiratory and cardiac arrest on 7 October 2021 and died in hospital on 8 October 2021. The principal concerns included delays transferring her to adult neurology, a telephone consultation despite her being non-verbal, an incorrect and inadequately documented medication tapering regime, and unanswered attempts to obtain clarification. Broader concerns were raised about staffing shortages, unsafe backlogs and difficulties responding to patients and carers within the neurology department.
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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement identified actions addressing unsafe neurology practice
Wider context from the report “Notwithstanding Chloe’s death in 2021, the letter in July 2023 and follow-up in January 2024, many of the more significant actions identified remained as part of an Action Plan . Business cases were being drawn up for a number of areas (but not additional consultants) and these had not yet been approved, nor was it guaranteed that they would be .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays and unsafe processes in investigation reporting and results access
Wider context from the report “The consultant in question gave evidence of a very bleak picture of ongoing practice in the neurology department; a letter from all four consultants in that department had been sent to the Trust in July 2023, where patient care was described as ‘sub-optimal’, and numerous concerns were set out including:
o Chronic staff shortages in respect of doctors, nurses and administrative staff within the neurology department
o Substantial and unsafe backlogs for first and follow up appointments
o Inability to answer, in a timely manner, the volume of phone calls, phone messages and emails from patients/carers raising queries.
o The delays / ways in which investigations are carried out and reported , and the way in which clinical staff can access results .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Provision of medication tapering instructions based on incorrect doses
Wider context from the report “A handwritten note of a tapering regime based on incorrect doses was sent to Chloe.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Chronic staffing shortages across neurology doctors, nurses and administrative staff
Wider context from the report “The consultant in question gave evidence of a very bleak picture of ongoing practice in the neurology department; a letter from all four consultants in that department had been sent to the Trust in July 2023, where patient care was described as ‘sub-optimal’, and numerous concerns were set out including:
o Chronic staff shortages in respect of doctors, nurses and administrative staff within the neurology department
o Substantial and unsafe backlogs for first and follow up appointments
o Inability to answer, in a timely manner, the volume of phone calls, phone messages and emails from patients/carers raising queries.
o The delays / ways in which investigations are carried out and reported, and the way in which clinical staff can access results.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish medication doses and apply appropriate conversion factors
Wider context from the report “An overworked consultant under considerable pressure, did not have time before or during the consultation to establish the dose that Chloe was taking and/or apply the appropriate conversion factor , for medications that can interact negatively at higher doses .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unsafe backlogs for neurology first and follow-up appointments
Wider context from the report “The consultant in question gave evidence of a very bleak picture of ongoing practice in the neurology department; a letter from all four consultants in that department had been sent to the Trust in July 2023, where patient care was described as ‘sub-optimal’, and numerous concerns were set out including:
o Chronic staff shortages in respect of doctors, nurses and administrative staff within the neurology department
o Substantial and unsafe backlogs for first and follow up appointments
o Inability to answer, in a timely manner, the volume of phone calls, phone messages and emails from patients/carers raising queries.
o The delays / ways in which investigations are carried out and reported, and the way in which clinical staff can access results.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to deliver medication tapering information through a valid and timely communication channel
Wider context from the report “The same regime was repeated in a letter to the Epilepsy Nurses, but this letter was not received until October 2021 (in paper form) as the initial email was sent to an address that no longer existed .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make timely referrals to adult neurology services
Wider context from the report “Neurology departments are so overwhelmed and/or understaffed that a vulnerable young girl (particularly so during the Covid-19 pandemic), was not referred in a timely manner to adult neurology services and in fact, it transpired a referral had not been made at all . This appears to have been done for the first time in August 2021.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Worsening unsafe condition of the neurology department
Wider context from the report “The state of the department , compared to when Chloe died was described as ‘worse’ .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide visual assessment when clinically required
Wider context from the report “An initial consultation with a complex non-verbal patient was arranged over the telephone , notwithstanding the concerns about a tremor which would have required visual assessment .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to respond to patient communications requiring medication clarification
Wider context from the report “Phone calls and messages left with the neurology department went unanswered , at a time when clarity over the tapering regime was needed .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient national neurologist capacity relative to demand
Wider context from the report “The independent consultant neurologist in giving evidence expressed that this was not an unfamiliar picture across a number of different Trusts and that there was a recognised shortage of neurologists and increase in demand for that speciality nationally .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to answer patient and carer communications in a timely manner
Wider context from the report “The consultant in question gave evidence of a very bleak picture of ongoing practice in the neurology department; a letter from all four consultants in that department had been sent to the Trust in July 2023, where patient care was described as ‘sub-optimal’, and numerous concerns were set out including:
o Chronic staff shortages in respect of doctors, nurses and administrative staff within the neurology department
o Substantial and unsafe backlogs for first and follow up appointments
o Inability to answer, in a timely manner, the volume of phone calls, phone messages and emails from patients/carers raising queries.
o The delays / ways in which investigations are carried out and reported, and the way in which clinical staff can access results.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record medication tapering regimes in clinical notes
Wider context from the report “No note was made of the tapering regime for the medication change in Chloe’s notes.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unsafe practice in the neurology department
Wider context from the report “A further letter was sent by Chloe’s consultant in January 2024 in lieu of her attending a meeting where progress was to be discussed. That letter highlighted that, not only did the concerns remain live , she believed that the department had now reached levels of ‘unsafe practice’ .
” 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 Audit neurology clinic records for record-keeping compliance and conduct quarterly reviews for divisional governance assurance.
Verbatim wording from the response “To ensure adherence to the expected standards we have completed an audit of neurology clinic records during February and March 2024.The results of this audit showed overall good compliance with dictation, headers, footers, and onward referrals. Small deviations that were picked up were fed back to the team and actioned. Audit reviews will continue quarterly to provide assurance to the divisional governance meeting. These are in addition to the Trust wide record keeping audits.” Source location Response from Mid and South Essex 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 Appoint two nursing posts within the neurology team.
Verbatim wording from the response “We now have two nursing posts within the team, both roles have recently been appointed to. Our overall administrative support has also increased and additional funding for administrative staff has been obtained for our Multiple Sclerosis service that sits under the Neurology umbrella.” Source location Response from Mid and South Essex 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 Operate specialist neurology consultations in person rather than routinely by telephone for clinically vulnerable, complex patients.
Verbatim wording from the response “We agree that a telephone appointment was not appropriate to fully assess Chloe’s clinical presentation on this occasion. However, at that time we were operating clinics differently to manage the significant risks presented by the COVID-19 pandemic.” Source location Response from Mid and South Essex 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 Increase neurology administrative support and obtain additional funding for administrative staff in the Multiple Sclerosis service.
Verbatim wording from the response “We now have two nursing posts within the team, both roles have recently been appointed to. Our overall administrative support has also increased and additional funding for administrative staff has been obtained for our Multiple Sclerosis service that sits under the Neurology umbrella.” Source location Response from Mid and South Essex 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 Communicate and reinforce the requirement that medication tapering regimes are recorded in notes and scanned into electronic patient records.
Verbatim wording from the response “It is our usual practice to record tapering regimes in patient notes, and this is the expected standard as set out in our clinical record keeping standards policy. The regime was recorded in the letter to Chloe’s GP dated 8 September 2021, however the related table drawn up by the Consultant should have been included in Chloe’s notes.” Source location Response from Mid and South Essex 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 Establish neurology medical staffing with four consultants and three specialty doctors, with annual staffing-needs review.
Verbatim wording from the response “In addition to this, we have invested in staffing within the neurology service. Our medical staffing is now fully established which includes four consultants and three specialty doctors. Our medical staffing is reviewed annually to check the needs of the service are properly met.” Source location Response from Mid and South Essex 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 Continue implementing and monitoring actions from the Serious Incident investigation and neurology improvement action plan.
Verbatim wording from the response “The matters raised in the Consultant’s letter in July 2023 were of great concern. I am aware my colleague Dr David Walker, Chief Medical Officer, wrote to you at the time to confirm the work we were taking to ensure the service was safe, a copy of his letter is attached. Our Serious Incident investigation went on to investigate these concerns, and those findings have informed the detailed action plan attached.” Source location Response from Mid and South Essex NHS
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consultants already had 24/7 pharmacy support and online resources for dosage-conversion queries, although the available support was not accessed.
Verbatim wording from the response “Our consultants are also supported by the pharmacy team who are available 24/7 to assist with dosage conversion queries and ad hoc queries. They also have access to online support and resources. Unfortunately, the consultant did not access this support.” Source location Response from Mid and South Essex NHS
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The delay in referral was not attributable to the Trust, which disputes responsibility for the alleged failure to refer Chloe to adult neurology.
Verbatim wording from the response “We acknowledge your concern that there was a delay in Chloe’s referral to adult neurology services, however this delay was not attributable to Mid and South Essex Hospital NHS Foundation Trust.
Chloe was known to our paediatric services however, once she reached 16 years of age her epilepsy was managed by the Royal London Hospital in conjunction with her GP; we did not receive any communication from them relating to her transitional care.” Source location Response from Mid and South Essex NHS
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Telephone assessment was selected as safer during the COVID-19 pandemic because Chloe was clinically vulnerable to potentially life-threatening infection.
Verbatim wording from the response “We agree that a telephone appointment was not appropriate to fully assess Chloe’s clinical presentation on this occasion. However, at that time we were operating clinics differently to manage the significant risks presented by the COVID-19 pandemic.” Source location Response from Mid and South Essex NHS
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation After age 16, Chloe’s epilepsy was managed by the Royal London Hospital and her GP, who were responsible for transitional communication.
Verbatim wording from the response “We acknowledge your concern that there was a delay in Chloe’s referral to adult neurology services, however this delay was not attributable to Mid and South Essex Hospital NHS Foundation Trust.
Chloe was known to our paediatric services however, once she reached 16 years of age her epilepsy was managed by the Royal London Hospital in conjunction with her GP; we did not receive any communication from them relating to her transitional care.” Source location Response from Mid and South Essex NHS
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The consultant had time to establish Chloe’s dose because it was documented and clinic capacity was available before the appointment.
Verbatim wording from the response “Chloe’s then current dose was readily available to the Consultant prior to her appointment, it was listed on the second page of the GP letter 10 August 2021. We have reviewed the clinic that took place on 3 September 2021 and can confirm that prior to Chloe’s appointment there was one unfilled clinical slot. This is a slot we plan to keep free for urgent/ unexpected cases; and there was one further patient who did not attend. We therefore consider the consultant had time to establish Chloe’s current dose prior to the consultation.” Source location Response from Mid and South Essex NHS
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust considers its neurology staffing establishment appropriate to meet service needs after staffing increases and annual review arrangements.
Verbatim wording from the response “In addition to this, we have invested in staffing within the neurology service. Our medical staffing is now fully established which includes four consultants and three specialty doctors. Our medical staffing is reviewed annually to check the needs of the service are properly met.” Source location Response from Mid and South Essex NHS
Open published response
8 Dec 2023 WILLIAM BRIAN KIN GRAY · Prevention of Future Deaths report Essex
View report summary
Concerns raised 11 Failure of ambulance investigations to compare attendances and identify learning View source Failure to provide guidance on inflation pressure when securing a paediatric airway adjunct in life-threatening asthma View source Failure to assess, audit and plan for disruption to children’s asthma service access View source Under-resourcing of the asthma and allergy children’s service View source Failure of hospital paediatric doctors to recognise intramuscular adrenaline treatment for life-threatening asthma View source Failure of ambulance investigations to identify omitted emergency treatments and access View source Failure to incorporate investigation learning into training and alerts View source Lack of clear ambulance guidance for recognising and managing life-threatening childhood asthma and failed airway management View source Failure to involve children directly in asthma service consultations View source Limited availability of trained paediatric endotracheal intubation capability View source Non-mandatory asthma training for health professionals caring for children and young people View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
WILLIAM BRIAN KIN GRAY · 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
William had poorly controlled asthma and experienced a life-threatening asthma attack on 29 May 2021, followed by respiratory and cardiac arrest and a brain injury not compatible with life. The report identified multiple concerns, including failures to assess, review, escalate and treat his asthma, ambulance treatment and airway-management issues, gaps in investigation and training, and limitations in asthma and emergency-care 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance investigations to compare attendances and identify learning
Wider context from the report “(3) Learning and sharing lessons learned is a function of investigation. The Trust investigation report did not:
(a) scrutinise the ambulance attendance to William on 27 October 2020 in comparison to the attendance on 29 May 2021 and missed an opportunity to understand :
i. the timeliness of the administration of adrenalin during a life-threatening asthma attack in accordance with the JRCALC guidelines and that there may be additional training needs. Two paramedics attended both on 27 October 2020 and 29 May 2021 but did not consider the administration of intramuscular adrenalin on the second occasion.
ii. Whilst life-threatening asthma in children is an extremely rare call, the same two paramedics attended on 27 October and 29 May and initial treatment given differed during a life-threatening asthma attack
iii. that ambulance crew focused on the airway to exclusion of other treatment options and did not recognise the significant amount of inflation pressures that are required to manage the airway of an asthmatic child in respiratory arrest. Crew were misled in thinking that the airway adjunct equipment was not the correct size as a consequence, and were swapping the adjuncts
iv. that the same paramedic was left managing an airway throughout the arrest despite the arrival of more experienced colleagues that arrived as backup, including an LMO until HEMS took over.
The Trust did not address the issues at 3 (a) i-iv above in their annual training following William’s death and no alerts or learning notes have been circulated.
(b) East of England Ambulance NHS Trust investigation did not identify a number of risks and omissions its investigation of this child death:
i. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required
ii. Intramuscular adrenalin was not administered for life threatening asthma for a child in respiratory arrest in accordance with JRCALC
iii. Intravenous adrenalin was not given or attempted when the patient went into cardiac arrest in accordance with the resuscitation guidelines and Intraosseous access was not attempted for a child in cardiac arrest for at least 10 minutes and only when the patient was in the ambulance.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide guidance on inflation pressure when securing a paediatric airway adjunct in life-threatening asthma
Wider context from the report “(2) Life threatening childhood asthma is a rare occurrence for ambulance paramedics and the Joint Royal Colleges Ambulances Liaison Committee (JRCALC) Guidelines sets out treatment for it, however as paramedics rarely attend:
a. Clarity is required on what should be categorised as a life-threatening asthma. With guidance to enter the algorithm immediately to administer intramuscular adrenalin the purpose being to avoid cardiac arrest. Paramedics are more familiar with administration of intravenous adrenaline during resuscitation once cardiac arrest has occurred
b. does not contain clear guidance or advice on what to do when crew cannot ventilate, cannot oxygenate, or cannot intubate
c. when to abort repeated unsuccessful attempts to secure an airway and progress to hospital
d. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess, audit and plan for disruption to children’s asthma service access
Wider context from the report “(6) The Asthma & Allergy Childrens and Young Persons Service (the Service)
a. At the time of William’s initial referral to the Service in 2018 this consisted of one nurse for approximately 2000 children, and this increased to two nurses in November 2020. The evidence heard is that whilst the number of nurses has increased so has the geographical area that the Service covers, and that there are ongoing plans to increase this further. The Service remains under resourced whilst attempting to expand.
b. The Service continued to operate during the pandemic and did not introduce video calls when they could not make face-to-face attendances . There was no risk assessment of the impact on the Service , and no audit of whether this was sufficient to manage the Service . There is no contingency plan in place should this issue arise again .
c. The Service relied on telephone contact Nurses did not speak to William although he was old enough to be involved in his care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Under-resourcing of the asthma and allergy children’s service
Wider context from the report “(6) The Asthma & Allergy Childrens and Young Persons Service (the Service)
a. At the time of William’s initial referral to the Service in 2018 this consisted of one nurse for approximately 2000 children, and this increased to two nurses in November 2020. The evidence heard is that whilst the number of nurses has increased so has the geographical area that the Service covers, and that there are ongoing plans to increase this further. The Service remains under resourced whilst attempting to expand .
b. The Service continued to operate during the pandemic and did not introduce video calls when they could not make face-to-face attendances. There was no risk assessment of the impact on the Service, and no audit of whether this was sufficient to manage the Service. There is no contingency plan in place should this issue arise again.
c. The Service relied on telephone contact Nurses did not speak to William although he was old enough to be involved in his care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital paediatric doctors to recognise intramuscular adrenaline treatment for life-threatening asthma
Wider context from the report “(1) Experienced hospital paediatric doctors all gave evidence that they were unaware that administration of intramuscular adrenaline by paramedics is part of the Joint Royal Colleges Ambulances Liaison Committee JRCALC protocol for life-threatening asthma . The beneficial effects of the administration adrenalin was not considered , William’s presentation on arrival at hospital was falsely reassuring.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance investigations to identify omitted emergency treatments and access
Wider context from the report “(3) Learning and sharing lessons learned is a function of investigation. The Trust investigation report did not:
(a) scrutinise the ambulance attendance to William on 27 October 2020 in comparison to the attendance on 29 May 2021 and missed an opportunity to understand:
i. the timeliness of the administration of adrenalin during a life-threatening asthma attack in accordance with the JRCALC guidelines and that there may be additional training needs. Two paramedics attended both on 27 October 2020 and 29 May 2021 but did not consider the administration of intramuscular adrenalin on the second occasion.
ii. Whilst life-threatening asthma in children is an extremely rare call, the same two paramedics attended on 27 October and 29 May and initial treatment given differed during a life-threatening asthma attack
iii. that ambulance crew focused on the airway to exclusion of other treatment options and did not recognise the significant amount of inflation pressures that are required to manage the airway of an asthmatic child in respiratory arrest. Crew were misled in thinking that the airway adjunct equipment was not the correct size as a consequence, and were swapping the adjuncts
iv. that the same paramedic was left managing an airway throughout the arrest despite the arrival of more experienced colleagues that arrived as backup, including an LMO until HEMS took over.
The Trust did not address the issues at 3 (a) i-iv above in their annual training following William’s death and no alerts or learning notes have been circulated.
(b) East of England Ambulance NHS Trust investigation did not identify a number of risks and omissions its investigation of this child death:
i. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required
ii. Intramuscular adrenalin was not administered for life threatening asthma for a child in respiratory arrest in accordance with JRCALC
iii. Intravenous adrenalin was not given or attempted when the patient went into cardiac arrest in accordance with the resuscitation guidelines and Intraosseous access was not attempted for a child in cardiac arrest for at least 10 minutes and only when the patient was in the ambulance.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate investigation learning into training and alerts
Wider context from the report “(3) Learning and sharing lessons learned is a function of investigation. The Trust investigation report did not:
(a) scrutinise the ambulance attendance to William on 27 October 2020 in comparison to the attendance on 29 May 2021 and missed an opportunity to understand:
i. the timeliness of the administration of adrenalin during a life-threatening asthma attack in accordance with the JRCALC guidelines and that there may be additional training needs. Two paramedics attended both on 27 October 2020 and 29 May 2021 but did not consider the administration of intramuscular adrenalin on the second occasion.
ii. Whilst life-threatening asthma in children is an extremely rare call, the same two paramedics attended on 27 October and 29 May and initial treatment given differed during a life-threatening asthma attack
iii. that ambulance crew focused on the airway to exclusion of other treatment options and did not recognise the significant amount of inflation pressures that are required to manage the airway of an asthmatic child in respiratory arrest. Crew were misled in thinking that the airway adjunct equipment was not the correct size as a consequence, and were swapping the adjuncts
iv. that the same paramedic was left managing an airway throughout the arrest despite the arrival of more experienced colleagues that arrived as backup, including an LMO until HEMS took over.
The Trust did not address the issues at 3 (a) i-iv above in their annual training following William’s death and no alerts or learning notes have been circulated .
(b) East of England Ambulance NHS Trust investigation did not identify a number of risks and omissions its investigation of this child death:
i. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required
ii. Intramuscular adrenalin was not administered for life threatening asthma for a child in respiratory arrest in accordance with JRCALC
iii. Intravenous adrenalin was not given or attempted when the patient went into cardiac arrest in accordance with the resuscitation guidelines and Intraosseous access was not attempted for a child in cardiac arrest for at least 10 minutes and only when the patient was in the ambulance.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear ambulance guidance for recognising and managing life-threatening childhood asthma and failed airway management
Wider context from the report “(2) Life threatening childhood asthma is a rare occurrence for ambulance paramedics and the Joint Royal Colleges Ambulances Liaison Committee (JRCALC) Guidelines sets out treatment for it, however as paramedics rarely attend:
a. Clarity is required on what should be categorised as a life-threatening asthma. With guidance to enter the algorithm immediately to administer intramuscular adrenalin the purpose being to avoid cardiac arrest. Paramedics are more familiar with administration of intravenous adrenaline during resuscitation once cardiac arrest has occurred
b. does not contain clear guidance or advice on what to do when crew cannot ventilate, cannot oxygenate, or cannot intubate
c. when to abort repeated unsuccessful attempts to secure an airway and progress to hospital
d. inflation pressure being a potential cause of failure to secure a paediatric airway adjunct in life threatening asthma the consequence of this being increased ventilations pressure would be required
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve children directly in asthma service consultations
Wider context from the report “(6) The Asthma & Allergy Childrens and Young Persons Service (the Service)
a. At the time of William’s initial referral to the Service in 2018 this consisted of one nurse for approximately 2000 children, and this increased to two nurses in November 2020. The evidence heard is that whilst the number of nurses has increased so has the geographical area that the Service covers, and that there are ongoing plans to increase this further. The Service remains under resourced whilst attempting to expand.
b. The Service continued to operate during the pandemic and did not introduce video calls when they could not make face-to-face attendances. There was no risk assessment of the impact on the Service, and no audit of whether this was sufficient to manage the Service. There is no contingency plan in place should this issue arise again.
c. The Service relied on telephone contact Nurses did not speak to William although he was old enough to be involved in his care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited availability of trained paediatric endotracheal intubation capability
Wider context from the report “(4) The Trust issued a Clinical Instruction on 17 September 2020 that paramedics must not insert endotracheal tubes as a safety measure to avoid adverse incidents as there was a difficulty in keeping paramedics skills up to a level of competency. Evidence was heard that the Trust has since revised its policy and reintroduced endotracheal intubation for a specialist cohort of paramedic crew:
i. The Trust treatment for those aged 12 and over permits endotracheal intubation by those ambulance crew with specialist qualifications however, they cannot intubate children under 12 who are entirely reliant on HEMS arriving in sufficient time if the airway cannot be sufficiently managed.
ii. Essex is a large county and there are very few paramedics trained on any one shift to provide endotracheal intubation
iii. there is a difference in provision of life-saving treatment in Essex between those over 12 and for children under 12 and HEMS is a charity with very limited resource across a very large county .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Non-mandatory asthma training for health professionals caring for children and young people
Wider context from the report “(5) Training for health professionals who care for children and young people is not mandatory
The National Capabilities Framework for Professionals who care for Children and Young People with Asthma (NHS Health Education England) contains tiers of training and national capabilities but is not mandatory
” 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 Share learning on pre-hospital adrenaline use and its implications with relevant clinical staff through team briefings and email.
Verbatim wording from the response “The Inquest findings in this tragic case have highlighted the need for our training to specifically include the potential impact of pre-hospital resuscitation measures on our patients. Following the Inquest conclusion in November 2023, our clinicians immediately shared the learning with their teams to raise awareness of the JRCALC protocol on managing severe asthma in children, and since then, a plan has been devised for wider learning.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop training materials and a robust plan for training medical and nursing staff on medicines in asthma and pre-hospital adrenaline use.
Verbatim wording from the response “The Inquest findings in this tragic case have highlighted the need for our training to specifically include the potential impact of pre-hospital resuscitation measures on our patients. Following the Inquest conclusion in November 2023, our clinicians immediately shared the learning with their teams to raise awareness of the JRCALC protocol on managing severe asthma in children, and since then, a plan has been devised for wider learning.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the asthma medicines training session, repeat and refresh it at least quarterly, and monitor attendance compliance.
Verbatim wording from the response “████████ Consultant Paediatrician, who you will be aware was a witness at the Inquest hearing for Master Gray, has been collaborating with colleagues to produce training materials and a robust plan to train medical and nursing staff. Attached to this letter is a copy of the slides that will be used to deliver the first training session to staff on 30 January 2024, ‘Understanding medicines in asthma’. Slide ten will focus specifically on the role of Adrenaline in treating acute asthma, both in-hospital and pre-hospital settings.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
18 Jul 2023 Ronald Scott Ashdown · Prevention of Future Deaths report Essex
View report summary
Concerns raised 4 Failure to provide critical primary evidence for root cause analysis View source Risk of infection and future death from failure to provide basic nursing care View source Safeguarding investigations undermined by misleading root cause analysis View source Failure to provide basic personal hygiene care to physically dependent patients View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ronald Scott Ashdown · 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
Ronald Scott Ashdown died from aspiration pneumonia on 15 August 2021, following severe disability caused by a hypoxic brain injury after a cardiac arrest in 2013. Concerns included failures in basic personal hygiene while he was dependent on hospital staff, and a flawed investigation that failed to consider photographic evidence and contributed to subsequent safeguarding investigations being undermined.
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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide critical primary evidence for root cause analysis
Wider context from the report “(a) The extent of the Trust’s inexplicable failure to provide critical primary evidence for the purposes of the RCA led directly to an erroneously exculpatory RCA Report; without an accurate and reliable RCA the lessons upon which important changes to Trust systems and practice depend cannot be identified and acted upon in a timely fashion ;
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Risk of infection and future death from failure to provide basic nursing care
Wider context from the report “(c) Although the failure to provide such basic nursing care, in the specific context of RA’s identified cause of death (and notwithstanding his vulnerability to infection), had no causal relevance to his death, I am nonetheless entirely satisfied that in myriad other cases the identified failure of this kind gives rise to the obvious risk of infection and consequently the risk of future 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Safeguarding investigations undermined by misleading root cause analysis
Wider context from the report “(d) Finally, the evidence confirmed that the misleading failures in the Trust’s RCA fed into and undermined the subsequent Thurrock Local Authority Safeguarding Adult Review Investigation and a wider systemic section 42 Safeguarding investigation , both of which will now require review with the concomitant delay involved .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide basic personal hygiene care to physically dependent patients
Wider context from the report “(b) The evidence confirmed that, despite his clear vulnerability and complete physical dependence on Trust staff providing basic nursing care, including simple personal hygiene, RA did not receive such basic care for an extended period – probably over several days . This does not indicate, as appears to have been suggested at one point by the Trust, a failure in record keeping but, rather, a serious failure in the provision of the most basic of nursing care . Running as it did over several days, the evidence confirmed that this failure to provide basic care likely extended beyond one or two members of staff and, further, was simply not picked up by the more senior nurses on the Ward .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an amended safeguarding policy covering section 42 enquiries, inter-organisational information sharing, Datix evidence uploads, and Executive Assurance Group review of recommendations.
Verbatim wording from the response “In our letter of 21 June 2023, we confirmed we were in the process of re-drafting our safeguarding policy. Attached to this letter is the amended policy which now has clear guidance on the management of section 42 safeguarding enquiries and how information should be shared between organisations. The policy makes clear that all evidence received by the Trust from external sources, including photographs, should be uploaded to Datix, our shared management software. The risk of omitting salient information for our investigations is inherently reduced.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch a ward manager supervisory role with linked performance indicators to strengthen supervision and audit of nursing care.
Verbatim wording from the response “The action plan is underpinned by a focus on matron and ward manager leadership. We are planning to launch a ward manager supervisory role with linked key performance indicators later this month which will allow closer supervision and audit of the nursing care provided This will include monitoring the quality of the nursing care we provide. We are passionate about getting the basics right for our patients and this work feeds into an extensive Trust-wide plan to achieve this.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain systems and processes to monitor compliance with patients’ personal care standards.
Verbatim wording from the response “I am confident we are doing all we can to meet the personal care needs of our patients, and that we have systems and processes in place to monitor compliance with this standard. We will continue to strengthen our governance in relation to safeguarding practices and information sharing with external stakeholders; ensuring that all documentation is considered when completing our internal investigations.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue strengthening safeguarding governance and information sharing with external stakeholders, including consideration of all documentation in internal investigations.
Verbatim wording from the response “I am confident we are doing all we can to meet the personal care needs of our patients, and that we have systems and processes in place to monitor compliance with this standard. We will continue to strengthen our governance in relation to safeguarding practices and information sharing with external stakeholders; ensuring that all documentation is considered when completing our internal investigations.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing systems and processes are considered sufficient to monitor compliance with patients’ personal care needs.
Verbatim wording from the response “I am confident we are doing all we can to meet the personal care needs of our patients, and that we have systems and processes in place to monitor compliance with this standard. We will continue to strengthen our governance in relation to safeguarding practices and information sharing with external stakeholders; ensuring that all documentation is considered when completing our internal investigations.” Source location Response from Mid and South Essex NHS Foundation Trust
Open published response
19 Sep 2020 Frederick Joseph Terry · Prevention of Future Deaths report Essex
View report summary
Concerns raised 11 Unavailability or unsuitability of resuscitation equipment on the maternity ward View source Lack of risk assessment for delivery options available to mothers View source Deficiencies in engagement and induction of locum staff View source Failure to manage staff levels on the maternity ward View source Deficiencies in training and procedures for communication with the family View source Deficiencies in training and procedures for communication between clinical personnel in the delivery theatre View source Excessive force in the application and traction of forceps View source Unavailability of a bleep in the neonatal unit View source Inaccuracy of record keeping View source Failure to recognise an occipito-posterior position before forceps delivery View source Deficiencies in resuscitation procedures on the maternity ward View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Frederick Joseph Terry · 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
Baby Frederick Joseph Terry was delivered by caesarean section after a failed forceps attempt on 16 November 2019, and death was confirmed after 40 minutes of resuscitation attempts. The stated cause of death was hypovolaemic shock due to skull fracture, scalp laceration and haemorrhage arising from birth trauma. Concerns included risk assessment and forceps delivery, excessive force and traction, staff training and levels, communication, record keeping, resuscitation equipment and procedures, and neonatal unit support.
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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability or unsuitability of resuscitation equipment on the maternity ward
Wider context from the report “Availability and suitability of resuscitation equipment and procedures on the maternity ward. The Trust’s Neonatal Resuscitation Policy may need to be revisited
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of risk assessment for delivery options available to mothers
Wider context from the report “Lack of risk assessment leading to the options available to mothers as to delivery
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in engagement and induction of locum staff
Wider context from the report “Concerns about the engagement and induction of locum staff and management of staff levels on the maternity ward
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to manage staff levels on the maternity ward
Wider context from the report “Concerns about the engagement and induction of locum staff and management of staff levels on the maternity ward
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in training and procedures for communication with the family
Wider context from the report “Training and procedures in respect of how communications with the family should be carried out . This should cover the duty of candour .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in training and procedures for communication between clinical personnel in the delivery theatre
Wider context from the report “Training and procedures in respect of how communications should occur between all clinical personnel in the delivery theatre
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Excessive force in the application and traction of forceps
Wider context from the report “The injuries imply an excessive degree of force in the application of the forceps and the traction
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a bleep in the neonatal unit
Wider context from the report “The need for a bleep in the neonatal unit
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccuracy of record keeping
Wider context from the report “Accuracy of record keeping
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise an occipito-posterior position before forceps delivery
Wider context from the report “Forceps delivery was attempted without recognising an occipito-posterior position . More training in this respect is required and the use of cans developed.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in resuscitation procedures on the maternity ward
Wider context from the report “Availability and suitability of resuscitation equipment and procedures on the maternity ward . The Trust’s Neonatal Resuscitation Policy may need to be revisited
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement ultrasound training to identify fetal position and training on the use and application of obstetric instruments.
Verbatim wording from the response “Training in the use of ultrasound to define the fetal position as part of the risk assessment has been implemented with specific training by ████████, on the use and application of obstetric instruments. Situational awareness and communication forms part of the midwives, doctors and nurses mandatory training programme.” Source location 2020-0173-Response-from-Mid-and-South-Essex-Foundation-Trust-Redacted.pdf
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 Include situational-awareness and communication training in mandatory training for midwives, doctors, and nurses.
Verbatim wording from the response “Training in the use of ultrasound to define the fetal position as part of the risk assessment has been implemented with specific training by ████████, on the use and application of obstetric instruments. Situational awareness and communication forms part of the midwives, doctors and nurses mandatory training programme.” Source location 2020-0173-Response-from-Mid-and-South-Essex-Foundation-Trust-Redacted.pdf
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 Strengthen locum processes through a checklist, paid completion time, and technical-skills self-assessment during recruitment vetting.
Verbatim wording from the response “Processes have been strengthened with a specific Obstetrics and Gynaecology locum checklist in place, with one additional paid hour to complete and a self-assessment tool for obstetric technical skills has been added to the locum recruitment vetting process. The Trust has also employed a further Obstetric Consultant on a 1 year basis (whilst MSE reconfiguration in place). The Senior Nurse in the Neonatal unit now carries a 24 hour bleep and is summoned as required using the ‘Code Blue’ emergency call.” Source location 2020-0173-Response-from-Mid-and-South-Essex-Foundation-Trust-Redacted.pdf
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 Employ an additional obstetric consultant on a one-year basis during the MSE reconfiguration.
Verbatim wording from the response “Processes have been strengthened with a specific Obstetrics and Gynaecology locum checklist in place, with one additional paid hour to complete and a self-assessment tool for obstetric technical skills has been added to the locum recruitment vetting process. The Trust has also employed a further Obstetric Consultant on a 1 year basis (whilst MSE reconfiguration in place). The Senior Nurse in the Neonatal unit now carries a 24 hour bleep and is summoned as required using the ‘Code Blue’ emergency call.” Source location 2020-0173-Response-from-Mid-and-South-Essex-Foundation-Trust-Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the Below Ten Thousand Feet initiative with SBAR to focus theatre teams on immediate safety concerns.
Verbatim wording from the response “To endorse effective communication in theatres the ‘Below Ten Thousand Feet’ initiative has been driven with an aim on focussing on immediate safety concerns, this is used in conjunction with the SBAR communication tool.” Source location 2020-0173-Response-from-Mid-and-South-Essex-Foundation-Trust-Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide the neonatal unit senior nurse with a 24-hour bleep linked to the Code Blue emergency call.
Verbatim wording from the response “Processes have been strengthened with a specific Obstetrics and Gynaecology locum checklist in place, with one additional paid hour to complete and a self-assessment tool for obstetric technical skills has been added to the locum recruitment vetting process. The Trust has also employed a further Obstetric Consultant on a 1 year basis (whilst MSE reconfiguration in place). The Senior Nurse in the Neonatal unit now carries a 24 hour bleep and is summoned as required using the ‘Code Blue’ emergency call.” Source location 2020-0173-Response-from-Mid-and-South-Essex-Foundation-Trust-Redacted.pdf
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 Update assisted-vaginal-birth guidelines with risk assessment, improved documentation, and immediate newborn head-trauma checks.
Verbatim wording from the response “The guidelines have been updated to reflect the Royal College of Obstetricians and Gynaecologists recent guideline on Assisted Vaginal Birth (April, 2020),¹ this includes a risk assessment to assist with decision making for an assisted vaginal birth, an improved documentation proforma following an assisted vaginal birth and reference to ensuring that the baby’s head is checked immediately at birth for signs of trauma when obstetric instruments have been applied.” Source location 2020-0173-Response-from-Mid-and-South-Essex-Foundation-Trust-Redacted.pdf
Open published response
Concerns raised 5 Failure to follow the trust's own policies and guidelines for cancer screening, referrals, diagnosis and treatment View source Failure to follow NICE guidelines for cancer treatment View source Failure to follow NICE guidelines for cancer referrals View source Failure to follow NICE guidelines for cancer screening View source Failure to follow NICE guidelines for cancer diagnosis View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
David John Lindsey · 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 John Lindsey died at home on 25 July 2017; the stated cause of death was small bowel cancer. His family raised concerns that the trust failed to follow NICE guidelines and its own policies concerning cancer screening, referrals, diagnosis and treatment, after investigations over more than a year without a diagnosis or treatment.
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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the trust's own policies and guidelines for cancer screening, referrals, diagnosis and treatment
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The family contend that the trust has failed to follow NICE guidelines in respect of cancer screening, referrals, diagnosis and treatment
(2) They further contend that the trust has failed to follow its own policies and guidelines in this regard .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow NICE guidelines for cancer treatment
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The family contend that the trust has failed to follow NICE guidelines in respect of cancer screening, referrals, diagnosis and treatment
(2) They further contend that the trust has failed to follow its own policies and guidelines in this regard.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow NICE guidelines for cancer referrals
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The family contend that the trust has failed to follow NICE guidelines in respect of cancer screening, referrals , diagnosis and treatment
(2) They further contend that the trust has failed to follow its own policies and guidelines in this regard.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow NICE guidelines for cancer screening
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The family contend that the trust has failed to follow NICE guidelines in respect of cancer screening , referrals, diagnosis and treatment
(2) They further contend that the trust has failed to follow its own policies and guidelines in this regard.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow NICE guidelines for cancer diagnosis
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The family contend that the trust has failed to follow NICE guidelines in respect of cancer screening, referrals, diagnosis and treatment
(2) They further contend that the trust has failed to follow its own policies and guidelines in this regard.
” Open source report
Concerns raised 3 Failure to communicate relevant dementia information to transport and support services View source Lack of commissioned services' access to relevant hospital records View source Failure to arrange carer attendance for patients with dementia 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
Mr Roy Henry Oakley · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Roy Henry Oakley was taken to Orsett Hospital for a routine blood test and, after being told to wait in the coffee shop without a settled collection arrangement, went to the ambulance bays and suffered an accident. He died on 12 June 2015. The report identified concerns that his dementia was not communicated to the transport and phlebotomy services, that no carer had been arranged to attend with him, and that information-sharing limitations may have played some part in his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate relevant dementia information to transport and support services
Wider context from the report “TAS had not been told that Mr Oakley suffered from Dementia and nobody had arranged for a Carer to attend with him. During the course of the inquest it emerged that the Phlebotomy Service who arranged the transport, were unaware that Mr Oakley had Dementia . The Phlebotomy Service is, commissioned out to a private company by Basildon Hospital and they do not have access to Basildon Hospitals Record Keeping System which flagged up Mr Oakley’s Dementia. Other commissioned out services are in a similar position. The failure to communicate and the lack of information sharing may have played some part in the death of Mr Oakley.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of commissioned services' access to relevant hospital records
Wider context from the report “TAS had not been told that Mr Oakley suffered from Dementia and nobody had arranged for a Carer to attend with him. During the course of the inquest it emerged that the Phlebotomy Service who arranged the transport, were unaware that Mr Oakley had Dementia. The Phlebotomy Service is, commissioned out to a private company by Basildon Hospital and they do not have access to Basildon Hospitals Record Keeping System which flagged up Mr Oakley’s Dementia . Other commissioned out services are in a similar position . The failure to communicate and the lack of information sharing may have played some part in the death of Mr Oakley.
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange carer attendance for patients with dementia
Wider context from the report “TAS had not been told that Mr Oakley suffered from Dementia and nobody had arranged for a Carer to attend with him . During the course of the inquest it emerged that the Phlebotomy Service who arranged the transport, were unaware that Mr Oakley had Dementia. The Phlebotomy Service is, commissioned out to a private company by Basildon Hospital and they do not have access to Basildon Hospitals Record Keeping System which flagged up Mr Oakley’s Dementia. Other commissioned out services are in a similar position. The failure to communicate and the lack of information sharing may have played some part in the death of Mr Oakley.
” Open source report
Concerns raised 4 Failure to disseminate Trust Policy and NPSA Guidance to all staff View source Weaknesses in training systems View source Lack of knowledge of how many trained staff are on duty to carry out procedures View source Failure to check whether staff are up to date in training for carrying out procedures View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Charles Leyin · 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
John Charles Leyin was admitted to Basildon Hospital after suffering a stroke and later died after difficulties with feeding arrangements, including a nasogastric tube being placed into his lung. The concerns included failures to disseminate relevant policy and guidance, weaknesses in training systems, inadequate checks of staff training, and uncertainty about the number of trained staff available for such 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to disseminate Trust Policy and NPSA Guidance to all staff
Wider context from the report “(1) There was a failure on the part of the Hospital to ensure the dissemination of Trust Policy and NPSA Guidance to all staff .
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Weaknesses in training systems
Wider context from the report “(2) There were weaknesses in the training systems in place
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of how many trained staff are on duty to carry out procedures
Wider context from the report “(4) At any one time there seemed to be a lack of knowledge as to how many trained staff were on duty to carry out such procedures
” 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 Mid and South Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to check whether staff are up to date in training for carrying out procedures
Wider context from the report “(3) Checks were not made as to whether or not staff were up to date in their training for carrying out procedures such as the insertion of a nasogastric tube .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Standardise dissemination of clinical guidelines so practice changes are identified centrally and cascaded to all clinical divisions.
Verbatim wording from the response “Since 2013 there has been an overhaul of the way in which NPSA Alerts and guidance are disseminated to Trust Staff. The Trust has appointed a Risk and Document Control Manager, who works within the central Clinical Governance Team. As part of their role they have oversight of all NPSA and other alerts, in addition to a role providing oversight of document control, related to Corporate and Clinical policies. It was evident that the process for disseminating clinical guidelines was fragmented. This process has now been standardised to ensure that any change to clinical practice is identified centrally and that this is cascaded to all clinical Divisions. Furthermore, a new system for the management of cascading patient safety alerts is under development, which will evidence action taken by Divisions, so that any non-compliance is addressed quickly and efficiently.” Source location 2014-0563-Response-by-Basildon-Thurrock-University-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Appoint a Risk and Document Control Manager to oversee patient-safety alerts and corporate and clinical policy document control.
Verbatim wording from the response “Since 2013 there has been an overhaul of the way in which NPSA Alerts and guidance are disseminated to Trust Staff. The Trust has appointed a Risk and Document Control Manager, who works within the central Clinical Governance Team. As part of their role they have oversight of all NPSA and other alerts, in addition to a role providing oversight of document control, related to Corporate and Clinical policies. It was evident that the process for disseminating clinical guidelines was fragmented. This process has now been standardised to ensure that any change to clinical practice is identified centrally and that this is cascaded to all clinical Divisions. Furthermore, a new system for the management of cascading patient safety alerts is under development, which will evidence action taken by Divisions, so that any non-compliance is addressed quickly and efficiently.” Source location 2014-0563-Response-by-Basildon-Thurrock-University-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the training system and identify weaknesses in nasogastric-tube competence training.
Verbatim wording from the response “The training system was reviewed as a result of this incident and weaknesses noted. The whole system and way the NG competence training was undertaken was strengthened.” Source location 2014-0563-Response-by-Basildon-Thurrock-University-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen nasogastric-tube competence training through designated trainers and assessors, structured competency stages, verified records and monthly compliance reporting.
Verbatim wording from the response “The training system was reviewed as a result of this incident and weaknesses noted. The whole system and way the NG competence training was undertaken was strengthened.” Source location 2014-0563-Response-by-Basildon-Thurrock-University-Hospitals-NHS-Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a system recording divisional action on patient-safety alerts and enabling prompt escalation of non-compliance.
Verbatim wording from the response “Since 2013 there has been an overhaul of the way in which NPSA Alerts and guidance are disseminated to Trust Staff. The Trust has appointed a Risk and Document Control Manager, who works within the central Clinical Governance Team. As part of their role they have oversight of all NPSA and other alerts, in addition to a role providing oversight of document control, related to Corporate and Clinical policies. It was evident that the process for disseminating clinical guidelines was fragmented. This process has now been standardised to ensure that any change to clinical practice is identified centrally and that this is cascaded to all clinical Divisions. Furthermore, a new system for the management of cascading patient safety alerts is under development, which will evidence action taken by Divisions, so that any non-compliance is addressed quickly and efficiently.” Source location 2014-0563-Response-by-Basildon-Thurrock-University-Hospitals-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust considers its training, compliance reporting and locally held records sufficient to mitigate the risk of a similar incident.
Verbatim wording from the response “I hope that this has provided you with sufficient assurance that we have undertaken a series of actions to mitigate any risk of a similar incident happening again. Further assurance can be provided through training records that are held locally at the Trust.” Source location 2014-0563-Response-by-Basildon-Thurrock-University-Hospitals-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Senior Ward Sisters are responsible for maintaining local staff training records, supported by monthly competence-compliance reports as a fallback.
Verbatim wording from the response “It was clear following the incident that additional checks were required to ensure compliance with training. As the manager responsible for the team the onus is on the Senior Ward Sisters to maintain their records locally. However, the monthly competence compliance report is circulated to the Heads of Nursing and Senior Ward Sisters as a fall back mechanism and enables them to keep track of their staff records as well. Paper copies of the nurses’ Competency Framework are kept in staff records on the ward.” Source location 2014-0563-Response-by-Basildon-Thurrock-University-Hospitals-NHS-Trust
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Addressed to Basildon and Thurrock University Hospitals NHS Foundation Trust, now represented here by Mid and South Essex NHS Foundation Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations