24 Jun 2026 Nola-Reign Morgan · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 6 Delays in transferring patients between antenatal and HDU wards View source Failure to identify causes of transfer delays and take steps to avoid unnecessary delay recurring View source Insufficient training to enable obstetric and midwifery teams to identify the risk of chorioamnionitis and ensure adequate monitoring View source Lack of specific guidance for identifying and treating chorioamnionitis in pre-term mothers View source Lack of national antenatal guidance establishing when and in what circumstances fetal monitoring should be used, especially when chorioamnionitis is suspected View source Failure of local antenatal monitoring guidance to address chorioamnionitis, transfer times and consideration of continuous fetal monitoring View source See 3 more concerns
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No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Nola-Reign Morgan · 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
Nola-Reign Morgan was born prematurely on 5 February 2024 after her mother developed suspected chorioamnionitis, and died three days later despite resuscitation and neonatal care. The report identified delays in transferring her mother to the labour ward and high dependency unit, a period without fetal monitoring, and gaps in national and local guidance and staff training on monitoring and managing suspected chorioamnionitis in pre-term pregnancies.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring patients between antenatal and HDU wards
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the future.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to identify causes of transfer delays and take steps to avoid unnecessary delay recurring
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the future.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Insufficient training to enable obstetric and midwifery teams to identify the risk of chorioamnionitis and ensure adequate monitoring
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the future.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of specific guidance for identifying and treating chorioamnionitis in pre-term mothers
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the future.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of national antenatal guidance establishing when and in what circumstances fetal monitoring should be used, especially when chorioamnionitis is suspected
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the future.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure of local antenatal monitoring guidance to address chorioamnionitis, transfer times and consideration of continuous fetal monitoring
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the future.
” Open source report
30 Apr 2026 Poppy Hope LOMAS · Prevention of Future Deaths report North London
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Concerns raised 4 Use of terminology failing to convey the gravity and unsafe nature of delivery against medical advice View source Unavailability of a pulse oximeter for maternal heart rate in the home delivery kit View source Failure to hold a multidisciplinary risk discussion for an unsafe home birth View source Failure to obtain consent documenting the risks of an unsafe home birth 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
Poppy Hope LOMAS · 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
Poppy Hope LOMAS died in hospital on 26 October 2022, aged 7 days, after being born in poor condition following a home delivery. The report describes multiple unrecognised risk factors during the delivery and identifies concerns about consent and risk communication, multidisciplinary review, terminology used for unsafe deliveries, and the absence of a maternal pulse oximeter from the home delivery kit.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Use of terminology failing to convey the gravity and unsafe nature of delivery against medical advice
Wider context from the report “It is a matter of concern that the nationally used expression “Out of Guidance” is used in these circumstances, which may fail to convey the gravity of the decisions being taken , rather than an expression that captures all elements:- in particular that the delivery is against medical advice, the Royal College of Obstetricians and Gynaecologists guidance and that as a consequence it is an unsafe 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a pulse oximeter for maternal heart rate in the home delivery kit
Wider context from the report “It is a matter of concern that the Home Delivery kit does not include a pulse oximeter for maternal heart rate .
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to hold a multidisciplinary risk discussion for an unsafe home birth
Wider context from the report “It is a matter of concern that where the patient has chosen to have an unsafe birth at home consideration is not given to holding a Multi-Disciplinary Team Meeting with the consultant obstetrician, hospital midwives & community midwives and the patient , to ensure that the patient receives an understanding of the risks to the baby and to themselves..
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain consent documenting the risks of an unsafe home birth
Wider context from the report “It is a matter of concern that where the patient has chosen to have an unsafe birth at home and has decided to refuse to consent to the care the hospital recommend for the management of the unsafe birth, that consideration is not given to the patient signing a consent form that clearly sets out the risks .
” 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 Provide existing NICE guidance covering home-birth eligibility, informed choice, clinical support, risk assessment, transfer, and documentation when advice is not followed.
Verbatim wording from the response “Although these matters of concern appear to be for the NHS Trust to consider, and HM Coroner has not requested any further national guidance be produced in this area, I have provided full details below of the NICE guidance that exists, which I hope is of use.” Source location Response from National Institute for Health and Care Excellence
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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 contents of home delivery kits are outside NICE’s remit and are better addressed by other organisations.
Verbatim wording from the response “The specific contents of home delivery kits issued to midwives for use during home births is not a matter for NICE. Other organisations such as the RCM and specialist societies are better placed to make recommendations in this area.” Source location Response from National Institute for Health and Care Excellence
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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 NICE considers producing a specific document recording refusal of advice legally difficult, while professionals can document discussions and decisions.
Verbatim wording from the response “At NICE we feel that it would be legally difficult to produce a specific document recording when a patient chose not to take the advice given, but as noted above, professionals are advised to document discussions and decisions on preferred care.” Source location Response from National Institute for Health and Care Excellence
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PFD Monitor interpretation Professionals must address alternative care when NICE recommendations are not followed in the specific circumstances.
Verbatim wording from the response “We have considered the information provided in the report, and would comment that it should be standard practice, if a patient decides not to follow advice given, that the healthcare professional should document the discussion, any professional concerns and care planned that is acceptable to the patient. NICE cannot give recommendations on alternative care where our recommendations are not followed; this would need to be addressed by the professional in the specific circumstances.” Source location Response from National Institute for Health and Care Excellence
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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 Amendments to NICE guidance language are not appropriate because the terminology reflects sensitivity around paternalism and patient choice.
Verbatim wording from the response “The National Institute for Health and Care Excellence (NICE) has considered the comments made regarding the term 'birth outside of guidance'. This term has been chosen carefully to reflect the sensitivities around discussions where women have felt in the past that their care has been paternalistic and choice has been removed, and we therefore do not feel that amendments to the language within NICE guidance are appropriate.” Source location Response from National Institute for Health and Care Excellence
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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 NHS Trust should consider support and consent matters because they concern local NHS delivery rather than requested national guidance.
Verbatim wording from the response “Matters 2 and 3” Source location Response from National Institute for Health and Care Excellence
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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 Support under the Royal College of Midwives guideline falls outside NICE’s remit because NICE did not produce that guideline.
Verbatim wording from the response “The support that the NHS trust can provide to the patient in these circumstances is covered in the Royal College of Midwives guideline Care Outside Guidance.” Source location Response from National Institute for Health and Care Excellence
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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 NICE cannot recommend expressions used by NHS staff because wording must remain case relevant and part of professional skill.
Verbatim wording from the response “NICE is unable to make recommendations on expressions used by NHS staff as these should be case relevant and part of a professional skill set.” Source location Response from National Institute for Health and Care Excellence
Open published response
Concerns raised 3 Failure to ensure accurate and complete handover information View source Lack of written national guidance for handovers across healthcare settings View source Lack of written local guidance for undertaking and recording handovers View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
James Fitzpatrick · 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
James Fitzpatrick, an 89-year-old man with decompensated heart failure and respiratory illness, became unresponsive after coughing and was found with food material in his mouth; his death was confirmed on 14 February 2024. The principal concerns were the lack of written national and local guidance for care handovers, and the risk that incomplete or incorrect handover information could affect patient care and contribute to a future death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure accurate and complete handover information
Wider context from the report “(4) Two weeks prior to his death, Jim was moved to another ward within Alderney Hospital. There was a verbal handover undertaken which was recorded in the electronic patient records. No written handover was provided. The patient records referred to him being a “high risk of choking” and “on an unofficial soft diet”. This information was not true and was not recorded anywhere else in his records or risk assessments.
(5) Further evidence was given that at the time of Jim’s death there were a number of agency workers at Alderney Hospital, and they would rely on information provided to them at the start of their shift during the handover as they would not have time to go through each patient’s records to appraise themselves of the patient’s history and risks. A daily written handover sheet was provided at the beginning of each shift which would be updated during the day, however from the daily handover sheet provided to the Court for the day of Jim’s death, pertinent general information about Jim was missing from that handover sheet .
(6) The lack of written local and national guidance on the handover of a patient’s care creates a risk that incorrect or incomplete information can be passed to those caring for an individual which may impact upon the patient’s care and may lead to a 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of written national guidance for handovers across healthcare settings
Wider context from the report “(1) There is a lack of written national guidance on how handovers between Doctors, Nurses and support staff should be undertaken either when a patient is moved between wards or hospitals, or when there is the handover to staff starting a shift who will be taking over the care of the person. Whilst it is acknowledged that each Trust has different policies and procedures in place, there is no generic national guidance to assist in ensuring relevant, pertinent and critical information is passed on to those who will be caring for the patient .
(2) Evidence was provided that national guidance currently exists in England and Wales for handovers relating to emergency care in acute hospitals, however there is no other guidance for other healthcare settings as to what a handover should include or how it should be undertaken .
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of written local guidance for undertaking and recording handovers
Wider context from the report “(3) Within DHUFT there is a lack of written guidance or policy as to how handovers should be undertaken and recorded by those working within the 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 Publish a quality standard requiring structured patient handovers during transitions of care for adults admitted with a medical emergency.
Verbatim wording from the response “NICE has published limited guidance in this area. NICE guideline Emergency and acute medical care in over 16s: service delivery and organisation (NG94) covers organising and delivering emergency and acute medical care for people aged over 16 in the community and in hospital, and recommends the use of structured handovers during transitions of care. The NICE quality standard Emergency and acute medical care in over 16s (QS174) states in quality statement 4 that ‘Adults admitted with a medical emergency have a structured patient handover during transitions of care’. However, these recommendations do not quite apply to the circumstances of this report” Source location 2026-0087 - Response from National Institute for Health and Care Excellence
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a guideline recommending structured patient handovers during transitions of care for adults receiving emergency and acute medical care.
Verbatim wording from the response “NICE has published limited guidance in this area. NICE guideline Emergency and acute medical care in over 16s: service delivery and organisation (NG94) covers organising and delivering emergency and acute medical care for people aged over 16 in the community and in hospital, and recommends the use of structured handovers during transitions of care. The NICE quality standard Emergency and acute medical care in over 16s (QS174) states in quality statement 4 that ‘Adults admitted with a medical emergency have a structured patient handover during transitions of care’. However, these recommendations do not quite apply to the circumstances of this report” Source location 2026-0087 - Response from National Institute for Health and Care Excellence
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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 NMC is responsible for responding to concerns about incorrect information handed over during a previous patient transfer.
Verbatim wording from the response “4. In a previous transfer, incorrect information was handed over about the person concerned
This area of concern is for the NMC to respond to.” Source location 2026-0087 - Response from National Institute for Health and Care Excellence
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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 DHUFT is responsible for addressing the lack of written local handover guidance or policy.
Verbatim wording from the response “3. Within DHUFT there is a lack of written guidance or policy as to how handovers should be undertaken and recorded
This area of concern is for DHUFT to respond to.” Source location 2026-0087 - Response from National Institute for Health and Care Excellence
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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 Detailed handover guidance for every healthcare facility would be impractical for a central organisation and unsuitable for differing local contexts.
Verbatim wording from the response “We believe that detailed specific guidance for every individual healthcare facility on patient handover would be very challenging for a central organisation to produce and would not be well adapted to the local setting and context. Instead, each organisation should produce local, relevant guidance based on the resources outlined above.” Source location 2026-0087 - Response from National Institute for Health and Care Excellence
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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 An additional general recommendation to include all pertinent information in written handover sheets is unlikely to be effective.
Verbatim wording from the response “5. Staff relied on information provided to them at the start of their shift during the handover and a daily written handover sheet, provided at the beginning of each shift and updated during the day
I have addressed this point above in explaining the various guidelines that exist for healthcare practitioners. We do not feel that an additional general recommendation to ‘ensure all pertinent information is included in written handover sheets’ is likely to prove effective.” Source location 2026-0087 - Response from National Institute for Health and Care Excellence
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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 Existing guidance from the NMC, GMC, NHS England and CQC is sufficient, so further NICE guidance on handovers is unlikely to improve safety.
Verbatim wording from the response “We have carefully considered this request, and our conclusion is that further NICE guidance in this area would not add to the guidance already available from other organisations such as the Nursing and Midwifery Council (NMC) the General Medical Council (GMC) and NHS England and overseen by the Care Quality Commission (CQC). I have explained our reasoning for this below” Source location 2026-0087 - Response from National Institute for Health and Care Excellence
Open published response
29 Jan 2026 Antonio Galisi-Swallow · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1 Lack of national guidance for propofol use for short-term sedation in children and young people on PICUs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Antonio Galisi-Swallow · 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
Antonio Galisi-Swallow died in hospital on 7 October 2021 after developing Propofol-Related Infusion Syndrome following continuous propofol sedation after cardiac surgery. The inquest heard that there was no national guidance for short-term propofol sedation in children and young people on PICUs, and an expert witness supported a guideline subsequently developed by Leeds Teaching Hospitals Trust.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for propofol use for short-term sedation in children and young people on PICUs
Wider context from the report “During the inquest, the court was told that there is no national guidance for the use of propofol for short term sedation in children and young people on PICU’s .
” Open source report
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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 Developing national propofol guidance for paediatric intensive care is not within the appropriate organisational role.
Verbatim wording from the response “The patient safety leads at NICE have discussed the report and understand that your request is that we develop national guidance on propofol for short term sedation in children and young people on paediatric intensive care units (PICUs).” Source location Response from National Institute for Health and Care Excellence
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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 NHS England or the Paediatric Critical Care Society should address propofol guidance and consider requiring local PICU protocols.
Verbatim wording from the response “prescribe, review and monitoring details, and limitations on use). As these issues will vary by locality, they are best described in local guidance.” Source location Response from National Institute for Health and Care Excellence
Open published response
27 Jan 2026 Pippa Isobel Waller GILLIBRAND · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 9 Lack of national or local home birth data collection View source Lack of guidance on the threshold for transfer from home birth to hospital View source Lack of guidance on midwife training for competent home birth management View source Lack of guidance on information for expectant parents about home birth risks and team experience View source Lack of guidance on midwife experience requirements for home birth management View source Lack of guidance on backup arrangements for electronic system failure during home births View source Lack of guidance on safe home birth staffing and equipment levels View source Lack of guidance on supervision during home births View source Lack of national guidance on the home birth model of care View source See 6 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. 3
Action
Maintain national intrapartum-care guidance covering home-birth eligibility, informed choice, observations, and thresholds for transfer to obstetric-led care.
Stated completedThe respondent said that this action was complete when they made their response on 29 January 2026. View source
Action
Provide implementation resources for intrapartum-care guidance, including a comparison of birth settings, estimated maternal and neonatal risks, and links to endorsed supporting resources.
Stated completedThe respondent said that this action was complete when they made their response on 29 January 2026. View source
Action
Maintain national safe-midwifery-staffing guidance covering staffing establishments, skill mix, staffing assessment, and monitoring across home and community maternity settings.
Stated completedThe respondent said that this action was complete when they made their response on 29 January 2026. View source Respondent positions A position is what this recipient says about the concern when it does not describe a specific action. 13
Position
NICE disputes that no guidance exists on thresholds for transferring women from home birth to obstetric-led care.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
Midwife training and competency requirements should be addressed by the NMC and NHS England’s relevant workforce and education directorate.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
Position
Responsibility for backup systems when electronic systems fail rests with NHS care commissioning bodies, particularly NHS England.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
Position
National sources already record home birth data, including planned and actual place of birth and relevant serious incidents or deaths.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
Information about the required experience of midwifery teams supporting home births is outside NICE’s role.
Outside remitThe respondent said that this matter was outside its role or authority. View source
Position
Routine home birth data collection is likely commissioned by NHS England and supported by the Healthcare Quality Improvement Partnership.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
Position
The NMC and Royal College of Midwives should consider required experience standards for midwifery teams supporting home births.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
Position
Existing NICE safe midwifery staffing guidance covers home and community settings, including staffing levels, establishment and skill mix.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Existing NICE tools and endorsed resources provide parents with information about home birth risks to support informed choice.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Current NICE guidance appropriately covers home birth risks, eligibility, informed choice, midwife support and transfer considerations.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
The NMC and Royal College of Midwives are better placed to consider professional support and supervision for attending midwives.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
Position
Training and competency requirements for midwives are outside NICE’s remit.
Outside remitThe respondent said that this matter was outside its role or authority. View source
Position
Professional support and supervision for attending midwives are outside NICE’s remit.
Outside remitThe respondent said that this matter was outside its role or authority. View source See 12 more positions
×
AI-generated summary
Pippa Isobel Waller GILLIBRAND · 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
Pippa Isobel Waller Gillibrand was delivered by forceps in poor condition after a home birth was continued despite staffing, equipment and fetal heart-rate monitoring issues, and she later died in hospital from a severe irreversible brain injury. The report identified concerns about the lack of guidance on home-birth staffing, midwife competence, transfer thresholds, equipment, supervision, electronic-recording failures and information for parents, as well as the absence of national or local home-birth outcome data.
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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of national or local home birth data collection
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on the threshold for transfer from home birth to hospital
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on midwife training for competent home birth management
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth , given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on information for expectant parents about home birth risks and team experience
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on midwife experience requirements for home birth management
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on backup arrangements for electronic system failure during home births
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on safe home birth staffing and equipment levels
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on supervision during home births
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on the home birth model of care
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” 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 Maintain national intrapartum-care guidance covering home-birth eligibility, informed choice, observations, and thresholds for transfer to obstetric-led care.
Verbatim wording from the response “Home birth is covered in NICE’s guideline on intrapartum care (NG235). The risks and benefits of home birth compared to birth in an alongside midwifery unit, freestanding midwifery unit and hospital are covered, with information for counselling detailed in tables 6 to 9. The guideline provides comprehensive guidance on intrapartum care, including (but not limited to) home births. The guideline covers:” Source location 2026-0042 - Response from NICE
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 implementation resources for intrapartum-care guidance, including a comparison of birth settings, estimated maternal and neonatal risks, and links to endorsed supporting resources.
Verbatim wording from the response “We provide several tools and resources to assist NHS commissioning bodies to implement our recommendations. For intrapartum care (NG235), these include a tabulated comparison of the different places of birth containing an estimate of the risks to the mother and the baby. There is also a link to endorsed resources produced by NHS England that support the implementation of recommendations in this guideline.” Source location 2026-0042 - Response from NICE
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 national safe-midwifery-staffing guidance covering staffing establishments, skill mix, staffing assessment, and monitoring across home and community maternity settings.
Verbatim wording from the response “NICE’s guideline on safe midwifery staffing for maternity settings (NG4) covers safe midwifery staffing in all maternity settings, including at home and in the community.” Source location 2026-0042 - Response from NICE
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 NICE disputes that no guidance exists on thresholds for transferring women from home birth to obstetric-led care.
Verbatim wording from the response “c. There is no guidance on the threshold for transfer to hospital from a home birth.” Source location 2026-0042 - Response from NICE
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 Midwife training and competency requirements should be addressed by the NMC and NHS England’s relevant workforce and education directorate.
Verbatim wording from the response “Training of midwives and the attainment and assessment of competencies are not within NICE’s remit. I recommend that you address these concerns to the organisations responsible for training and regulation of midwives (such as the Nursing and Midwifery Council (NMC) and NHS England’s Workforce, Training and Education Directorate).” Source location 2026-0042 - Response from NICE
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 Responsibility for backup systems when electronic systems fail rests with NHS care commissioning bodies, particularly NHS England.
Verbatim wording from the response “f. There is no system for back-up should electronic systems fail” Source location 2026-0042 - Response from NICE
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 National sources already record home birth data, including planned and actual place of birth and relevant serious incidents or deaths.
Verbatim wording from the response “2. There is no national or local collection of data around home births.” Source location 2026-0042 - Response from NICE
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 Information about the required experience of midwifery teams supporting home births is outside NICE’s role.
Verbatim wording from the response “It is, however, true that NICE does not provide information on the required experience of the midwifery team for supporting home births, but this is outside our role. This is an issue for the NMC and the RCM to consider.” Source location 2026-0042 - Response from NICE
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 Routine home birth data collection is likely commissioned by NHS England and supported by the Healthcare Quality Improvement Partnership.
Verbatim wording from the response “NICE does not collect routine data around home births. This is likely to be commissioned by NHSE and supported by the Healthcare Quality Improvement Partnership (HQIP). These organisations will be better placed to respond to the concerns raised here.” Source location 2026-0042 - Response from NICE
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 NMC and Royal College of Midwives should consider required experience standards for midwifery teams supporting home births.
Verbatim wording from the response “It is, however, true that NICE does not provide information on the required experience of the midwifery team for supporting home births, but this is outside our role. This is an issue for the NMC and the RCM to consider.” Source location 2026-0042 - Response from NICE
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 NICE safe midwifery staffing guidance covers home and community settings, including staffing levels, establishment and skill mix.
Verbatim wording from the response “d. There is no guidance on safe staffing and equipment levels for home birth” Source location 2026-0042 - Response from NICE
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 NICE tools and endorsed resources provide parents with information about home birth risks to support informed choice.
Verbatim wording from the response “g. There is no information which should be provided to expectant parents around the risks of home birth or the experience of the team to enable them to make an informed choice (about whether to have a home birth).” Source location 2026-0042 - Response from NICE
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 Current NICE guidance appropriately covers home birth risks, eligibility, informed choice, midwife support and transfer considerations.
Verbatim wording from the response “Within the guideline, medical conditions and other factors that may affect the choice of planned place of birth are not given as contraindications to home birth but indicate where care in an obstetric unit would be expected to reduce risk to the mother or the baby. There are also recommendations that support further discussion with an appropriately trained senior or consultant midwife and/or a senior or consultant obstetrician (if there are obstetric issues) if such a discussion is wanted by the midwife or the woman. See recommendations 1.3.9 to 1.3.11 and tables 6 to 9.” Source location 2026-0042 - Response from NICE
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 NMC and Royal College of Midwives are better placed to consider professional support and supervision for attending midwives.
Verbatim wording from the response “We are unclear what this refers to. If this relates to ‘support’ for the attending midwives rather than supervision, we believe this is a concern about professional support and supervision, which is outside of NICE’s remit. As discussed above the NMC and RCM, will be better placed to consider the report and respond” Source location 2026-0042 - Response from NICE
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 Training and competency requirements for midwives are outside NICE’s remit.
Verbatim wording from the response “a. There is no guidance on the training that a midwife should undergo to ensure they are competent to manage a home birth” Source location 2026-0042 - Response from NICE
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 Professional support and supervision for attending midwives are outside NICE’s remit.
Verbatim wording from the response “e. There is no guidance on ‘supervision which should be provided during a home birth’.” Source location 2026-0042 - Response from NICE
Open published response
Concerns raised 2 Lack of defined boundaries and guidance for doula interactions with maternity services View source Lack of regulation of doula care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Matilda Pomfret Thomas · 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
Matilda Pomfret Thomas died aged 15 days from hypoxic ischaemic encephalopathy after a difficult home labour in which fetal distress and meconium were observed, but transfer to hospital did not occur until later. The principal concern was the lack of regulation, registration, training and guidance for doulas, including how their role should interact with midwifery 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of defined boundaries and guidance for doula interactions with maternity services
Wider context from the report “Doulas provide continuity of care and give emotional, informational and practical support throughout pregnancy, labour and after the birth of a baby: those words come from Doula UK’s website. Doula UK is the largest representative body for Doulas, but it is not a regulatory body, it does not represent all doulas, indeed many doulas are not members of Doula UK. Doula UK have put in place membership requirements, training offers and much guidance, but the role of a doula is clearly diffuse in practical terms and capable of multiple understandings not just by doulas but their clients and midwives .
It appears that doulas have been increasingly used and increasingly offer services - as here - on a paid basis.
As MNSI (Maternity & Newborn Safety Investigations - formerly HSIB) put it in their report into this birth, “MNSI acknowledges that there is no regulation of doula care or any guidance on how the two services interact with each other . MNSI considers the dynamics of a situation, where a third party are involved can provide additional challenges for staff, such as making clinical recommendations against personal recommendations or views and providing usual care that could be viewed as interference rather than surveillance.”
MNSI have identified 12 cases in which there was evidence that doulas worked outside of the defined boundaries of their role and in which the care or advice provided by the doula was considered to have potentially had an influence on the poor outcome for the family.
There was evidence given at the inquest by experienced midwifery professionals highlighting that provision of guidance would be helpful for all involved with a birth at which a doula was present .
The issues of doula registration, regulation and training are therefore points of concern I would commend for review.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of regulation of doula care
Wider context from the report “Doulas provide continuity of care and give emotional, informational and practical support throughout pregnancy, labour and after the birth of a baby: those words come from Doula UK’s website. Doula UK is the largest representative body for Doulas, but it is not a regulatory body , it does not represent all doulas, indeed many doulas are not members of Doula UK. Doula UK have put in place membership requirements, training offers and much guidance, but the role of a doula is clearly diffuse in practical terms and capable of multiple understandings not just by doulas but their clients and midwives.
It appears that doulas have been increasingly used and increasingly offer services - as here - on a paid basis.
As MNSI (Maternity & Newborn Safety Investigations - formerly HSIB) put it in their report into this birth, “MNSI acknowledges that there is no regulation of doula care or any guidance on how the two services interact with each other. MNSI considers the dynamics of a situation, where a third party are involved can provide additional challenges for staff, such as making clinical recommendations against personal recommendations or views and providing usual care that could be viewed as interference rather than surveillance.”
MNSI have identified 12 cases in which there was evidence that doulas worked outside of the defined boundaries of their role and in which the care or advice provided by the doula was considered to have potentially had an influence on the poor outcome for the family.
There was evidence given at the inquest by experienced midwifery professionals highlighting that provision of guidance would be helpful for all involved with a birth at which a doula was present.
The issues of doula registration, regulation and training are therefore points of concern I would commend for review.
” Open source report
×
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 Doula registration, regulation and training are outside NICE’s responsibility.
Verbatim wording from the response “The registration, regulation and training of Doulas is not the responsibility of NICE and is better addressed by the Nursing and Midwifery Council (NMC), Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG).” Source location Response from National Institute for Health and Care Excellence
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 Doula registration, regulation and training should be addressed by the NMC, RCM and RCOG.
Verbatim wording from the response “The registration, regulation and training of Doulas is not the responsibility of NICE and is better addressed by the Nursing and Midwifery Council (NMC), Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG).” Source location Response from National Institute for Health and Care Excellence
Open published response
18 Dec 2025 Edward Richard Jones · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 2 Absence of a validated and sufficiently discriminating sepsis screening tool for escalation in Paediatric Emergency Departments View source Failure to consistently deploy the Sepsis Screening Tool across Paediatric Emergency and paediatric in-patient settings View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Edward Richard Jones · 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
Edward Richard Jones died in the Leeds General Infirmary from bacterial sepsis caused by invasive Group A Streptococcus. The inquest identified concerns including failure to respond adequately to a continuously high PAWS score, failure to repeat a venous blood gas showing raised lactate, and delay in administering antibiotics. The hospital trust’s Sepsis Screening Tool was not used, and staffing and bed shortages prolonged shared care in the Paediatric Emergency 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Absence of a validated and sufficiently discriminating sepsis screening tool for escalation in Paediatric Emergency Departments
Wider context from the report “The inquest was told it is acknowledged nationally that there is no Sepsis Screening Tool which is validated for use in Paediatric Emergency Departments or has a sensitivity or specificity which makes it a useful tool for escalation within a Paediatric Emergency Department .
LTHT has developed a Sepsis Screening Tool (SST) which is designed to be used by relatively junior nursing staff to improve the likelihood of considering sepsis and therefore requesting a senior medical review. The SST is intended to be completed at admission or if there is a clinical deterioration, such as an increase in PAWS score to 10 or above.
The tool contains various checkbox items that if present suggest a high risk of sepsis. These include abnormal respiratory rate, mottling, rash or appearing blue, high heart rate, low blood pressure, altered conscious level and parental or health professional concern. High temperature needs to be 38 degrees C or more and then only in patients less than 4 months old so is less discriminatory.
There are secondary checkbox items indicating a moderate risk of sepsis including new leg pain, cold extremities, reduced urine output and temperature at any age greater than 39 degrees C.
A single positive score mandates urgent assessment by a senior decision maker defined as a doctor of ST4 grade or higher, or equivalent allied health professional and if sepsis is confirmed to ensure prompt management, including giving IV antibiotics within 60 minutes.
The SST tool is not designed to diagnose sepsis directly as this is the task of the senior decision maker but rather to prompt a targeted assessment, which will confirm sepsis or specifically eliminate it.
Acknowledging that the trust’s SST had not been deployed in any assessment of Edward that was undertaken in the LGI PED, a trust witness told the inquest that work was ongoing to ensure a consistent application of the SST as between the PED and the paediatric in-patient units at the Leeds Children’s Hospital.
As a coroner making a report of this nature, it is not for me to recommend to any third party that the Sepsis Screening Tool developed by the Leeds Teaching Hospitals Trust, or any document like it, should be either more widely disseminated to, or adopted as official guidance for, Paediatric Emergency Departments across England and Wales.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to consistently deploy the Sepsis Screening Tool across Paediatric Emergency and paediatric in-patient settings
Wider context from the report “The inquest was told it is acknowledged nationally that there is no Sepsis Screening Tool which is validated for use in Paediatric Emergency Departments or has a sensitivity or specificity which makes it a useful tool for escalation within a Paediatric Emergency Department.
LTHT has developed a Sepsis Screening Tool (SST) which is designed to be used by relatively junior nursing staff to improve the likelihood of considering sepsis and therefore requesting a senior medical review. The SST is intended to be completed at admission or if there is a clinical deterioration, such as an increase in PAWS score to 10 or above.
The tool contains various checkbox items that if present suggest a high risk of sepsis. These include abnormal respiratory rate, mottling, rash or appearing blue, high heart rate, low blood pressure, altered conscious level and parental or health professional concern. High temperature needs to be 38 degrees C or more and then only in patients less than 4 months old so is less discriminatory.
There are secondary checkbox items indicating a moderate risk of sepsis including new leg pain, cold extremities, reduced urine output and temperature at any age greater than 39 degrees C.
A single positive score mandates urgent assessment by a senior decision maker defined as a doctor of ST4 grade or higher, or equivalent allied health professional and if sepsis is confirmed to ensure prompt management, including giving IV antibiotics within 60 minutes.
The SST tool is not designed to diagnose sepsis directly as this is the task of the senior decision maker but rather to prompt a targeted assessment, which will confirm sepsis or specifically eliminate it.
Acknowledging that the trust’s SST had not been deployed in any assessment of Edward that was undertaken in the LGI PED , a trust witness told the inquest that work was ongoing to ensure a consistent application of the SST as between the PED and the paediatric in-patient units at the Leeds Children’s Hospital .
As a coroner making a report of this nature, it is not for me to recommend to any third party that the Sepsis Screening Tool developed by the Leeds Teaching Hospitals Trust, or any document like it, should be either more widely disseminated to, or adopted as official guidance for, Paediatric Emergency Departments across England and Wales.
” 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 Update paediatric sepsis guidance in 2026 and consider replacing the traffic-light system with an NPEWS-based approach.
Verbatim wording from the response “We are planning to update our guidance on paediatric sepsis in 2026 and will consider adapting the current ‘traffic light’ system to one that is based on NPEWS.” Source location Response from National Institute for Health and Care Excellence
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 There are several sepsis screening or trigger tools available for use in paediatric emergency departments, contrary to the report’s premise.
Verbatim wording from the response “Contrary to your comment that nationally there is no sepsis screening tool validated for use in a paediatric emergency department, there are several screening tools that clinicians can use. These include our guidance NG254, the Sepsis Trust documents, the AoMRC documents, or local guides, such as the one from Leicester (see attached). These are, however, ‘sepsis trigger scores’ and rely on both an earlier more general severity of illness score (such as NPEWS, PAWS etc.) and a clinician observing the child and thinking ‘could this be sepsis’. Our guidance” Source location Response from National Institute for Health and Care Excellence
Open published response
5 Nov 2025 Jennifer Cahill and Agnes Cahill · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 15 Lack of specialist commissioning of home birth services View source Failure to personalise and individualise pregnancy and birth risk assessment View source Failure to routinely provide women with community midwives’ delivery experience View source Unavailability or significant delay of required interventions during high-risk home births View source Lack of national data collection on home birth transfers, outcomes and out-of-guidance care View source Omission of maternal death risk from intrapartum guidance View source Inconsistent models of home birth care View source Failure to discuss maternal and neonatal death risk with women considering home birth View source Lack of national guidance on home birth care View source Lack of a national framework for safe home birth eligibility and midwifery practice View source Lack of mandated delivery experience requirements for midwives maintaining registration View source Lack of national guidance on staffing, training and experience for home birth midwives View source Use of pregnancy terminology that obscures stage-specific risk View source Lack of bespoke training needs analysis for home birth team midwives View source Lack of national guidance on the ethical responsibility and proportionality of offering home birth under the NHS 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
Jennifer Cahill and Agnes Cahill · 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
Jennifer Cahill died in hospital on 4 June 2024 after post-partum haemorrhage, a fourth-degree perineal tear and cardiac arrest following a home birth. Her daughter, Agnes Cahill, was born on 2 June 2024, required resuscitation after complications during birth, and died in neonatal intensive care on 7 June 2024. The report identified concerns including failures in antenatal planning, fetal monitoring, resuscitation and post-birth care, as well as the absence of national guidance and a robust framework for supporting higher-risk home births.
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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of specialist commissioning of home birth services
Wider context from the report “3. The lack of national guidance means there are differing models of care and unlike other specialities home births are not a specialist commissioned service . There is no national guidance considering the ethical responsibility and proportionality of offering a home birth model under the NHS framework.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to personalise and individualise pregnancy and birth risk assessment
Wider context from the report “6. Terminology around pregnancies describes them as ‘high’ or ‘low risk pregnancy’ and leads women to consider that pregnancy encompasses all stages through to delivery of a child. Practice does not personalise or individualise risk so women can fully understand what the level of risk is for them in actually being pregnant, or what the level of risk is for them in giving birth .
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely provide women with community midwives’ delivery experience
Wider context from the report “7. In order to maintain their skills, there is no set number of deliveries a community midwife must conduct following qualification. There is no mandated number of deliveries that any midwife (irrespective of the settings in which they are working) must complete once they have qualified as a midwife in order to maintain their registration. The level of experience of community midwives in conducting deliveries is not information routinely provided to women to inform their decision whether to have a homebirth.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Unavailability or significant delay of required interventions during high-risk home births
Wider context from the report “2. There is an increase in the number of women with ‘high risk pregnancies’ requesting home births where required interventions cannot take place or would be significantly delayed and there is no robust framework for midwives supporting home birth care. There is no national guidance to support consistent practice across the country including, for example, details of clinical scenarios where women, following robust assessment, have been considered too high risk to safely receive care in a home-setting.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of national data collection on home birth transfers, outcomes and out-of-guidance care
Wider context from the report “9. The lack of national data collection means there is no data to evidence the number of women who are transferred in during labour or after birth, maternal or neonatal outcomes, number of women who are considered out of guidance .
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Omission of maternal death risk from intrapartum guidance
Wider context from the report “5. NICE guidance on intrapartum care (2023 updated June 2025) Section 1.3.3 only refers to the potential risk of death to a baby . There is no mention in the guidance of risk to the mother .
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Inconsistent models of home birth care
Wider context from the report “3. The lack of national guidance means there are differing models of care and unlike other specialities home births are not a specialist commissioned service. There is no national guidance considering the ethical responsibility and proportionality of offering a home birth model under the NHS framework.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss maternal and neonatal death risk with women considering home birth
Wider context from the report “4. Even though there is a very small risk of death, this is not something which is discussed with women particularly in relation to maternal death , even if the woman has a recognised risk such as a post-partum haemorrhage. There is no guidance to ensure the risk of death to both mother and baby is discussed with any woman considering a home birth irrespective of being considered high or low 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on home birth care
Wider context from the report “1. There is no national guidance in respect of home births . Specifically, robust evidenced based guidance on home birth care , similar to that which is in place for intrapartum care in a hospital setting.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of a national framework for safe home birth eligibility and midwifery practice
Wider context from the report “2. There is an increase in the number of women with ‘high risk pregnancies’ requesting home births where required interventions cannot take place or would be significantly delayed and there is no robust framework for midwives supporting home birth care . There is no national guidance to support consistent practice across the country including, for example, details of clinical scenarios where women, following robust assessment, have been considered too high risk to safely receive care in a home-setting .
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of mandated delivery experience requirements for midwives maintaining registration
Wider context from the report “7. In order to maintain their skills, there is no set number of deliveries a community midwife must conduct following qualification . There is no mandated number of deliveries that any midwife (irrespective of the settings in which they are working) must complete once they have qualified as a midwife in order to maintain their registration. The level of experience of community midwives in conducting deliveries is not information routinely provided to women to inform their decision whether to have a homebirth.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on staffing, training and experience for home birth midwives
Wider context from the report “10. The no national guidance on the model of staffing, training and experience for midwives providing home birth 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Use of pregnancy terminology that obscures stage-specific risk
Wider context from the report “6. Terminology around pregnancies describes them as ‘high’ or ‘low risk pregnancy’ and leads women to consider that pregnancy encompasses all stages through to delivery of a child . Practice does not personalise or individualise risk so women can fully understand what the level of risk is for them in actually being pregnant, or what the level of risk is for them in giving birth.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of bespoke training needs analysis for home birth team midwives
Wider context from the report “8. No bespoke training needs analysis has been conducted focusing on midwives practicing in home birth teams .
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on the ethical responsibility and proportionality of offering home birth under the NHS
Wider context from the report “3. The lack of national guidance means there are differing models of care and unlike other specialities home births are not a specialist commissioned service. There is no national guidance considering the ethical responsibility and proportionality of offering a home birth model under the NHS framework .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review guidance to consider defining high- and low-risk pregnancy and distinguishing pregnancy risks from labour and birth risks.
Verbatim wording from the response “There is a discussion about this in the final scope (the final scope defines what the guideline will and will not cover and to whom it will apply) for intrapartum care for women with existing medical conditions or obstetric complications and their babies (NG121). It defines a high risk pregnancy:
“A pregnancy is ‘high risk’ when the likelihood of an adverse outcome for the woman or the baby is greater than that of the ‘normal population’. A labour is ‘high risk’ when adverse outcomes arise in association with labour.”” Source location Response from National Institute for Health and Care Excellence
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 Points 7–9 fall outside NICE’s role and therefore are not addressed by NICE.
Verbatim wording from the response “Points 7-9 do not relate to the role of NICE.” Source location Response from National Institute for Health and Care Excellence
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 Current NICE intrapartum guidance appropriately covers home births, and insufficient evidence justifies changing its recommendations.
Verbatim wording from the response “Intrapartum care (NG235) covers assessment in the first stage of labour in any setting, including the observations of the mother and the unborn baby that should lead to the transfer of the woman to obstetric-led care, noting also that multiple risk factors may increase the urgency of the transfer, particularly if they have a cumulative effect. The guideline notes the more frequent observations of the mother and the unborn baby that should be undertaken in the second stage.” Source location Response from National Institute for Health and Care Excellence
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 Ethical responsibilities for individual healthcare workers are addressed by professional regulators, DHSC and NHS England rather than solely by NICE.
Verbatim wording from the response “The ethics of service delivery for an individual health care worker are covered by the relevant regulator. For example, the Nursing and Midwifery Council (NMC) and the General Medical Council (GMC) along with the Department of Health and Social Care (DHSC) and NHS England (NHSE).” Source location Response from National Institute for Health and Care Excellence
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 RCOG advice, potentially through a practice paper and consent document, would be the appropriate response to the requested national guidance.
Verbatim wording from the response “There is no national guidance to support women or their care providers in this setting. We would suggest that advice from the Royal College of Obstetricians and Gynaecologists (RCOG) would be most appropriate to address this point, perhaps in a practice paper with a consent advice document.” Source location Response from National Institute for Health and Care Excellence
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 Training midwives is outside NICE’s responsibility.
Verbatim wording from the response “Training of midwives is not the responsibility of NICE and is better addressed by the Nursing and Midwifery Council (NMC), Royal College of Midwives (RCM) and educational bodies who provide such training.” Source location Response from National Institute for Health and Care Excellence
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 Further research to quantify mortality risk for individuals at greater risk is needed from appropriate bodies.
Verbatim wording from the response “We are aware that The Birthplace Study found that for multiparous women home births are as safe as hospital births. For first-time mothers, there is a slightly increased risk of adverse outcomes for the baby. Our patient safety leads are not aware if home births, as currently practised in the UK, are any more or less safe for women. This is supported by a meta-analysis published in 2019 Perinatal or neonatal mortality among women who intend at the onset of labour to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: A systematic review and meta-analyses - ScienceDirect.” Source location Response from National Institute for Health and Care Excellence
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 Midwife training is better addressed by the NMC, RCM and educational bodies providing training.
Verbatim wording from the response “Training of midwives is not the responsibility of NICE and is better addressed by the Nursing and Midwifery Council (NMC), Royal College of Midwives (RCM) and educational bodies who provide such training.” Source location Response from National Institute for Health and Care Excellence
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 It is not possible to define every high-risk home-birth scenario because suitability depends on local and individual factors, including transfer capacity.
Verbatim wording from the response “It is not possible for us to list all the potential scenarios that might occur, nor to define what is ‘too high risk’ as this will depend upon many local and individual factors. Local transfer times, staffing, and the ability to escalate care quickly are key determinants of whether planned home birth is appropriate for an individual.” Source location Response from National Institute for Health and Care Excellence
Open published response
3 Sep 2025 Peter Malcolm THOMAS · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 3 Lack of guidance preventing CIWA-based prescribing of unnecessary sedatives at significant dose and frequency View source Failure of NICE alcohol-withdrawal guidelines to explicitly address the relevant clinical situation View source Failure of the CIWA protocol to account for advancing age, different metabolic rate, delirium, confusion and lack of collateral evidence View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter Malcolm THOMAS · 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
Peter Malcolm Thomas, aged 78, was admitted with a serious infection and delirium after collapsing, but was treated under the CIWA protocol after giving an erroneous account of alcohol use. He received 80 mg of diazepam over six hours, did not regain consciousness after antidote treatment, and died from bronchopneumonia associated with osteomyelitis and peripheral vascular disease. The principal concerns were that CIWA may not account adequately for age, delirium, confusion, metabolic differences, or lack of collateral information, and that its use could result in unnecessary high-dose sedation and future deaths.
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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance preventing CIWA-based prescribing of unnecessary sedatives at significant dose and frequency
Wider context from the report “(2) Clinicians without further guidance on its use, will continue to be at risk of implementing the CIWA protocol and prescribing sedatives at significant dose and frequency when it is not required , which presents risks of over-sedation and its consequences, particularly in the elderly and potentially delirious cohort, based upon pattern recognition rather than reliable evidence
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure of NICE alcohol-withdrawal guidelines to explicitly address the relevant clinical situation
Wider context from the report “(3) the NICE guidelines on the management of alcohol withdrawal do not explicitly deal with the situation here , which could well recur and lead to future deaths
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure of the CIWA protocol to account for advancing age, different metabolic rate, delirium, confusion and lack of collateral evidence
Wider context from the report “(1) I am concerned that the CIWA protocol is something of a blunt instrument, not at all nuanced to take account of for example, advancing age and different metabolic rate, delirium and confusion and lack of collateral evidence
” 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 Reconsider the alcohol-withdrawal guidance, including CIWA-Ar and pharmacological treatment, at the February–March 2026 prioritisation board meeting.
Verbatim wording from the response “In the case of the CIWA-Ar scale, this protocol was not produced by NICE, and so we are unable to amend it, but it is appropriate for us to consider whether it is still relevant for NICE to recommend its use as an assessment and monitoring tool in our guidance.” Source location Response from National Institution for Health and Care Excellence
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 the alcohol-withdrawal guidance topic and conclude that an update should be considered.
Verbatim wording from the response “The prioritisation board has previously considered the topic of alcohol withdrawal, and considering the volume of new evidence in this area, and the time since our guidance on this topic area was originally published, the board concluded that an update should be considered.” Source location Response from National Institution for Health and Care Excellence
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 Individual clinicians retain responsibility for treatment decisions and applying guidance appropriately to each patient’s circumstances.
Verbatim wording from the response “As background regarding the status of NICE guidelines, it is important to note that the recommendations in our guidelines represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals and practitioners are expected to take NICE guidelines fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory for the NHS to apply the recommendations, and the guideline does not override the responsibility for clinicians to make decisions appropriate to the circumstances of the individual, in consultation with them (and their families and carers or guardian where appropriate).” Source location Response from National Institution for Health and Care Excellence
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 recommendations adequately convey the need for professional skill in assessing and monitoring acute alcohol withdrawal.
Verbatim wording from the response “Our opinion is that these recommendations adequately convey the need for professional skill in the assessment and monitoring of patients and in the application of our recommendations.” Source location Response from National Institution for Health and Care Excellence
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 NICE cannot amend the CIWA-Ar protocol because it was not produced by NICE.
Verbatim wording from the response “In the case of the CIWA-Ar scale, this protocol was not produced by NICE, and so we are unable to amend it, but it is appropriate for us to consider whether it is still relevant for NICE to recommend its use as an assessment and monitoring tool in our guidance.” Source location Response from National Institution for Health and Care Excellence
Open published response
11 Aug 2025 QUY THI PHAM · Prevention of Future Deaths report Essex
View report summary
Concerns raised 8 Failure to identify concerning intermenstrual bleeding when post-partum menstrual cycles are irregular View source Strict application of national cervical screening guidelines excluding women with atypical post-partum risk presentations View source Failure to account for women who have not received HPV vaccination in cervical cancer screening View source Unavailability of staffing for cervical screening appointments View source Failure to identify early-stage cervical cancer without bleeding symptoms View source Failure to distinguish post-partum bleeding from abnormal bleeding View source Cervical screening guidance failing to identify post-partum women without resumed coitus as potentially at risk View source Failure to provide timely post-partum cervical smear testing View source See 5 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
QUY THI PHAM · 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
Quy Thi Pham died at Basildon Hospital on 3 September 2024 after an extremely rare and rapidly progressing early-stage cervical cancer caused metastatic pulmonary hypertension and irreversible cardiac arrest. She had been advised to wait until 12 weeks post-partum for cervical screening, and a later appointment was cancelled because of staff shortages and not rebooked. Concerns were raised about the application of national cervical screening guidance to post-partum women and whether it may exclude some women from timely diagnosis.
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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to identify concerning intermenstrual bleeding when post-partum menstrual cycles are irregular
Wider context from the report “(4) The Trust hospital Consultant had raised concerns about the National Cervical Screening Guidance in the past and that may mean that a cohort of women may be excluded:
i. The national guidance to identify post-coital bleeding as a symptom of concern for cervical cancer may not be helpful as not all post-partum women have resumed coitus
ii. Post-partum colp can persist or be misinterpreted, meaning that bleeding may not be understood as abnormal
iii. Women may not have a regular menstrual cycle, and bleeding may not be easy to identify as intermenstrual in accordance with the national guidance to give rise to a cause for concern
iv. Rare complications of early-stage cervical cancer may not always manifest with symptoms of bleeding
v. Not all women residing in the UK have had the HPV vaccine
Those providing cervical screening services may be strictly applying the national guidelines and, with the proposed changes in National Screening this may increase the risk for women identified above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Strict application of national cervical screening guidelines excluding women with atypical post-partum risk presentations
Wider context from the report “(4) The Trust hospital Consultant had raised concerns about the National Cervical Screening Guidance in the past and that may mean that a cohort of women may be excluded:
i. The national guidance to identify post-coital bleeding as a symptom of concern for cervical cancer may not be helpful as not all post-partum women have resumed coitus
ii. Post-partum colp can persist or be misinterpreted, meaning that bleeding may not be understood as abnormal
iii. Women may not have a regular menstrual cycle, and bleeding may not be easy to identify as intermenstrual in accordance with the national guidance to give rise to a cause for concern
iv. Rare complications of early-stage cervical cancer may not always manifest with symptoms of bleeding
v. Not all women residing in the UK have had the HPV vaccine
Those providing cervical screening services may be strictly applying the national guidelines and, with the proposed changes in National Screening this may increase the risk for women identified above .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to account for women who have not received HPV vaccination in cervical cancer screening
Wider context from the report “(4) The Trust hospital Consultant had raised concerns about the National Cervical Screening Guidance in the past and that may mean that a cohort of women may be excluded:
i. The national guidance to identify post-coital bleeding as a symptom of concern for cervical cancer may not be helpful as not all post-partum women have resumed coitus
ii. Post-partum colp can persist or be misinterpreted, meaning that bleeding may not be understood as abnormal
iii. Women may not have a regular menstrual cycle, and bleeding may not be easy to identify as intermenstrual in accordance with the national guidance to give rise to a cause for concern
iv. Rare complications of early-stage cervical cancer may not always manifest with symptoms of bleeding
v. Not all women residing in the UK have had the HPV vaccine
Those providing cervical screening services may be strictly applying the national guidelines and, with the proposed changes in National Screening this may increase the risk for women identified above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Unavailability of staffing for cervical screening appointments
Wider context from the report “(2) Ms Pham attended the GP surgery at approximately 9 weeks post-partum and was informed that she must wait until she was at least 12 weeks post-partum to have her smear. This appointment was then cancelled due to staff shortages .
(3) The Trust hospital Consultant explained that the most important factor to diagnose a patient is having a smear test and that it was not prohibited to have a smear test at 9-weeks post-partum, especially if a patient had not had a previous smear test, as in the case of Ms Pham who had an early-stage cervical cancer with no infiltration into surrounding organs or structures.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to identify early-stage cervical cancer without bleeding symptoms
Wider context from the report “(4) The Trust hospital Consultant had raised concerns about the National Cervical Screening Guidance in the past and that may mean that a cohort of women may be excluded:
i. The national guidance to identify post-coital bleeding as a symptom of concern for cervical cancer may not be helpful as not all post-partum women have resumed coitus
ii. Post-partum colp can persist or be misinterpreted, meaning that bleeding may not be understood as abnormal
iii. Women may not have a regular menstrual cycle, and bleeding may not be easy to identify as intermenstrual in accordance with the national guidance to give rise to a cause for concern
iv. Rare complications of early-stage cervical cancer may not always manifest with symptoms of bleeding
v. Not all women residing in the UK have had the HPV vaccine
Those providing cervical screening services may be strictly applying the national guidelines and, with the proposed changes in National Screening this may increase the risk for women identified above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to distinguish post-partum bleeding from abnormal bleeding
Wider context from the report “(4) The Trust hospital Consultant had raised concerns about the National Cervical Screening Guidance in the past and that may mean that a cohort of women may be excluded:
i. The national guidance to identify post-coital bleeding as a symptom of concern for cervical cancer may not be helpful as not all post-partum women have resumed coitus
ii. Post-partum colp can persist or be misinterpreted, meaning that bleeding may not be understood as abnormal
iii. Women may not have a regular menstrual cycle, and bleeding may not be easy to identify as intermenstrual in accordance with the national guidance to give rise to a cause for concern
iv. Rare complications of early-stage cervical cancer may not always manifest with symptoms of bleeding
v. Not all women residing in the UK have had the HPV vaccine
Those providing cervical screening services may be strictly applying the national guidelines and, with the proposed changes in National Screening this may increase the risk for women identified above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Cervical screening guidance failing to identify post-partum women without resumed coitus as potentially at risk
Wider context from the report “(4) The Trust hospital Consultant had raised concerns about the National Cervical Screening Guidance in the past and that may mean that a cohort of women may be excluded:
i. The national guidance to identify post-coital bleeding as a symptom of concern for cervical cancer may not be helpful as not all post-partum women have resumed coitus
ii. Post-partum colp can persist or be misinterpreted, meaning that bleeding may not be understood as abnormal
iii. Women may not have a regular menstrual cycle, and bleeding may not be easy to identify as intermenstrual in accordance with the national guidance to give rise to a cause for concern
iv. Rare complications of early-stage cervical cancer may not always manifest with symptoms of bleeding
v. Not all women residing in the UK have had the HPV vaccine
Those providing cervical screening services may be strictly applying the national guidelines and, with the proposed changes in National Screening this may increase the risk for women identified above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely post-partum cervical smear testing
Wider context from the report “(2) Ms Pham attended the GP surgery at approximately 9 weeks post-partum and was informed that she must wait until she was at least 12 weeks post-partum to have her smear . This appointment was then cancelled due to staff shortages.
(3) The Trust hospital Consultant explained that the most important factor to diagnose a patient is having a smear test and that it was not prohibited to have a smear test at 9-weeks post-partum , especially if a patient had not had a previous smear test, as in the case of Ms Pham who had an early-stage cervical cancer with no infiltration into surrounding organs or structures.
” 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 Notify Agilio Software of the concerns about cervical screening information.
Verbatim wording from the response “We will make Agilio aware of the concerns you raise so that they can check for any updates to the NHS Cervical Screening Programme when they next update this topic.” Source location Response from NICE
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 NHS England’s NHS Cervical Screening Programme is best placed to address the concerns about postpartum cervical screening.
Verbatim wording from the response “Firstly, it may be helpful for me to clarify that the recommendation that cervical screening should be delayed for women who are less than 12 weeks post-partum does not come from guidance produced by NICE, but from Public Health England (PHE) guidelines, ‘Ceasing and deferring women from the NHS Cervical Screening Programme (PHE, 2019)’. We believe that the issues raised within your report are therefore best addressed by NHS England’s NHS Cervical Screening programme, and I note that your report has also been sent to them.” Source location Response from NICE
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 recommendation to delay cervical screening for women under 12 weeks postpartum does not originate from NICE guidance.
Verbatim wording from the response “Firstly, it may be helpful for me to clarify that the recommendation that cervical screening should be delayed for women who are less than 12 weeks post-partum does not come from guidance produced by NICE, but from Public Health England (PHE) guidelines, ‘Ceasing and deferring women from the NHS Cervical Screening Programme (PHE, 2019)’. We believe that the issues raised within your report are therefore best addressed by NHS England’s NHS Cervical Screening programme, and I note that your report has also been sent to them.” Source location Response from NICE
Open published response
8 Jul 2025 Liliwen Iris THOMAS · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 3 Lack of explicit guidance on analgesia levels during induction and labour View source Failure to appropriately control analgesia during induction and labour View source Lack of explicit guidance on supervision of women under analgesia View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Liliwen Iris THOMAS · 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
Liliwen Iris THOMAS was delivered unattended in hospital after her mother, who had received analgesia, was not attended to or physically checked frequently enough for progression to active labour to be recognised. Liliwen was in a very poor condition and died later that day; the inquest identified concerns including the effects of analgesia, insufficient supervision, absence of resuscitation at birth, congenital infection and placental malperfusion. The report also identified that current NICE guidelines did not explicitly address analgesia levels and supervision.
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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of explicit guidance on analgesia levels during induction and labour
Wider context from the report “(1) Liliwen’s mother was given unlimited Entonox, as well as routine doses of pethidine and codeine. The result was that she effectively became comatose for a period of time, during which she delivered Liliwen;
(2) Cardiff & Vale Health Board have taken significant steps to significantly restrict the use of analgesia during induction and labour, including reductions of prescribed doses, allowing only limited access to analgesia on the wards and increased levels of supervision of mothers under analgesia;
(3) They have seen an escalation in the numbers of women being transferred from the induction ward to the delivery suite as a consequence of reduced analgesia, which would otherwise have masked the transition to active labour; and
(4) The current NICE guidelines on Induction of Labour and Intrapartum Care do not deal explicitly with analgesia levels and supervision.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately control analgesia during induction and labour
Wider context from the report “(1) Liliwen’s mother was given unlimited Entonox, as well as routine doses of pethidine and codeine. The result was that she effectively became comatose for a period of time , during which she delivered Liliwen;
(2) Cardiff & Vale Health Board have taken significant steps to significantly restrict the use of analgesia during induction and labour, including reductions of prescribed doses, allowing only limited access to analgesia on the wards and increased levels of supervision of mothers under analgesia;
(3) They have seen an escalation in the numbers of women being transferred from the induction ward to the delivery suite as a consequence of reduced analgesia, which would otherwise have masked the transition to active labour; and
(4) The current NICE guidelines on Induction of Labour and Intrapartum Care do not deal explicitly with analgesia levels and supervision.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of explicit guidance on supervision of women under analgesia
Wider context from the report “(1) Liliwen’s mother was given unlimited Entonox, as well as routine doses of pethidine and codeine. The result was that she effectively became comatose for a period of time, during which she delivered Liliwen;
(2) Cardiff & Vale Health Board have taken significant steps to significantly restrict the use of analgesia during induction and labour, including reductions of prescribed doses, allowing only limited access to analgesia on the wards and increased levels of supervision of mothers under analgesia;
(3) They have seen an escalation in the numbers of women being transferred from the induction ward to the delivery suite as a consequence of reduced analgesia, which would otherwise have masked the transition to active labour; and
(4) The current NICE guidelines on Induction of Labour and Intrapartum Care do not deal explicitly with analgesia levels and supervision.
” 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 Consider updating NG207 recommendations on the frequency of clinical assessments before active labour and during increasing pain relief.
Verbatim wording from the response “I can confirm that we will consider updating the recommendations in our guidelines on inducing labour (NG207) and intrapartum care (NG235) as a result of the issues raised in your report. This will include the following specific considerations:” Source location Response from NICE
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 Consider updating NG235 pain-relief guidance on combination therapies and required further monitoring.
Verbatim wording from the response “I can confirm that we will consider updating the recommendations in our guidelines on inducing labour (NG207) and intrapartum care (NG235) as a result of the issues raised in your report. This will include the following specific considerations:” Source location Response from NICE
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 Policies and practices within Cardiff and Vale University Health Board are outside the areas NICE can comment on.
Verbatim wording from the response “Given that some of the matters of concern relate to policies and practices within Cardiff and Vale University Health Board, these are not areas that we can comment on, but I understand that you have also shared your report with the Health Board.
Once we have concluded our review and decided on any updates needed to our guidance, we will write to you once more with the outcome.
I hope that the information above is helpful and would like to reiterate my sincere condolences to Liliwen’s family.” Source location Response from NICE
Open published response
Concerns raised 2 Lack of clear and consistent guidance on ECGs during annual monitoring of long-term antipsychotic medication View source Failure to include ECGs in annual reviews for people prescribed antipsychotic medication long term View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Aaron ATKINSON · 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 Atkinson was found deceased at his home on 20 April 2023, and the death was unexpected. The inquest conclusion was unascertained, with medical evidence considering seizure and positional asphyxia, or cardiac arrhythmia associated with prescribed medication. The principal concern was that annual reviews for people taking long-term antipsychotic medication may not consistently include ECGs despite recognised risks of QT interval prolongation and lethal cardiac arrhythmias.
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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of clear and consistent guidance on ECGs during annual monitoring of long-term antipsychotic medication
Wider context from the report “Whilst Aaron had annual GP reviews related to prescription of anti-psychotic medication (Risperidone, although the inquest heard that prescription of Ritalin was also a relevant factor, particularly in combination with Risperidone), to check for signs of adverse side effects and physical health complications, those reviews did not include ECGs (electrocardiograms) to check for signs of adverse effects on electrical activity of the heart. On the medical evidence before the inquest antipsychotic medication carries recognised risk of QT interval prolongation and lethal cardiac arrhythmias.
It does not appear that the recognised risk of QT interval prolongation and lethal cardiac arrhythmias from long term prescription of antipsychotic medication is reflected in guidance to medical practitioners and prescribers, nationally or locally in terms of performing ECGs.
The relevant NICE (National Institute for Clinical Excellence) guidance (web link below) refers to ECG testing under How should I monitor someone taking antipsychotics? and recommends Electrocardiography (ECG) - after dose changes. Ideally, also annually.
The local Derbyshire Integrated Care Board guidance (web link below) does not identify need for ECG to be included in annual monitoring in primary care unless if new medicines or changes to physical health have increased the risk of prolonged QTc arrange ECG.
It appears there is lack of clarity and consistency for annual reviews to include ECGs where people are prescribed antipsychotic medication long term. Given the recognised risks explained at inquest then not providing annual ECGs for long term users of those medications appears to pose risk of death.
NICE web link: https://cks.nice.org.uk/topics/bipolar-disorder/prescribing-information/antipsychotics/
Derbyshire web link (DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC)): https://www.derbyshiremedicinesmanagement.nhs.uk/assets/Clinical_Guidelines/Formulary_by_BNF_chapter_prescribing_guidelines/BNF_chapter_4/Antipsychotics_Prescribing_and_Management.pdf
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to include ECGs in annual reviews for people prescribed antipsychotic medication long term
Wider context from the report “Whilst Aaron had annual GP reviews related to prescription of anti-psychotic medication (Risperidone, although the inquest heard that prescription of Ritalin was also a relevant factor, particularly in combination with Risperidone), to check for signs of adverse side effects and physical health complications, those reviews did not include ECGs (electrocardiograms) to check for signs of adverse effects on electrical activity of the heart . On the medical evidence before the inquest antipsychotic medication carries recognised risk of QT interval prolongation and lethal cardiac arrhythmias.
It does not appear that the recognised risk of QT interval prolongation and lethal cardiac arrhythmias from long term prescription of antipsychotic medication is reflected in guidance to medical practitioners and prescribers, nationally or locally in terms of performing ECGs.
The relevant NICE (National Institute for Clinical Excellence) guidance (web link below) refers to ECG testing under How should I monitor someone taking antipsychotics? and recommends Electrocardiography (ECG) - after dose changes. Ideally, also annually.
The local Derbyshire Integrated Care Board guidance (web link below) does not identify need for ECG to be included in annual monitoring in primary care unless if new medicines or changes to physical health have increased the risk of prolonged QTc arrange ECG.
It appears there is lack of clarity and consistency for annual reviews to include ECGs where people are prescribed antipsychotic medication long term . Given the recognised risks explained at inquest then not providing annual ECGs for long term users of those medications appears to pose risk of death .
NICE web link: https://cks.nice.org.uk/topics/bipolar-disorder/prescribing-information/antipsychotics/
Derbyshire web link (DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC)): https://www.derbyshiremedicinesmanagement.nhs.uk/assets/Clinical_Guidelines/Formulary_by_BNF_chapter_prescribing_guidelines/BNF_chapter_4/Antipsychotics_Prescribing_and_Management.pdf
” 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 Share the report with the Clinical Knowledge Summaries publisher to support awareness of the ECG-monitoring concern.
Verbatim wording from the response “As part of this process, we have shared this report with Agilio Software for their awareness. The publishers of the CKS referred to have outlined that the recommendation on ECGs is taken from the Summary of Product Characteristics (SPC) information for each drug, provided below:” Source location 2025-0329 Response from National Institute for Health and Care Excellence
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 Agilio Software, the CKS publisher, is responsible for further changes and detailed information about CKS prescribing content.
Verbatim wording from the response “As part of this process, we have shared this report with Agilio Software for their awareness. The publishers of the CKS referred to have outlined that the recommendation on ECGs is taken from the Summary of Product Characteristics (SPC) information for each drug, provided below:” Source location 2025-0329 Response from National Institute for Health and Care Excellence
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 There is insufficient evidence to justify annual ECGs for everyone prescribed long-term antipsychotics.
Verbatim wording from the response “In summary, we do not believe there is evidence for justification for annual ECGs for everyone prescribed long term antipsychotics. Prescribing information for risperidone does not include a requirement for continued ECG monitoring, however the publishers of the CKS will make some changes to the prescribing information on this topic to ensure it is clear where ECG monitoring is required.” Source location 2025-0329 Response from National Institute for Health and Care Excellence
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 SPC, NICE guidance and BNF provisions do not require continued annual ECG monitoring for risperidone.
Verbatim wording from the response “There is no requirement for continued (e.g. annual) ECG monitoring with risperidone in the SPC, NICE guideline or the British National Formulary (BNF). The local guidelines say the following in annual monitoring: if new medicines or changes to physical health have increased the risk of prolonged QTc arrange ECG.” Source location 2025-0329 Response from National Institute for Health and Care Excellence
Open published response
24 Apr 2025 Jacqueline Anne Potter · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 5 Failure to restrict in-patient access to self-harm websites through secure unit Wi-Fi View source Failure to provide families with codified risk and safety planning information for first overnight leave View source Insufficient availability of specialist menopausal practitioners in primary and Trust-wide care View source Lack of mandatory menopausal training for relevant clinical practitioners View source Failure to recognise the clinical importance of menopausal symptoms and care 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
Jacqueline Anne Potter · 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
Jacqueline Anne Potter, known as Anne, died on 5 December 2022 after taking a car and deliberately driving into the path of an HGV tanker on the A303 during overnight leave from a psychiatric unit. The report raises concerns about families not receiving a codified risk and safety planning document for a patient’s first overnight leave, unrestricted access to self-harm websites through secure unit Wi-Fi, and inadequate recognition and provision of menopausal care and training.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict in-patient access to self-harm websites through secure unit Wi-Fi
Wider context from the report “(2) It transpired during the Inquest that if an in-patient (detained or voluntary) accesses the secure unit Wi-Fi there are no algorithms or ‘search detection features’ to prevent access to websites pertaining to self harm and so these can be readily accessed by a group who are already vulnerable due to their acute mental health presentation with some element of inherent risk of suicide . It was noted, quite rightly, by legal representatives that workplace organisations can block access to certain sites they deem it undesirable for their workforce to access (such as sites relating to gambling, sexually inappropriate content etc) which shows that it is possible to limit access to certain websites and content when using a Wi-Fi provider. By allowing an already vulnerable group to have unfettered access to websites dedicated to self harm creates a risk of further deaths .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to provide families with codified risk and safety planning information for first overnight leave
Wider context from the report “(1) Anne was not sent home for her first overnight leave with any codified ‘Risk’ and ‘Safety Planning’ document. Whilst it was widely accepted in this case that Anne’s husband was well versed and knowledgeable about his wife’s risks and the measures that might be necessary to help keep her safe whilst she was at home, not all families are as involved in their loved one’s psychiatric care, despite the Trust following the Triangle of Care principles.
Whilst families are not mental health practitioners and are not expected to adopt that role within the community there appears to be an opportunity to supply families with a short, codified document dealing with salient points of risks and safety planning when a patient goes for their first overnight leave since being detained . This may equip families with the knowledge to spot signs of declining mental presentation and/or risk and provide them with the knowledge and/or tools to take appropriate steps to assist in safeguarding their loved ones whilst they are in the community.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of specialist menopausal practitioners in primary and Trust-wide care
Wider context from the report “(ii) I was told that the Trust has just one ‘menopause specialist’ (a GP) who covers the entire Trust operations . Not all GP surgeries have a menopause specialist practitioner (or access to one) despite a GP usually being the first port of call for women in the community when seeking primary care. Those GP Surgeries who do have a practitioner who acts as a ‘specialist’ is often a GP with a personal interest who has taken the initiative to go on courses and broaden their learning and understanding, rather than any mandatory requirement for a Surgery [or group with multiple surgeries] to have an available community ‘front-line’ specialist .
I was told that the Trust does not have an “expert” in this field and it would be difficult to have one as menopause isn’t a disease or an illness. Whilst I do not dispute that is it not a disease, menopause is a condition; it does have symptoms and it does have recognised presentations, yet there appears to be a failure to recognise this condition as having equal importance to other ailments or diagnoses.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory menopausal training for relevant clinical practitioners
Wider context from the report “(i) Certain elements of medicine and clinical practice training are compulsory but having heard evidence at the Inquest around mandatory and statutory training modules I learnt that this covers areas such as GDPR training and disposal of sharp objects such as syringes. I was surprised to learn that menopausal training is not mandatory in any area of clinical practice or specialism . I am concerned that there is no requirement to undertake essential compulsory menopausal training for those working in ‘relevant’ clinical practices such as Mental Health Practice, Obstetrics and Gynaecology and Oncology, or even general as a general GP.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the clinical importance of menopausal symptoms and care
Wider context from the report “I was told during a previous PFD Response relating to menopausal knowledge and care within the NHS that “It is important to ensure that women understand common symptoms such as anxiety, stress and depression which they might experience during the menopause and where and when to seek help. The NHS website has resources….” This emphasises my concerns entirely; the lack of importance given to menopausal symptoms . If someone has concerns about heart disease, a worrying lump, a broken bone etc they expect to be able to consult a medically qualified professional who has a knowledge and understanding of their condition or presentation and can diagnose and treat accordingly; not just [and I paraphrase] ‘have a look at a website to help’.
I appreciate that each and every woman will experience perimenopause and menopause differently, their individual experience is unique to them and this, to some degree, creates difficulties as a ‘one size fits all’ approach (which is perhaps achievable in other medical specialisms and disciplines) cannot be offered, but the lack of recognition of the importance of this condition remains a significant concern . I had previously been told (back in a 2024 PFD response) of a roll-out of specialist menopausal care and upskilling of GPs but there was little evidence during the inquest that this has happened/is happening and women continue to approach and navigate the menopause without the support of expert clinicians or practitioners who understand and can treat the symptoms they are experiencing .
” 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 Update menopause and mental health guidance following surveillance of relevant evidence and recommendations.
Verbatim wording from the response “We note your report also mentions a previous prevention of future death report sent to NICE, NHS England and Somerset NHS Foundation Trust in June 2024 on a similar matter. Within our response, sent in August 2024, we stated that following publication of the menopause update in November 2024, we would assess if any further changes relating to mental health and menopause are needed, in response to the HSIB recommendation and taking into account the issues raised in the initial PFD.” Source location Response from NICE
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 NICE considers its updated menopause and mental health guidelines up to date and continues surveillance of relevant studies.
Verbatim wording from the response “We note your report also mentions a previous prevention of future death report sent to NICE, NHS England and Somerset NHS Foundation Trust in June 2024 on a similar matter. Within our response, sent in August 2024, we stated that following publication of the menopause update in November 2024, we would assess if any further changes relating to mental health and menopause are needed, in response to the HSIB recommendation and taking into account the issues raised in the initial PFD.” Source location Response from NICE
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 NHS England and the Royal Colleges are better placed to address the lack of specialist menopausal care and GP upskilling.
Verbatim wording from the response “5. There has not been a roll-out of specialist menopausal care and upskilling of GPs, as was promised in a previous PFD.” Source location Response from NICE
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 Setting undergraduate and trainee doctors’ curricula, including compulsory menopause training, is outside NICE’s responsibility.
Verbatim wording from the response “3. No compulsory training in menopause” Source location Response from NICE
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 Managing Wi-Fi access to harmful websites in NHS facilities is outside NICE’s responsibility, so NICE cannot comment.
Verbatim wording from the response “2. Wi-Fi access to harmful websites whilst in NHS facilities.” Source location Response from NICE
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 NHS England and the Royal Colleges are better placed to address the lack of NHS menopause specialists and services.
Verbatim wording from the response “4. Lack of menopause specialists or menopause services in the NHS” Source location Response from NICE
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 General Medical Council and Health Education England are responsible for considering menopause training curricula.
Verbatim wording from the response “Again, we do not consider that this concern is directly for NICE as we are not responsible for setting the curriculum for undergraduate and trainee doctors in the UK, this is the role of the General Medical Council (GMC). We understand that there is currently work being done to integrate menopause care into both GP and specialist training curricula, with menopause as part of the GP Specialty Training Curriculum (although still not a standalone module) and the RCOG launching a Special Interest Training Module (SITM) in Menopause Care in 2024. However, only a very small number of trainees will access this. It is the view of our consultant clinical advisers that menopause care is not consistently or comprehensively taught across all UK medical schools, and there is no national standard requiring in-depth menopause training for all medical students.” Source location Response from NICE
Open published response
Concerns raised 1 Insufficient guidance on management actions for abnormal antenatal CTG View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alonzo Christopher Andrew Wood · 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
Alonzo Christopher Andrew Wood was born on 23 September 2023 and died on 26 September 2023 from multi-organ failure associated with a significant hepatic congenital haemangioma. A spontaneous bleed occurred between 21 September and his birth, leaving him critically unwell at delivery. The report also identified insufficient guidance on management actions following an abnormal antenatal CTG, including whether and when delivery should occur.
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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Insufficient guidance on management actions for abnormal antenatal CTG
Wider context from the report “During the course of the evidence I was informed that the clinicians consider that there is insufficient guidance as to the management actions that should be taken in the event of an abnormal antenatal CTG . In particular, the clinicians indicated that there was no guidance where there has been an abnormal CTG antenatally as to whether delivery should occur and, if so, in what period . As such, the decision making is reliant on individual clinical judgment .
” 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 Work with others to assess whether a practice guide can be produced for practitioners.
Verbatim wording from the response “We will consider reviewing the evidence on antenatal CTG interpretation and actions to be taken as a result however, there is unlikely to be sufficient evidence of the required quality for NICE to produce a guideline in this area. Our patient safety leads will also work with others to see if they can produce a practice guide to inform practitioners.” Source location Response from NICE
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 Consider reviewing evidence on antenatal CTG interpretation and resulting actions.
Verbatim wording from the response “We will consider reviewing the evidence on antenatal CTG interpretation and actions to be taken as a result however, there is unlikely to be sufficient evidence of the required quality for NICE to produce a guideline in this area. Our patient safety leads will also work with others to see if they can produce a practice guide to inform practitioners.” Source location Response from NICE
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 Insufficient high-quality evidence is likely to prevent NICE producing guidance on antenatal CTG interpretation and resulting actions.
Verbatim wording from the response “We will consider reviewing the evidence on antenatal CTG interpretation and actions to be taken as a result however, there is unlikely to be sufficient evidence of the required quality for NICE to produce a guideline in this area. Our patient safety leads will also work with others to see if they can produce a practice guide to inform practitioners.” Source location Response from NICE
Open published response
Concerns raised 2 Failure of prescribing software to trigger alerts for the interaction between amitriptyline, paroxetine and ivabradine View source Lack of prescriber understanding of the interaction between ivabradine, amitriptyline and paroxetine View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Chloe Elizabeth Burgess · 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 Elizabeth Burgess was found deceased at home on 8 September 2023. The report states that interactions between amitriptyline, paroxetine and ivabradine, together with an episode of sleep apnoea, contributed to severe cardiac arrhythmia and sudden cardiac death. The principal concerns were that the potential dangers of this medication combination were not widely appreciated and did not trigger alerts in prescribing software, and that prescribers of ivabradine should have a full understanding of the potential interaction.
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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure of prescribing software to trigger alerts for the interaction between amitriptyline, paroxetine and ivabradine
Wider context from the report “The inquest heard evidence that the potential dangers of the combination of amitriptyline, paroxetine and ivabradine is not widely appreciated and does not trigger an alert on the prescribing software used in primary care or by pharmacists . The potential dangers related to a failure to metabolise amitriptyline which can, incrementally, lead to toxicity.
I am also concerned that those prescribing ivabradine should have a full understanding of the potential interaction with amitriptyline and paroxetine.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of prescriber understanding of the interaction between ivabradine, amitriptyline and paroxetine
Wider context from the report “The inquest heard evidence that the potential dangers of the combination of amitriptyline, paroxetine and ivabradine is not widely appreciated and does not trigger an alert on the prescribing software used in primary care or by pharmacists. The potential dangers related to a failure to metabolise amitriptyline which can, incrementally, lead to toxicity.
I am also concerned that those prescribing ivabradine should have a full understanding of the potential interaction with amitriptyline and paroxetine .
” Open source report
×
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 BNF publishers, rather than NICE, are best placed to address concerns about drug interactions.
Verbatim wording from the response “We have reflected on the circumstances surrounding Chloe’s death, and the concerns raised in your report regarding drug interactions. The British National Formulary (BNF) provides key information on the selection, prescribing, dispensing and administration of medicines and we believe that they would be best placed to address your concerns.” Source location Response from National Institute for Health and Care Excellence
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 NICE cannot comment on drug-interaction concerns because BNF content responsibility remains with its publishers.
Verbatim wording from the response “The BNF is a joint publication of the BMJ Group and Pharmaceutical Press, the publishing division of the Royal Pharmaceutical Society. While we make the BNF available on the NICE website, responsibility for the content remains with the publishers and therefore NICE cannot comment on the concerns you have raised.” Source location Response from National Institute for Health and Care Excellence
Open published response
Concerns raised 2 Lack of national guidelines and a standard operating procedure for Bone Marrow Aspirate and trephine biopsy methodology View source Lack of a database to record Bone Marrow Aspirate and trephine biopsy procedures and outcomes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Amelia Alexandra Anuszka RIDOUT · 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
Amelia Ridout, a six-year-old girl with suspected aplastic anaemia, died after a bone marrow aspirate and trephine procedure under general anaesthetic caused internal bleeding from an iliac artery injury. Despite prolonged resuscitation and emergency surgery, the bleeding could not be stopped. The concerns identified were the development and publication of national guidelines and a standard operating procedure for these procedures, including recommended methodology, and the development of a database to record procedures and outcomes.
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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidelines and a standard operating procedure for Bone Marrow Aspirate and trephine biopsy methodology
Wider context from the report “To consider the development and publication of a national guidelines and standard operating procedure for the carrying out of Bone Marrow Aspirate (BMA) and trephine biopsy to include recommended methodology .
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of a database to record Bone Marrow Aspirate and trephine biopsy procedures and outcomes
Wider context from the report “To consider the development of a data base to record these procedures and their outcomes .
” 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 Contribute to the BSH good practice paper on bone marrow aspirate and trephine biopsy, including applicable NICE references, and liaise with BSH and NHS England during its development.
Verbatim wording from the response “We note that you have also written to the British Society for Haematology (BSH) and NHS England and as part of our process, our consultant clinical advisors have been in communication with these two organisations and will contribute as needed in the production of a good practice paper for bone marrow aspirate and trephine biopsy, which is being led by the BSH.” Source location Response from NICE
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 British Society for Haematology is leading development of the good practice paper on bone marrow aspirate and trephine biopsy.
Verbatim wording from the response “We note that you have also written to the British Society for Haematology (BSH) and NHS England and as part of our process, our consultant clinical advisors have been in communication with these two organisations and will contribute as needed in the production of a good practice paper for bone marrow aspirate and trephine biopsy, which is being led by the BSH.” Source location Response from NICE
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 Producing detailed guidance on how clinicians should perform standard bone marrow procedures is outside the organisation’s remit.
Verbatim wording from the response “This is a truly tragic outcome from a widely used intervention that is essential in haematological practice. Bleeding due to vascular injuries is recognised as a rare, but possible adverse outcome of the procedure. NICE have not published any specific procedural guidance on bone marrow aspirate and trephine biopsy however, NICE guidance refers to the need to carry out the procedure for diagnosis¹. NICE are not asked to develop guidance on all conditions and our recommendations do not cover all clinical circumstances. Our guidance focuses on the management and treatment of conditions and although we may outline recommendations on when an investigation or diagnostic test is necessary, it is not within our remit to produce detailed guidance on how clinicians should carry out a standard diagnostic procedure.” Source location Response from NICE
Open published response
7 Jan 2025 Thomas Henry Robin Kingston · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 2 Inadequate guidance on persisting with or switching SSRI medication when there is no benefit or adverse side effects View source Inadequate communication of suicide risks associated with SSRI medications View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Thomas Henry Robin Kingston · 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 Henry Robin Kingston, a 45-year-old man, died after sustaining a self-inflicted shotgun wound to the head at his parents’ property on 25 February 2024. The report raises concerns about communication of suicide risks associated with SSRI medication and whether guidance to continue or switch SSRI medication is appropriate when there is no benefit or adverse side effects are experienced.
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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Inadequate guidance on persisting with or switching SSRI medication when there is no benefit or adverse side effects
Wider context from the report “2. Whether the current guidance to persist with SSRI medication or switch to an alternative SSRI medication is appropriate when no benefit has been achieved and/ or especially when any adverse side effects are being experienced .
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication of suicide risks associated with SSRI medications
Wider context from the report “1. Whether there is adequate communication of the risks of suicide associated with the selective serotonin reuptake inhibitor (SSRI) medications ,
” Open source report
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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 Medication side-effect and SSRI safety concerns are best addressed initially by the MHRA, with NICE considering action after collaborative work concludes.
Verbatim wording from the response “Given that the matters of concern relate to the side effects and safety of medication, specifically selective serotonin reuptake inhibitors (SSRIs), we believe that the key issues raised are best addressed in the first instance by the Medicines and Healthcare products Regulatory Agency (MHRA), and I note that your report has also been sent to them.” Source location Response from NICE
Open published response
22 Nov 2024 Nicolette Elizabeth McCARTHY · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 3 Inadequacy of national guidance on smoking and section 17 leave View source Failure of the NHS smoke-free policy to reflect the safety requirements of mental health wards and patients seeking leave to smoke View source Poor supervision of patients smoking during short grounds leave View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nicolette Elizabeth McCARTHY · 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
Nicolette Elizabeth McCarthy was detained in a secure mental health unit after attempts to take her life and remained at risk of suicide. On 19 September 2023, she failed to return from a short period of leave and was not promptly treated as absent without leave; the inquest identified failures in systems and procedures intended to ensure her safety. The report raises concerns that smoke-free policies and unclear guidance may increase the risk of self-harm or suicide for mental health patients on unescorted leave.
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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of national guidance on smoking and section 17 leave
Wider context from the report “1) During the course of the inquest, I heard evidence from clinicians and staff at the Trust to the effect that the NHS England smoke free policy is placing mental health in patients at an increased risk from self-harm and suicide.
2) Although smoking cessation advice and treatment (e.g. gum, vapes etc.) are routinely offered to patients, the evidence was that many struggle to give up smoking on their admission to the ward, in part because the anxiety associated with stopping exacerbates their mental health symptoms. Staff also felt that forcing patients to stop smoking against their will (e.g. by prohibiting them from smoking while on leave) would have a negative effect on their sense of autonomy and wellbeing, which are important for recovery.
3) The Trust understand that they are bound by the Health Act 2006 and by NHS England policy not to permit or facilitate smoking on the ward or anywhere on the grounds of the hospital. This is taken seriously and is interpreted to mean that staff are prohibited from facilitating smoking, for example by granting leave for the purpose of smoking or by escorting patients to smoke outside on short periods of leave. Senior staff also believed that it would be contrary to NHS policy to permit smoking in a secure area, for example the enclosed ward garden. At the same time, it was acknowledged that patients would inevitably seek leave to smoke and that this could not be denied without a negative impact on their mental health.
4) The jury heard evidence that patients, like Mrs McCarthy, were routinely given 15-minute grounds leave for the purpose of smoking, a practice that is discouraged by the Trust. Clinical staff felt that the policy placed them in a difficult position, torn between the need to comply with the smoke free policy, while also supporting patient autonomy and keeping safe those patients who are at a higher risk of self-harm or suicide.
5) There is a further contradiction caused by the smoke free policy, in that patients are not permitted to smoke on the grounds, but are not supposed to leave the grounds during short periods of ‘grounds’ leave. The result is that patients would spend their 15-minute leave smoking by the side of the road on the edge of the ward grounds, which is a poorly supervised area, and staff would avoid asking them too closely where they were going and would avoid standing close to them, even when smoking themselves. This contributed to the circumstances that allowed Mrs McCarthy to slip away unnoticed and ultimately to take her own life.
6) I also heard evidence from senior staff that the national policy guidance intended to address smoking and s17 leave (e.g. the NICE guidance and CQC guidance) does not adequately resolve these contradictions .
7) I am concerned that the NHS smoke free policy, while clearly motivated by a genuine and pressing concern to protect life and promote health, may not be adequately tailored to reflect the safety requirements of mental health wards or the reality that some mental health patients will inevitably seek short periods of leave to smoke. Action may need to be taken at the national policy level to provide clearer guidance and/or review the law to reduce the risk of patients in mental health wards absconding while on unescorted grounds leave.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure of the NHS smoke-free policy to reflect the safety requirements of mental health wards and patients seeking leave to smoke
Wider context from the report “1) During the course of the inquest, I heard evidence from clinicians and staff at the Trust to the effect that the NHS England smoke free policy is placing mental health in patients at an increased risk from self-harm and suicide .
2) Although smoking cessation advice and treatment (e.g. gum, vapes etc.) are routinely offered to patients, the evidence was that many struggle to give up smoking on their admission to the ward, in part because the anxiety associated with stopping exacerbates their mental health symptoms. Staff also felt that forcing patients to stop smoking against their will (e.g. by prohibiting them from smoking while on leave) would have a negative effect on their sense of autonomy and wellbeing, which are important for recovery.
3) The Trust understand that they are bound by the Health Act 2006 and by NHS England policy not to permit or facilitate smoking on the ward or anywhere on the grounds of the hospital. This is taken seriously and is interpreted to mean that staff are prohibited from facilitating smoking, for example by granting leave for the purpose of smoking or by escorting patients to smoke outside on short periods of leave. Senior staff also believed that it would be contrary to NHS policy to permit smoking in a secure area, for example the enclosed ward garden. At the same time, it was acknowledged that patients would inevitably seek leave to smoke and that this could not be denied without a negative impact on their mental health.
4) The jury heard evidence that patients, like Mrs McCarthy, were routinely given 15-minute grounds leave for the purpose of smoking, a practice that is discouraged by the Trust. Clinical staff felt that the policy placed them in a difficult position, torn between the need to comply with the smoke free policy, while also supporting patient autonomy and keeping safe those patients who are at a higher risk of self-harm or suicide.
5) There is a further contradiction caused by the smoke free policy, in that patients are not permitted to smoke on the grounds, but are not supposed to leave the grounds during short periods of ‘grounds’ leave. The result is that patients would spend their 15-minute leave smoking by the side of the road on the edge of the ward grounds, which is a poorly supervised area, and staff would avoid asking them too closely where they were going and would avoid standing close to them, even when smoking themselves. This contributed to the circumstances that allowed Mrs McCarthy to slip away unnoticed and ultimately to take her own life.
6) I also heard evidence from senior staff that the national policy guidance intended to address smoking and s17 leave (e.g. the NICE guidance and CQC guidance) does not adequately resolve these contradictions.
7) I am concerned that the NHS smoke free policy, while clearly motivated by a genuine and pressing concern to protect life and promote health, may not be adequately tailored to reflect the safety requirements of mental health wards or the reality that some mental health patients will inevitably seek short periods of leave to smoke . Action may need to be taken at the national policy level to provide clearer guidance and/or review the law to reduce the risk of patients in mental health wards absconding while on unescorted grounds leave.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Poor supervision of patients smoking during short grounds leave
Wider context from the report “1) During the course of the inquest, I heard evidence from clinicians and staff at the Trust to the effect that the NHS England smoke free policy is placing mental health in patients at an increased risk from self-harm and suicide.
2) Although smoking cessation advice and treatment (e.g. gum, vapes etc.) are routinely offered to patients, the evidence was that many struggle to give up smoking on their admission to the ward, in part because the anxiety associated with stopping exacerbates their mental health symptoms. Staff also felt that forcing patients to stop smoking against their will (e.g. by prohibiting them from smoking while on leave) would have a negative effect on their sense of autonomy and wellbeing, which are important for recovery.
3) The Trust understand that they are bound by the Health Act 2006 and by NHS England policy not to permit or facilitate smoking on the ward or anywhere on the grounds of the hospital. This is taken seriously and is interpreted to mean that staff are prohibited from facilitating smoking, for example by granting leave for the purpose of smoking or by escorting patients to smoke outside on short periods of leave. Senior staff also believed that it would be contrary to NHS policy to permit smoking in a secure area, for example the enclosed ward garden. At the same time, it was acknowledged that patients would inevitably seek leave to smoke and that this could not be denied without a negative impact on their mental health.
4) The jury heard evidence that patients, like Mrs McCarthy, were routinely given 15-minute grounds leave for the purpose of smoking, a practice that is discouraged by the Trust. Clinical staff felt that the policy placed them in a difficult position, torn between the need to comply with the smoke free policy, while also supporting patient autonomy and keeping safe those patients who are at a higher risk of self-harm or suicide.
5) There is a further contradiction caused by the smoke free policy, in that patients are not permitted to smoke on the grounds, but are not supposed to leave the grounds during short periods of ‘grounds’ leave. The result is that patients would spend their 15-minute leave smoking by the side of the road on the edge of the ward grounds, which is a poorly supervised area , and staff would avoid asking them too closely where they were going and would avoid standing close to them , even when smoking themselves. This contributed to the circumstances that allowed Mrs McCarthy to slip away unnoticed and ultimately to take her own life.
6) I also heard evidence from senior staff that the national policy guidance intended to address smoking and s17 leave (e.g. the NICE guidance and CQC guidance) does not adequately resolve these contradictions.
7) I am concerned that the NHS smoke free policy, while clearly motivated by a genuine and pressing concern to protect life and promote health, may not be adequately tailored to reflect the safety requirements of mental health wards or the reality that some mental health patients will inevitably seek short periods of leave to smoke. Action may need to be taken at the national policy level to provide clearer guidance and/or review the law to reduce the risk of patients in mental health wards absconding while on unescorted grounds leave.
” Open source report
×
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 Contradictions in national policy concerning smoking cessation in acute mental-health inpatient care fall outside NICE’s remit.
Verbatim wording from the response “Given that the matters of concern relate to contradictions in national policy, these are not areas that are within NICE’s remit. We believe that the issues raised are best addressed by NHS England, and I note that your report has also been sent to them. The Care Quality Commission (CQC) may also be able to provide useful feedback to the points raised.” Source location Response from NICE
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 NHS England is considered best placed to address contradictions in national policy concerning smoking cessation in acute mental-health inpatient care.
Verbatim wording from the response “Given that the matters of concern relate to contradictions in national policy, these are not areas that are within NICE’s remit. We believe that the issues raised are best addressed by NHS England, and I note that your report has also been sent to them. The Care Quality Commission (CQC) may also be able to provide useful feedback to the points raised.” Source location Response from NICE
Open published response
8 Nov 2024 Imogen Heap · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 1 Under-appreciation of the risks posed by elevated propranolol medication levels View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Imogen Heap · 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
Imogen Heap, aged 17, died after ingesting a very large quantity of propranolol, with smaller amounts of fluoxetine and paracetamol, and subsequently suffering propranolol toxicity, bradycardia and cardiac arrest. The principal concern was that propranolol remains widely prescribed, including to young people with anxiety, while the risks of overdose may be under-appreciated.
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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Under-appreciation of the risks posed by elevated propranolol medication levels
Wider context from the report “My concern is that Propranolol continues to be a drug which is widely prescribed, and often to young people reporting symptoms of anxiety, but that there continues to be an under-appreciation of the level of risk posed by an elevated level of propranolol medication can be.
” 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 Complete a surveillance review of current evidence and discuss the findings with GP advisors regarding propranolol guidance.
Verbatim wording from the response “We also outlined that our guidance surveillance team would review any current evidence and consult with topic experts to consider whether an update to CG113 was required, we have now had a surveillance review and discussed with our GP advisors.” Source location Update from NICE 10 June 2025
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 guideline will not be updated at this time because MHRA found no need for a safety communication and noted widespread safe propranolol use.
Verbatim wording from the response “The Medicines & Healthcare products Regulatory Agency (MHRA) have told us that they will not be issuing a drug safety update (DSU) for propranolol. The MHRA stated that ‘The issue of whether or not a DSU was warranted was considered within MHRA in Autumn 2024 and then discussed at one of the monthly DSU planning meetings where a decision was taken not to issue a safety communication. One of the concerns with any communication was inadvertently raising the profile of propranolol overdose. A couple of factors which were taken into consideration are that (i) quite a lot of overdoses with propranolol are mixed overdoses of more than one drug, and that (ii) propranolol is used very widely with millions of items prescribed and used safely each year’. Therefore, our conclusion is that we will not be updating CG113 at this time.” Source location Update from NICE 10 June 2025
Open published response
5 Nov 2024 Audrey Margaret Lambert · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of national guidance for primary care clinicians on assessing whether to prolong anticoagulation for elderly immobile patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Audrey Margaret Lambert · 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
Audrey Margaret Lambert suffered an accidental fall at home on 25 March 2024, fractured her right proximal femur, underwent surgery and subsequently had significantly reduced mobility while receiving care at Brinnington Hall. She was found unresponsive on 28 May 2024 and died from pulmonary thromboembolism due to deep vein thrombosis. The concern was that there was no national guidance to help primary care clinicians assess whether anticoagulation should be prolonged for elderly, immobile patients after the standard post-operative course.
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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for primary care clinicians on assessing whether to prolong anticoagulation for elderly immobile patients
Wider context from the report “The inquest heard evidence that prior to the fall and fracture Mrs Lambert had been mobile. Following the operation her mobility was very limited. She was prescribed the standard heparin treatment post operatively. The inquest was told that it was recognised in her case that she had become very immobile since her fall. However the inquest was told that there was no national guidance that would assist clinicians in primary care in assessing whether they should consider prolonging the course of anti-coagulation prescribed in secondary care to reduce the ongoing risk of elderly immobile patients such as Mrs Lambert developing a fatal DVT in the community.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review guidance on stopping and starting VTE prophylaxis to determine whether an update is warranted.
Verbatim wording from the response “I can confirm that we will review our guidance on stopping and starting VTE prophylaxis to see if an update is warranted. The potential scope of this work is to be confirmed but it may cover the management of people with immobility, if there is sufficient good quality evidence on which to base recommendations.” Source location Response from NICE
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 national guidance addresses discharge VTE risk assessment and prophylaxis decisions, although it does not advise starting prophylaxis de novo in the community.
Verbatim wording from the response “In the circumstances outlined in your report we believe that an assessment of the venous thromboembolism (VTE) risk, balanced against the prophylaxis risk, should have been made at discharge. Although our VTE guideline [NG89] does not give advice on starting VTE prophylaxis de novo in the community, it does give advice on starting and continuing pharmacological VTE prophylaxis after surgery (recommendation 1.11) and having a clear discharge plan. Decisions on prophylaxis should be driven by the needs of the individual, balancing the person’s individual risk of VTE against their risk of bleeding when deciding whether to offer pharmacological thromboprophylaxis to surgical and trauma patients (recommendation 1.1.6).” Source location Response from NICE
Open published response
21 Oct 2024 Brian BEER · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1 Failure of NICE guidance to reflect up-to-date evidence on duration of post-surgical anticoagulation after hip-fracture surgery View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Brian BEER · 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
Brian Beer died peacefully in hospital on 1 March 2024 from small bowel ischaemia caused by a superior mesenteric artery blood clot, following hip fracture surgery after an unwitnessed fall. The principal concern was whether current NICE guidance on the duration of post-surgical prophylactic anticoagulation adequately reflects emerging evidence about risks after hip-fracture surgery, particularly in immobile and elderly patients.
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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure of NICE guidance to reflect up-to-date evidence on duration of post-surgical anticoagulation after hip-fracture surgery
Wider context from the report “If NICE guidelines as to prophylactic anti-coagulation after surgery on a hip fracture do not reflect the most up-to-date international learning , then there is a risk of future deaths being contributed to by hospitals following NICE guidelines when a longer period of anti-coagulation post-surgery would better protect them against recognised complications of the surgery .
” 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 new evidence on prophylaxis duration and consider sufficiently robust findings through a surveillance review.
Verbatim wording from the response “In line with the expert haematologist and her colleagues, we are not aware of evolving international consensus over the length of time for prophylaxis after a fractured neck of femur and the possibility of mesenteric thrombosis. NICE will continue to monitor new” Source location Response from National Institute of Health and Care Excellence
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 Decisions to continue or discontinue anticoagulation after surgery remain matters for clinicians’ individual assessment and clinical judgement.
Verbatim wording from the response “The decision whether to continue or discontinue anti-coagulation would be a matter for clinical judgement based on careful assessment of an individual patient and their progress after surgery.” Source location Response from National Institute of Health and Care Excellence
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 Insufficient international consensus and evidence currently prevent extending guidance on prophylaxis duration and possible mesenteric thrombosis; new evidence will be monitored.
Verbatim wording from the response “In line with the expert haematologist and her colleagues, we are not aware of evolving international consensus over the length of time for prophylaxis after a fractured neck of femur and the possibility of mesenteric thrombosis. NICE will continue to monitor new” Source location Response from National Institute of Health and Care Excellence
Open published response
Concerns raised 4 Extremely limited doctor training on ME/CFS treatment, especially severe ME View source Lack of specialist healthcare provision for patients with severe ME View source Failure of NICE guidance to provide detailed guidance on managing severe ME at home or in the community View source Lack of current funding for ME/CFS treatment research and understanding of causes 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
Maeve Boothby O’Neill · 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
Maeve Boothby O’Neill, who had severe ME and was bedbound, died at home on 3 October 2021 after three hospital admissions during 2021. The report identified concerns about the lack of specialist care provision for severe ME, limited research funding and medical training, and insufficient guidance on managing severe ME in the home or community, including nutritional 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Extremely limited doctor training on ME/CFS treatment, especially severe ME
Wider context from the report “(3) During the course of the inquest it became clear that there was extremely limited training for Doctors on ME/ CFS and how to treat it – especially in relation to severe ME .
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of specialist healthcare provision for patients with severe ME
Wider context from the report “(1) During the course of the evidence it became clear that there were no specialist hospitals or hospices, beds, wards or other health care provision in England for patients with severe Myalgic encephalopathies (ME) . This meant that the Royal Devon and Exeter Hospital had no commissioned service to treat Maeve and patients like her .
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure of NICE guidance to provide detailed guidance on managing severe ME at home or in the community
Wider context from the report “(4 ) During the course of the inquest it became clear that the 2021 NICE guidelines on ME did not provide any detailed guidance at all on how severe ME should be managed at home or in the community and in particular whether or not there is any necessary adaptation needed to the 2017 guidance on Nutrition support for adults : oral nutrition support , enteral tube feeding and parenteral nutrition .
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of current funding for ME/CFS treatment research and understanding of causes
Wider context from the report “(2) During the course of the inquest it became clear that there was no current available funding for the research and development of treatment and further learning for understanding the causes of ME / Chronic Fatigue Syndrome (CFS) .
” 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 Review post-NG206 evidence on dietary management for people with severe or very severe ME/CFS to determine whether guideline amendments are needed.
Verbatim wording from the response “In response to your report, and our learning and reflections following Maeve’s death, we will:” Source location Response from NICE
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 Consider appropriate ME/CFS guideline amendments emphasizing the need for appropriate nutritional support.
Verbatim wording from the response “In response to your report, and our learning and reflections following Maeve’s death, we will:” Source location Response from NICE
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 NICE could not make more specific severe ME/CFS dietary recommendations because good-quality evidence was lacking.
Verbatim wording from the response “Our guideline includes recommendations on care for people with severe or very severe ME/CFS (section 1.17). They include general recommendations on dietary management and strategies. We were not able to make more specific recommendations due to a lack of good quality evidence. For this reason, the committee made the research recommendation noted above.” Source location Response from NICE
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 Commissioning and delivery of ME/CFS services are the responsibility of the relevant NHS body.
Verbatim wording from the response “Our guideline on myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome (ME/CFS): diagnosis and management [NG206] recommends that care for people with ME/CFS should be supported by advice and direct clinical consultation from an ME/CFS specialist team. Service commissioning and delivery is the responsibility of the relevant NHS body.” Source location Response from NICE
Open published response
29 Aug 2024 Kasey Beech · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Streaming patients without current chest pain to a MedOCC or equivalent service despite risk of sudden deterioration View source Failure to assess potentially life-threatening non-cardiac causes alongside cardiac causes of pain View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kasey Beech · 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
Kasey Beech attended Medway Maritime Hospital with difficulty breathing and chest pain, was directed to a service with a reported three-hour wait, and later suffered a cardiac arrest after her breathing suddenly worsened. She died at St Thomas’ Hospital on 13 October 2021 following treatment. The report raises concerns that the STREAMing model’s focus on current cardiac-sounding chest pain may delay consideration of other immediately life-threatening causes of deterioration, including infective exacerbation of asthma.
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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Streaming patients without current chest pain to a MedOCC or equivalent service despite risk of sudden deterioration
Wider context from the report “The focus of the current STREAMing guidance regarding the assessment of new non-injury ambulatory patients able to speak in complete sentences without becoming out of breath is on chest pain. The assessment relates to current chest pain and diagnostic investigations are in turn centred on whether there is a cardiac cause. Such patients who do not present with current chest pain are sent to the MedOCC.
However:
(i) pain can fluctuate over time and may not always be concurrent with the initial assessment;
(ii) pain may be masked by analgesia taken prior to assessment; and
(iii) the focus on a cardiac cause itself risks diverting a clinician from the wider question of identifying the cause of the pain. The consideration of differentials that may be immediately life-threatening, or place the patient at risk of a sudden deterioration (e.g. infective exacerbation of asthma) may be delayed, or not given adequate attention as a consequence.
While it is understood that a cardiac issue is high risk and requires prompt diagnosis, and that the exclusion of a cardiac cause causing current chest pain is also diagnostically helpful, I am concerned that the prioritisation of current cardiac-sounding chest-pain and the streaming to a MedOCC/equivalent service may be to the detriment of other patients who are nonetheless at risk of sudden deterioration and therefore creates a risk of future deaths (in both cardiac and non-cardiac patients).
It is understood that the current national guidelines are under review.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to assess potentially life-threatening non-cardiac causes alongside cardiac causes of pain
Wider context from the report “The focus of the current STREAMing guidance regarding the assessment of new non-injury ambulatory patients able to speak in complete sentences without becoming out of breath is on chest pain. The assessment relates to current chest pain and diagnostic investigations are in turn centred on whether there is a cardiac cause. Such patients who do not present with current chest pain are sent to the MedOCC.
However:
(i) pain can fluctuate over time and may not always be concurrent with the initial assessment;
(ii) pain may be masked by analgesia taken prior to assessment; and
(iii) the focus on a cardiac cause itself risks diverting a clinician from the wider question of identifying the cause of the pain. The consideration of differentials that may be immediately life-threatening, or place the patient at risk of a sudden deterioration (e.g. infective exacerbation of asthma) may be delayed, or not given adequate attention as a consequence.
While it is understood that a cardiac issue is high risk and requires prompt diagnosis, and that the exclusion of a cardiac cause causing current chest pain is also diagnostically helpful, I am concerned that the prioritisation of current cardiac-sounding chest-pain and the streaming to a MedOCC/equivalent service may be to the detriment of other patients who are nonetheless at risk of sudden deterioration and therefore creates a risk of future deaths (in both cardiac and non-cardiac patients).
It is understood that the current national guidelines are under review.
” 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 Update the guideline on asthma diagnosis, monitoring and chronic asthma management for publication.
Verbatim wording from the response “Although not directly mentioned in your report, you may be interested to learn that we are updating our guideline on Asthma: diagnosis, monitoring and chronic asthma management and this update is expected to publish on the 27 November.” Source location Response from NICE
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 NHS England is responsible for addressing concerns about its STREAMing prioritisation system.
Verbatim wording from the response “Given that the matters of concern relate to the prioritisation system (STREAMing) which was produced by NHS England, these are not areas that are within NICE’s remit. We believe that the issues raised are best addressed by NHS England, and note that you have also sent your report to them for response.” Source location Response from NICE
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 prioritisation system and acute-care organisation concerns fall outside NICE’s remit.
Verbatim wording from the response “Given that the matters of concern relate to the prioritisation system (STREAMing) which was produced by NHS England, these are not areas that are within NICE’s remit. We believe that the issues raised are best addressed by NHS England, and note that you have also sent your report to them for response.” Source location Response from NICE
Open published response
Concerns raised 6 Lack of clinical staff knowledge of the Acute Abdominal Pain Pathway View source Lack of a clearly documented and recorded process for patient self-discharge View source Failure to maintain a signed record of patient self-discharge View source Failure of the hospital SI process to include information from family and other interested persons View source Failure to record vomiting before hospital discharge View source Failure of the Acute Abdominal Pain Pathway documentation to provide sufficient clarity 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
Megan Ceris Williams · 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
Megan Ceris Williams developed abdominal pain and repeated vomiting between 1 and 5 May 2022, attended hospital twice, and died at home on 5 May 2022 after becoming breathless and losing consciousness. The inquest identified an undiagnosed small bowel obstruction apparently caused by adhesions from previous abdominal surgery. Concerns included possible missed opportunities for investigation, limited staff knowledge and clarity of the Acute Abdominal Pain Pathway, the lack of a signed self-discharge record, and the hospital investigation process not including information from family members.
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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical staff knowledge of the Acute Abdominal Pain Pathway
Wider context from the report “Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.
It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction.
The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022.
The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene.
The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged.
The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning.
The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family.
(a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP) .
(b) Given what was said about how clear the AAPP was, that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians.
(c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise.
(d) There was not a clearly documented and recorded process for patients who self-discharge from hospital.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of a clearly documented and recorded process for patient self-discharge
Wider context from the report “Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.
It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction.
The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022.
The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene.
The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged.
The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning.
The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family.
(a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP).
(b) Given what was said about how clear the AAPP was, that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians.
(c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise.
(d) There was not a clearly documented and recorded process for patients who self-discharge from hospital.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a signed record of patient self-discharge
Wider context from the report “Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.
It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction.
The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022.
The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene.
The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged.
The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning.
The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family.
(a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP).
(b) Given what was said about how clear the AAPP was, that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians.
(c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise.
(d) There was not a clearly documented and recorded process for patients who self-discharge from hospital.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure of the hospital SI process to include information from family and other interested persons
Wider context from the report “Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.
It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction.
The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022.
The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene.
The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged.
The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning.
The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family .
(a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP).
(b) Given what was said about how clear the AAPP was, that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians.
(c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise .
(d) There was not a clearly documented and recorded process for patients who self-discharge from hospital.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to record vomiting before hospital discharge
Wider context from the report “Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.
It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction.
The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022.
The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene.
The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged.
The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning.
The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family.
(a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP).
(b) Given what was said about how clear the AAPP was, that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians.
(c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise.
(d) There was not a clearly documented and recorded process for patients who self-discharge from hospital.
” 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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure of the Acute Abdominal Pain Pathway documentation to provide sufficient clarity
Wider context from the report “Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.
It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction.
The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022.
The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene.
The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged.
The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning.
The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family.
(a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP).
(b) Given what was said about how clear the AAPP was , that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians.
(c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise.
(d) There was not a clearly documented and recorded process for patients who self-discharge from hospital.
” Open source report
×
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 actions by NICE are considered necessary to address the issues raised in the report.
Verbatim wording from the response “On this occasion, we do not consider that there are any actions from NICE that would address the issues raised.” Source location Response from NICE
Open published response
Concerns raised 1 Potential increased risk of certain blood cancers among patients taking Clozapine View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sasha Drysdale · 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
Sasha Drysdale died on 28 March 2023 in hospital as a consequence of acute myeloid leukaemia transformed from myelodysplastic syndrome. She had previously been prescribed clozapine for treatment-resistant schizoaffective disorder and was detained under section 3 of the Mental Health Act 1983 at the time of her death. The concern raised was that further research is needed to establish whether clozapine materially increases the risk of certain blood cancers.
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 National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Potential increased risk of certain blood cancers among patients taking Clozapine
Wider context from the report “The court heard evidence as to a small number of studies conducted internationally which, whilst having small sample sizes, could be read as suggesting an increased incidence of certain forms of blood cancer amongst those taking Clozapine .
I am concerned that further research is needed to either refute or confirm whether or not taking Clozapine materially increases the risk of a patient developing certain blood cancers .
” Open source report
×
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 NIHR, rather than NICE, is responsible for clinical research into clozapine and related safety risks.
Verbatim wording from the response “Finally, NICE does not have a direct role in clinical research the UK; this is the role of the National Institute for Health and Care Research (NIHR). You may wish to contact them directly regarding any upcoming research on this subject area.” Source location Response from NICE
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 MHRA, rather than NICE, should lead surveillance and investigation of clozapine’s safety and haematological malignancy risks.
Verbatim wording from the response “In relation to the main issue that you have asked us to respond to, you may be aware that NICE is not the regulator for medicines and medical devices in the UK; this is the role of the Medicines & Healthcare products Regulatory Agency (MHRA). The MHRA is responsible for issuing the marketing authorisation for medicines (also known as the licence) and has ongoing responsibility for monitoring their safety.” Source location Response from NICE
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations