Concerns raised 4 Failure to communicate medication dosage errors to patients and GPs View source Failure to administer the prescribed steroid dosage accurately View source Failure of prednisolone guidance to reflect bowel perforation risk in diverticular disease View source Failure to apply policies regarding medication dosage errors View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
JOHN ALFRED ROBERTS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Alfred Roberts, aged 78, was admitted with vomiting and retching and was found to have an inoperable perforated sigmoid colon. He was discharged home for palliative care and died there on 26 June 2021. The substantive concerns related to an inadvertent reduction in his prednisolone dosage at Royal Cornwall Hospital and the adequacy of medication-error arrangements, as well as omissions in NICE’s BNF guidance about the risk of bowel perforation associated with corticosteroids in people with diverticular disease.
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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 communicate medication dosage errors to patients and GPs
Wider context from the report “(1) Royal Cornwall Hospital (RCHT)
• The concern is the inadvertent reduction of steroid dosage and the arrangements made in relation to the administration of medication dosages and the policies regarding dosage errors, and the application of those policies.
• The Court heard that the dosage of 100mg prednisolone was inadvertently reduced to 25mg from 7 to 13 June. The full dose of 100mg was given either side of that period, on 5 and 15 June 2021. No explanation was offered for this reduction other than it being an inadvertent mistake.
• RCHT Consultants accepted that the dosage error was a serious mistake. Furthermore, this mistake was not drawn to the patient John’s attention or to the attention of the GP via the discharge summary, which made no reference to the dosage error. It was unclear whether treating physicians or discharging physicians were aware of the dosage error.
(2) The National Institute for Clinical Excellence (NICE)
• The concern is regarding the accuracy and rigour of the British National Formulary (BNF) guidance on Prednisolone, published by NICE, The National Institute for Clinical Excellence
• BNF provides Key information on the selection, prescribing, dispensing and administration of medicines. The BNF aims to provide prescribers, pharmacists, and other healthcare professionals with sound up-to-date information about the use of medicines.
• Evidence was taken at Inquest from a consultant neurologist that recent literature suggests an association between steroids (such as prednisolone) and the risk of bowel perforation in those with diverticular disease. This is not reflected in the BNF guidance regarding prednisolone.
• In relation to a number of sections in the Prednisolone guidance it was found as follows
• The ‘Important safety information’ section does not refer to the risk of perforation from using corticosteroids for those with diverticular disease
• The ‘Contra-indications For all corticosteroids (systemic)’ section does not refer to need for caution in using corticosteroids for those with diverticular disease, albeit it does refer to caution in using with patients with diabetes mellitus and diverticulitis
• The ‘Side effects’ section makes no reference to bowel perforation as a risk, albeit it does make reference to peptic ulceration.
” Open source report × Source evidence
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 administer the prescribed steroid dosage accurately
Wider context from the report “(1) Royal Cornwall Hospital (RCHT)
• The concern is the inadvertent reduction of steroid dosage and the arrangements made in relation to the administration of medication dosages and the policies regarding dosage errors, and the application of those policies.
• The Court heard that the dosage of 100mg prednisolone was inadvertently reduced to 25mg from 7 to 13 June. The full dose of 100mg was given either side of that period, on 5 and 15 June 2021. No explanation was offered for this reduction other than it being an inadvertent mistake.
• RCHT Consultants accepted that the dosage error was a serious mistake. Furthermore, this mistake was not drawn to the patient John’s attention or to the attention of the GP via the discharge summary, which made no reference to the dosage error. It was unclear whether treating physicians or discharging physicians were aware of the dosage error.
(2) The National Institute for Clinical Excellence (NICE)
• The concern is regarding the accuracy and rigour of the British National Formulary (BNF) guidance on Prednisolone, published by NICE, The National Institute for Clinical Excellence
• BNF provides Key information on the selection, prescribing, dispensing and administration of medicines. The BNF aims to provide prescribers, pharmacists, and other healthcare professionals with sound up-to-date information about the use of medicines.
• Evidence was taken at Inquest from a consultant neurologist that recent literature suggests an association between steroids (such as prednisolone) and the risk of bowel perforation in those with diverticular disease. This is not reflected in the BNF guidance regarding prednisolone.
• In relation to a number of sections in the Prednisolone guidance it was found as follows
• The ‘Important safety information’ section does not refer to the risk of perforation from using corticosteroids for those with diverticular disease
• The ‘Contra-indications For all corticosteroids (systemic)’ section does not refer to need for caution in using corticosteroids for those with diverticular disease, albeit it does refer to caution in using with patients with diabetes mellitus and diverticulitis
• The ‘Side effects’ section makes no reference to bowel perforation as a risk, albeit it does make reference to peptic ulceration.
” Open source report × Source evidence
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 prednisolone guidance to reflect bowel perforation risk in diverticular disease
Wider context from the report “(1) Royal Cornwall Hospital (RCHT)
• The concern is the inadvertent reduction of steroid dosage and the arrangements made in relation to the administration of medication dosages and the policies regarding dosage errors, and the application of those policies.
• The Court heard that the dosage of 100mg prednisolone was inadvertently reduced to 25mg from 7 to 13 June. The full dose of 100mg was given either side of that period, on 5 and 15 June 2021. No explanation was offered for this reduction other than it being an inadvertent mistake.
• RCHT Consultants accepted that the dosage error was a serious mistake. Furthermore, this mistake was not drawn to the patient John’s attention or to the attention of the GP via the discharge summary, which made no reference to the dosage error. It was unclear whether treating physicians or discharging physicians were aware of the dosage error.
(2) The National Institute for Clinical Excellence (NICE)
• The concern is regarding the accuracy and rigour of the British National Formulary (BNF) guidance on Prednisolone, published by NICE, The National Institute for Clinical Excellence
• BNF provides Key information on the selection, prescribing, dispensing and administration of medicines. The BNF aims to provide prescribers, pharmacists, and other healthcare professionals with sound up-to-date information about the use of medicines.
• Evidence was taken at Inquest from a consultant neurologist that recent literature suggests an association between steroids (such as prednisolone) and the risk of bowel perforation in those with diverticular disease. This is not reflected in the BNF guidance regarding prednisolone.
• In relation to a number of sections in the Prednisolone guidance it was found as follows
• The ‘Important safety information’ section does not refer to the risk of perforation from using corticosteroids for those with diverticular disease
• The ‘Contra-indications For all corticosteroids (systemic)’ section does not refer to need for caution in using corticosteroids for those with diverticular disease , albeit it does refer to caution in using with patients with diabetes mellitus and diverticulitis
• The ‘Side effects’ section makes no reference to bowel perforation as a risk , albeit it does make reference to peptic ulceration.
” Open source report × Source evidence
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 apply policies regarding medication dosage errors
Wider context from the report “(1) Royal Cornwall Hospital (RCHT)
• The concern is the inadvertent reduction of steroid dosage and the arrangements made in relation to the administration of medication dosages and the policies regarding dosage errors, and the application of those policies.
• The Court heard that the dosage of 100mg prednisolone was inadvertently reduced to 25mg from 7 to 13 June. The full dose of 100mg was given either side of that period, on 5 and 15 June 2021. No explanation was offered for this reduction other than it being an inadvertent mistake.
• RCHT Consultants accepted that the dosage error was a serious mistake. Furthermore, this mistake was not drawn to the patient John’s attention or to the attention of the GP via the discharge summary, which made no reference to the dosage error. It was unclear whether treating physicians or discharging physicians were aware of the dosage error.
(2) The National Institute for Clinical Excellence (NICE)
• The concern is regarding the accuracy and rigour of the British National Formulary (BNF) guidance on Prednisolone, published by NICE, The National Institute for Clinical Excellence
• BNF provides Key information on the selection, prescribing, dispensing and administration of medicines. The BNF aims to provide prescribers, pharmacists, and other healthcare professionals with sound up-to-date information about the use of medicines.
• Evidence was taken at Inquest from a consultant neurologist that recent literature suggests an association between steroids (such as prednisolone) and the risk of bowel perforation in those with diverticular disease. This is not reflected in the BNF guidance regarding prednisolone.
• In relation to a number of sections in the Prednisolone guidance it was found as follows
• The ‘Important safety information’ section does not refer to the risk of perforation from using corticosteroids for those with diverticular disease
• The ‘Contra-indications For all corticosteroids (systemic)’ section does not refer to need for caution in using corticosteroids for those with diverticular disease, albeit it does refer to caution in using with patients with diabetes mellitus and diverticulitis
• The ‘Side effects’ section makes no reference to bowel perforation as a risk, albeit it does make reference to peptic ulceration.
” Open source report
Concerns raised 8 Call-handler pathway failing to consider adrenal crisis risk after trauma View source National treatment guidance failing to emphasise replacement steroid therapy after trauma or physiological stress View source Failure of acute hospital clinicians to recognise the need for replacement steroid therapy after trauma or physiological stress View source Absence of adrenal insufficiency prompts in emergency department and clerking documentation View source Guideline failing to emphasise replacement steroid therapy after trauma or physiological stress View source Unclear NHS England monitoring of compliance with National Patient Safety Alerts View source Insufficient clinician knowledge of adrenal insufficiency and replacement steroid therapy View source Failure of internal investigation coordination and learning from patient-safety incidents 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
DAVID ERNEST MASON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Ernest Mason, aged 82, fell at home on 5 March 2022, fractured his hip and was taken to hospital after an ambulance delay. He had Addison’s disease and died in the early hours of 7 March 2022 after developing an acute adrenal crisis. The principal concerns were that clinicians and ambulance staff did not recognise the need for additional steroid replacement after trauma and physiological stress, and that relevant clinical guidance, call-handler pathways and documentation prompts did not sufficiently address this risk.
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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 Call-handler pathway failing to consider adrenal crisis risk after trauma
Wider context from the report “2) Evidence heard at the inquest demonstrated that when information is given to an EOC (emergency operations centre) call-handler at WMAS that a patient has a diagnosis of Addison’s disease and has suffered trauma, the call-handler question pathway (which, the inquest heard, is based on a computer-programmed logarithm (designed by NHS Digital, now part of NHS England)) does not go on to consider the risk of adrenal insufficiency and the requirement for replacement steroid therapy to commence immediately . This appears to be potentially relevant both in respect of whether time-critical steroid treatment may be required (and thus for a holistic consideration of call categorisation) and safety-netting advice that should be given (for additional doses of steroid medication to be taken by the patient, prior to any ambulance arrival). Safety-netting advice takes on even greater significance in the current climate, where healthcare demand and pressures on capacity are often causing severe delays in ambulance attendance. Evidence heard at the inquest confirmed that the position is different if information is given that the patient is medically unwell, particularly if concerns of a cardiac nature are present or adrenal insufficiency may be the direct cause of current illness, with the call-handler question pathway then going on to consider the risk of adrenal insufficiency. Currently there is a cohort of patients (which included Mr Mason) whose risk of developing an adrenal crisis is not being considered by call-handlers at WMAS .
” Open source report × Source evidence
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 National treatment guidance failing to emphasise replacement steroid therapy after trauma or physiological stress
Wider context from the report “1) The relevant treatment guideline disclosed by WAHT (‘Guideline for the management of adrenal insufficiency in adults’) very much focuses on presentations of acute adrenal crisis and procedure-based/perioperative situations, and (save for a small section containing ‘sick day’ rules) does not emphasise that replacement steroid therapy must be given to patients with adrenal insufficiency who have suffered trauma or physiological stress . Evidence heard at the inquest suggested that this internal Trust guideline (and, one assumes, other such guidelines in other acute trusts in the country) is based upon various pieces of national guidance. It is my understanding that a new guideline in respect of managing the treatment of adrenal insufficiency is currently being developed by NICE. Consideration of these matters should be included as part of guideline development.
” Open source report × Source evidence
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 acute hospital clinicians to recognise the need for replacement steroid therapy after trauma or physiological stress
Wider context from the report “1) Evidence heard at the inquest demonstrated that no clinician involved in providing care to Mr Mason (in both the emergency department and the surgical trauma department) appreciated that , as someone who had Addison’s disease and who had suffered the trauma of a fall, long lie and a fractured hip, Mr Mason required additional replacement steroid therapy , to prevent the development of an acute adrenal crisis.
” Open source report × Source evidence
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 adrenal insufficiency prompts in emergency department and clerking documentation
Wider context from the report “4) Evidence heard at the inquest confirmed that no prompts exist on emergency department/clerking documentation at WAHT for clinicians to check whether a patient suffers from adrenal insufficiency . Although the inquest was informed that changes have been made in this regard by WAHT to some peri-operative patient documentation, the National Patient Safety Alert (NatPSA/2020/005/NHSPS) requires acute trusts to review admission/assessment/clerking documentation to ensure such prompts are included.
” Open source report × Source evidence
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 Guideline failing to emphasise replacement steroid therapy after trauma or physiological stress
Wider context from the report “2) The relevant internal Trust guideline disclosed by WAHT (‘Guideline for the management of adrenal insufficiency in adults’) very much focuses on presentations of acute adrenal crisis and procedure-based/perioperative situations, and (save for a small section containing ‘sick day’ rules, which are on the same page as advice to patients and families for long-term condition management) does not emphasise that replacement steroid therapy must be given to patients with adrenal insufficiency who have suffered trauma or physiological stress .
” Open source report × Source evidence
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 Unclear NHS England monitoring of compliance with National Patient Safety Alerts
Wider context from the report “2) Evidence heard at the inquest confirmed that no prompts exist on emergency department/clerking documentation at WAHT for clinicians to check whether a patient suffers from adrenal insufficiency. Although the inquest was informed that changes have been made in this regard by WAHT to some peri-operative patient documentation, the National Patient Safety Alert (NatPSA/2020/005/NHSPS) requires acute trusts to review admission/assessment/clerking documentation to ensure such prompts are included. It is not clear what follow-up action is taken by NHS England in relation to monitoring of compliance by NHS Trusts following National Patient Safety Alerts being issued.
” Open source report × Source evidence
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 clinician knowledge of adrenal insufficiency and replacement steroid therapy
Wider context from the report “3) Evidence heard at the inquest (relating to the trauma/surgical department at WAHT) suggested that it is likely that many clinicians (including at consultant level) do not have a well-developed understanding of adrenal insufficiency and the crucial importance of administering replacement steroid therapy to patients who, although not presenting as acutely unwell, are at risk of suffering an adrenal crisis .
” Open source report × Source evidence
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 internal investigation coordination and learning from patient-safety incidents
Wider context from the report “4) Evidence heard at the inquest confirmed that the investigation lead at WMAS had not been shown the inquest disclosure bundle , which had been disclosed to the legal department at WMAS a number of months prior to the inquest. This bundle contained relevant evidence from a different internal investigation (by WAHT), suggesting that the likely cause of Mr Mason’s deterioration and death was an acute adrenal crisis and not, as had been considered when a coronial referral had initially been made, hyperkalaemia and rhabdomyolysis (following a fall and long lie). This lack of internal co-ordination within WMAS prevented full internal investigation and learning in respect of the care given to Mr Mason by WMAS.
” 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 Cover identification, emergency management and prevention of adrenal crisis during trauma and other physiological stress in the new guideline.
Verbatim wording from the response “We have reflected on the circumstances surrounding Mr Mason’s death, and the concerns raised in your report. We note your suggestion that the issues raised in your report should be considered in the development of our new guideline on adrenal insufficiency, particularly that replacement steroid therapy must be given to patients with adrenal insufficiency who have suffered trauma or physiological stress.” Source location Response from NICE
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 Include two paramedic co-optees and relevant emergency-care health professionals on the adrenal insufficiency guideline committee.
Verbatim wording from the response “I can confirm that the scope of this guideline covers adrenal crisis including identification and emergency management and preventing adrenal crisis during periods of physiological stress, which includes trauma. Membership of the guideline committee recruited for this topic includes two paramedic co-optees, as well as health professionals who see people with adrenal crisis or who are at risk of adrenal crisis in the emergency department.” Source location Response from NICE
Open published response
28 Mar 2023 Louis James Rogers · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 10 Failure to document general practice assessment of febrile seizures View source Failure to make timely referrals from general practice to secondary medical services for febrile seizures View source Sudden unexpected death in childhood following febrile seizures View source Failure to make paramedic information available to all clinicians View source Lack of coordinated response across clinicians to febrile seizure presentations View source Delays in referral for assessment and investigation of febrile seizures View source Failure to ensure febrile seizure diagnoses are supported by the child’s presentation View source Failure to undertake a detailed history and full neurological examination in general practice View source Failure to follow escalation guidance for complex febrile seizures View source Insufficient information for parents and guardians after a child’s febrile seizure View source See 7 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
Louis James Rogers · 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
Louis James Rogers died after being found unresponsive at home following a period of clinical illness and was pronounced dead on 18 June 2021 despite resuscitation attempts. Autopsy identified a viral infection, and genetic studies confirmed Dravet’s Syndrome. The report raised concerns about the management and investigation of febrile seizures, information provided to parents, paramedic and general practice guidance, and the lack of a coordinated febrile seizure pathway.
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 document general practice assessment of febrile seizures
Wider context from the report “4. General Practice -
At his mother’s request after the possibility of a further seizure, Louis was reviewed by his general practitioner on the 13th May 2021 following which Louis’s mother was reassured without a detailed history from Louis’s mother or a full neurological examination and in the absence of documentation in circumstances whereby it was acknowledged there was sufficient information at that time to refer Louis to secondary services for the management of children with febrile seizures. It would therefore be appropriate to consider providing robust national guidance and education to general practitioners to ensure appropriate history, examination, investigation are undertaken to allow timely referrals to secondary medical services to 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 Failure to make timely referrals from general practice to secondary medical services for febrile seizures
Wider context from the report “4. General Practice -
At his mother’s request after the possibility of a further seizure, Louis was reviewed by his general practitioner on the 13th May 2021 following which Louis’s mother was reassured without a detailed history from Louis’s mother or a full neurological examination and in the absence of documentation in circumstances whereby it was acknowledged there was sufficient information at that time to refer Louis to secondary services for the management of children with febrile seizures. It would therefore be appropriate to consider providing robust national guidance and education to general practitioners to ensure appropriate history, examination, investigation are undertaken to allow timely referrals to secondary medical services to 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 Sudden unexpected death in childhood following febrile seizures
Wider context from the report “1. Management and investigation of Febrile Seizures
Evidence was heard that a number of children who have ‘febrile’ seizures subsequently die from ‘sudden unexpected death in childhood’ . Evidence was provided that there should be greater emphasis on medical education, research and public information for sudden unexpected deaths associated with febrile seizures. Further evidence was heard that referrals for assessment and investigation of febrile seizures should be undertaken earlier to exclude a more severe underlying illness.
” Open source report × Source evidence
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 make paramedic information available to all clinicians
Wider context from the report “5. Febrile Seizure Pathway
Evidence was heard that Louis was seen by a number of clinicians without a co-ordinated response to his presentation and that consideration should be given for all hospitals emergency departments and GP’s to be provided with a febrile seizure pathway as a checklist to ensure children are not given a diagnosis of a ‘febrile seizure when this is not supported by their presentation and for all consultations – including GP appointment and information from the paramedics is available for all clinicians to view to provide a holistic picture and to assist further management.
” Open source report × Source evidence
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 coordinated response across clinicians to febrile seizure presentations
Wider context from the report “5. Febrile Seizure Pathway
Evidence was heard that Louis was seen by a number of clinicians without a co-ordinated response to his presentation and that consideration should be given for all hospitals emergency departments and GP’s to be provided with a febrile seizure pathway as a checklist to ensure children are not given a diagnosis of a ‘febrile seizure when this is not supported by their presentation and for all consultations – including GP appointment and information from the paramedics is available for all clinicians to view to provide a holistic picture and to assist further management.
” Open source report × Source evidence
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 referral for assessment and investigation of febrile seizures
Wider context from the report “1. Management and investigation of Febrile Seizures
Evidence was heard that a number of children who have ‘febrile’ seizures subsequently die from ‘sudden unexpected death in childhood’. Evidence was provided that there should be greater emphasis on medical education, research and public information for sudden unexpected deaths associated with febrile seizures. Further evidence was heard that referrals for assessment and investigation of febrile seizures should be undertaken earlier to exclude a more severe underlying illness.
” Open source report × Source evidence
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 febrile seizure diagnoses are supported by the child’s presentation
Wider context from the report “5. Febrile Seizure Pathway
Evidence was heard that Louis was seen by a number of clinicians without a co-ordinated response to his presentation and that consideration should be given for all hospitals emergency departments and GP’s to be provided with a febrile seizure pathway as a checklist to ensure children are not given a diagnosis of a ‘febrile seizure when this is not supported by their presentation and for all consultations – including GP appointment and information from the paramedics is available for all clinicians to view to provide a holistic picture and to assist further management.
” Open source report × Source evidence
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 undertake a detailed history and full neurological examination in general practice
Wider context from the report “4. General Practice -
At his mother’s request after the possibility of a further seizure, Louis was reviewed by his general practitioner on the 13th May 2021 following which Louis’s mother was reassured without a detailed history from Louis’s mother or a full neurological examination and in the absence of documentation in circumstances whereby it was acknowledged there was sufficient information at that time to refer Louis to secondary services for the management of children with febrile seizures. It would therefore be appropriate to consider providing robust national guidance and education to general practitioners to ensure appropriate history, examination, investigation are undertaken to allow timely referrals to secondary medical services to 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 Failure to follow escalation guidance for complex febrile seizures
Wider context from the report “3. Improvement to and highlighting of the JRCALC guidelines for paramedic management of seizures in children
JRCALC guidelines indicated paramedics should have conveyed Louis to hospital or contacted the GP and/or Out of Hours GP service following Louis’s second seizure on 11th February 2020, as the close proximity of two seizures indicated it was a ‘complex febrile seizure’ rather than a febrile seizure. This led to a lost opportunity to expeditiously trigger further investigation and/or a referral to either the ‘first seizure’ service or to a specialist paediatrician for further assessment and management. Evidence was heard that improving and highlighting JRCALC guidelines with additional teaching would prevent this happening again.
” Open source report × Source evidence
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 information for parents and guardians after a child’s febrile seizure
Wider context from the report “2. Information provided to parents/guardians after their child had a Febrile Seizure
Evidence was heard that the NHS website and pamphlet provided to parents/guardians following a child’s febrile seizure is insufficiently informative to provide parents with sufficiently detailed information to assist them in picking up potential early indicators of a more severe illness e.g. issues with gait, co-ordination, definition of complex seizures, developmental regression etc.
” 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 Replace the epilepsy guideline with updated recommendations on referral and information and support after a first seizure.
Verbatim wording from the response “We believe that our guideline on epilepsies: diagnosis and management [CG137], which was in place at the time of Louis’ death, is directly relevant to this case. The guideline covered diagnosing, treating and managing epilepsy and seizures in children, young people and adults in primary and secondary care and made recommendations on what should happen following a first seizure (section 1.4), diagnosis (section 1.5) and investigations (sections 1.6).” 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 is supporting system-level research and action on SUDIC, while NICE would consider developing guidance only following an NHS England request.
Verbatim wording from the response “NICE’s chief medical officer, ████████, and interim senior responsible officer for patient safety, ████████, recently met with representatives of NHS England (NHSE) and the Royal College of Paediatrics and Child Health (RCPCH) to discuss this matter. We understand colleagues at NHSE have met with the National Child Mortality Database team and SUDIC charities and will be supporting a proposal for a round table to discuss and kickstart research and other actions in this area. The RCPCH has indicated that they are happy to support this approach and NICE would consider any request from NHSE to develop guidance in this area in the normal way.” 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 and the Clinical Knowledge Summary are considered sufficient to support timely assessment, investigation and referral for febrile seizures.
Verbatim wording from the response “We believe that our guideline on epilepsies: diagnosis and management [CG137], which was in place at the time of Louis’ death, is directly relevant to this case. The guideline covered diagnosing, treating and managing epilepsy and seizures in children, young people and adults in primary and secondary care and made recommendations on what should happen following a first seizure (section 1.4), diagnosis (section 1.5) and investigations (sections 1.6).” Source location Response from NICE
Open published response
30 Dec 2022 Gavin Peter Pedleham · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Lack of requirements for safe community storage of Oramorph and prevention of access by others View source Lack of regulations governing Oramorph use in community settings 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
Gavin Peter Pedleham · 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
Gavin Peter Pedleham inadvertently drank a dose of Oramorph left in a glass at a family Christmas party after consuming a significant quantity of alcohol. He was found dead the following morning, and the inquest recorded morphine and ethanol toxicity, concluding that his death was accidental. The substantive concern was that community use of Oramorph is not subject to similar safe-storage requirements as its use in institutional settings, allowing access by others.
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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 Lack of requirements for safe community storage of Oramorph and prevention of access by others
Wider context from the report “1. Oramorph is a controlled drug the storage, handling and administration of which in institutional settings is highly regulated. However, there are no similar regulations which govern its use in a community setting. There is no requirement for the recipient of the drug in the community to keep it in a safe place and ensure that it cannot be accessed by others .
” Open source report × Source evidence
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 regulations governing Oramorph use in community settings
Wider context from the report “1. Oramorph is a controlled drug the storage, handling and administration of which in institutional settings is highly regulated. However, there are no similar regulations which govern its use in a community setting . There is no requirement for the recipient of the drug in the community to keep it in a safe place and ensure that it cannot be accessed by others.
” 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 national guidance on safely storing controlled drugs, including discussing storage options, access, and incident risks.
Verbatim wording from the response “Having reviewed your report, and the circumstances surrounding Mr Pedleham’s death, we believe our guideline on controlled drugs: safe use and management [NG46] is directly relevant to this case. The scope of this guideline covers all settings, including people's own homes, where publicly funded health and social care is delivered. It was developed in line with UK controlled drugs legislation and regulations.” 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 Existing national guidance is sufficient to address the safe use of controlled drugs in community settings.
Verbatim wording from the response “We therefore believe that there is sufficient national guidance on the use of controlled drugs in a community setting.” Source location Response from National Institute for Health and Care Excellence
Open published response
30 Aug 2022 Glenn Barton · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 1 Failure of CT scan guidance to identify patients with non-anticoagulant blood-clotting conditions 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
Glenn Barton · 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
Glenn Barton fell and struck his head on 19 August 2020, later developing a major subdural haemorrhage and dying on 22 August 2020. The concern was that clinical guidance was ambiguous about whether patients with conditions such as leukaemia, which can affect blood clotting, should receive a CT scan after a head injury, creating a risk of missed opportunities to scan such 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 CT scan guidance to identify patients with non-anticoagulant blood-clotting conditions
Wider context from the report “NICE Guidance (Head injury: assessment and early management published January 2014) states at para 1.4.12 that only patients who are on anticoagulant treatment should be offered/given a CT scan following a head injury with no other symptoms of concern (i.e. no loss of conscious, vomiting and no reduced CGS). It was clear from the evidence that there are other naturally occurring conditions, such as leukaemia, which can affect the ability of a patient’s blood to clot and so it would place such patients in the same potential risk category as those on anticoagulants, yet it is clear that a distinction is made .
Consequently I am concerned that the guidance (that for the avoidance of doubt was followed during Glenn’s treatment) is ambiguous for such patients in terms of triage and treatment/investigatory pathway meaning that there may be missed opportunities to CT scan patients in the future.
” 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 Make a research recommendation on the risks associated with a history of bleeding or clotting disorders.
Verbatim wording from the response “As we develop guidance, we identify gaps and uncertainties in the evidence base which could benefit from further research. The most important unanswered questions are developed into research recommendations. The committee has made a research” Source location Response from NICE
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Finalise the update of the head injury guideline, incorporating the updated review of serious-outcome risks for people with head injuries and coagulopathies.
Verbatim wording from the response “We are currently finalising an update of our guideline on head injury [CG176]. As part of this, we did update our review of the risks of serious outcomes in people with head injuries and a history of coagulopathies. The guideline committee did not find convincing evidence that this should be an indication for a head CT in the absence of other signs and symptoms, with the exception of someone taking oral anticoagulants or antiplatelets, so have not added this to recommendation 1.4.12.” 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 Keep the risks associated with bleeding or clotting disorders under review to identify the need for further guidance updates.
Verbatim wording from the response “As we develop guidance, we identify gaps and uncertainties in the evidence base which could benefit from further research. The most important unanswered questions are developed into research recommendations. The committee has made a research” 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 Existing guidance requires assessing head-injury patients for any history of bleeding or clotting disorders.
Verbatim wording from the response “A history of bleeding or clotting disorders remains in recommendation 1.4.8 as a risk marker in people who have some loss of consciousness or amnesia.” 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 Insufficient convincing evidence prevented adding bleeding or clotting disorders as a standalone indication for head CT.
Verbatim wording from the response “We are currently finalising an update of our guideline on head injury [CG176]. As part of this, we did update our review of the risks of serious outcomes in people with head injuries and a history of coagulopathies. The guideline committee did not find convincing evidence that this should be an indication for a head CT in the absence of other signs and symptoms, with the exception of someone taking oral anticoagulants or antiplatelets, so have not added this to recommendation 1.4.12.” Source location Response from NICE
Open published response
Concerns raised 1 Lack of national guidance on feeding expectations for low-risk formula-fed babies in the first 72 hours View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Muhammad Zayaan ul Hasan · 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
Muhammad Zayaan ul Hasan was born on 18 November 2020 and died at home on 21 November 2020, aged three days, after developing poor feeding, sleepiness and abnormal breathing. The principal concern was a lack of national guidance on feeding expectations for low-risk formula-fed babies during the first 72 hours, which may contribute to premature discharge and inadequate information for families about warning signs.
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 on feeding expectations for low-risk formula-fed babies in the first 72 hours
Wider context from the report “The MATTER OF CONCERN is that there is a lack of national guidance on feeding expectation for a formula fed baby in the first 72 hours when the baby is considered to be low risk . This may lead to babies being prematurely discharged and to families not being provided with appropriate information on signs of concern.
” Open source report
Concerns raised 1 Lack of specific guidelines for the optimal management of fetal infection View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Thomas Hoskin · 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 Hoskin was born by forceps at West Middlesex University Hospital on 8 April 2019 after signs of acute infection during labour. His condition at birth was extremely poor, and despite resuscitation he died in hospital shortly after birth on 9 April 2019. The report identified a lack of specific guidelines for managing fetal infection, which can be fatal or life-changing, as a substantive concern.
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 specific guidelines for the optimal management of fetal infection
Wider context from the report “It was brought to the Court's attention that the focus of guidelines relate to maternal infection, which is rarely life-threatening, but not to the optimal management of fetal infection which can be fatal or life changing . For Thomas, the evolving infection caused fetal circulatory collapse at birth and he could not be resuscitated.
There appear to be no specific guidelines available to assist clinicians in this difficult situation and it was agreed by the independently instructed expert and the clinicians who gave evidence that this would be a helpful development.
” Open source report
Concerns raised 1 Failure of nitrofurantoin prescribing guidance to provide advice on monitoring for sudden pulmonary deterioration during short-term treatment in elderly 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
Jane Elizabeth ALLISON · 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
Jane Elizabeth ALLISON died in hospital on 20 November 2021 after being admitted with severe type 1 respiratory failure. She had received a 10-day course of nitrofurantoin for a urinary tract infection, and the inquest concluded that she died from the effects of prescribed medication. The principal concern was that BNF guidance did not sufficiently alert clinicians to the risk of sudden pulmonary deterioration or provide adequate monitoring advice in this circumstance.
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 nitrofurantoin prescribing guidance to provide advice on monitoring for sudden pulmonary deterioration during short-term treatment in elderly patients
Wider context from the report “In effect, my concern is that the BNF content had not advised to be alerted to the danger of sudden pulmonary deterioration in an elderly patient , and certainly not one who was fit and active, and not in the context of the duration of a prescribing, dispensing and administration period of only 10 days. Effectively, the BNF content did not cover the eventuality of this case in that it was deficient in providing advice as to monitoring and being alert for pulmonary failure .
” 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 Responsibility for BNF content remains with its publishers, so the matter is outside NICE’s authority to comment on or amend.
Verbatim wording from the response “The BNF is a joint publication of 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 2022-0071-Response-from-NICE_Published
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 Royal Pharmaceutical Society is better placed to respond to concerns about the BNF entry for nitrofurantoin.
Verbatim wording from the response “I am aware that your report has also been sent to the chief executive of the Royal Pharmaceutical Society who will be better placed to respond to your concerns.” Source location 2022-0071-Response-from-NICE_Published
Open published response
Concerns raised 5 Failure to provide for careful reassessment after each IV fluid bolus View source Lack of guidance for balancing antibiotic and HUS risks in suspected sepsis View source Failure to maintain aligned and current guidance on IV fluid bolus volumes for children presenting with shock View source Lack of guidance on who to involve in antibiotic decisions for suspected sepsis with possible HUS View source Unclear escalation thresholds for intensive care during fluid resuscitation View source See 2 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
Coco Bradford · 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
Coco Bradford, a 6-year-old girl with autism, developed diarrhoea and vomiting, was diagnosed with haemolytic uraemic syndrome, deteriorated despite treatment and died in Bristol on 31 July 2017. The substantive concerns relate to the size and review of intravenous fluid boluses, when to escalate intensive care, and how clinicians should weigh antibiotic treatment when bacterial gastroenteritis and possible sepsis coexist because antibiotics may worsen haemolytic uraemic syndrome.
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 provide for careful reassessment after each IV fluid bolus
Wider context from the report “1) In April 2009, NICE published CG 84 on Diarrhoea and Vomiting caused by gastroenteritis in Under 5s and management. Paragraph 1.3.3 deals with IV fluid management for patients presenting with shock. The guidance suggests rehydration with rapid IV infusion at 20mls/kg.
The guidance is now a little dated and it is at odds with the Resuscitation Council UK Guidelines issued in 2021 which provide that for children and infants presenting with shock, fluid should be given in boluses of 10mls/kg – there is an emphasis on smaller boluses with careful re-assessment after each bolus to enable early identification of signs and symptoms of fluid overload .
This was particularly relevant in Coco’s treatment where there was concern she may develop HUS with associated compromise of kidney function.
As there appears now to be a move towards smaller boluses of fluid with more frequent review, it may be that you will also feel it appropriate to reconsider when to escalate care to colleagues in intensive care i.e. whether it should still be after two boluses or after a particular total amount of fluid.
” Open source report × Source evidence
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 for balancing antibiotic and HUS risks in suspected sepsis
Wider context from the report “2) A second issue that came out of Coco’s inquest was the clinical conundrum of how to treat a child with bacterial (e coli 0157) gastroenteritis who is suspected of having a concomitant sepsis. The dilemma is that the administration of antibiotics may precipitate or worsen HUS and, if the child is subsequently found not to have sepsis, may inadvertently cause harm. It may be that you will feel that guidance on how to weigh the balance of risk and who to involve in the decision-making process would be of assistance to clinicians generally.
” Open source report × Source evidence
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 aligned and current guidance on IV fluid bolus volumes for children presenting with shock
Wider context from the report “1) In April 2009, NICE published CG 84 on Diarrhoea and Vomiting caused by gastroenteritis in Under 5s and management. Paragraph 1.3.3 deals with IV fluid management for patients presenting with shock. The guidance suggests rehydration with rapid IV infusion at 20mls/kg.
The guidance is now a little dated and it is at odds with the Resuscitation Council UK Guidelines issued in 2021 which provide that for children and infants presenting with shock, fluid should be given in boluses of 10mls/kg – there is an emphasis on smaller boluses with careful re-assessment after each bolus to enable early identification of signs and symptoms of fluid overload.
This was particularly relevant in Coco’s treatment where there was concern she may develop HUS with associated compromise of kidney function.
As there appears now to be a move towards smaller boluses of fluid with more frequent review, it may be that you will also feel it appropriate to reconsider when to escalate care to colleagues in intensive care i.e. whether it should still be after two boluses or after a particular total amount of fluid.
” Open source report × Source evidence
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 who to involve in antibiotic decisions for suspected sepsis with possible HUS
Wider context from the report “2) A second issue that came out of Coco’s inquest was the clinical conundrum of how to treat a child with bacterial (e coli 0157) gastroenteritis who is suspected of having a concomitant sepsis. The dilemma is that the administration of antibiotics may precipitate or worsen HUS and, if the child is subsequently found not to have sepsis, may inadvertently cause harm. It may be that you will feel that guidance on how to weigh the balance of risk and who to involve in the decision-making process would be of assistance to clinicians generally.
” Open source report × Source evidence
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 Unclear escalation thresholds for intensive care during fluid resuscitation
Wider context from the report “1) In April 2009, NICE published CG 84 on Diarrhoea and Vomiting caused by gastroenteritis in Under 5s and management. Paragraph 1.3.3 deals with IV fluid management for patients presenting with shock. The guidance suggests rehydration with rapid IV infusion at 20mls/kg.
The guidance is now a little dated and it is at odds with the Resuscitation Council UK Guidelines issued in 2021 which provide that for children and infants presenting with shock, fluid should be given in boluses of 10mls/kg – there is an emphasis on smaller boluses with careful re-assessment after each bolus to enable early identification of signs and symptoms of fluid overload.
This was particularly relevant in Coco’s treatment where there was concern she may develop HUS with associated compromise of kidney function.
As there appears now to be a move towards smaller boluses of fluid with more frequent review, it may be that you will also feel it appropriate to reconsider when to escalate care to colleagues in intensive care i.e. whether it should still be after two boluses or after a particular total amount of fluid .
” 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 the 2021 UK Resuscitation Council guideline and consider whether CG84 and related NICE guidance need updating.
Verbatim wording from the response “In light of our initial review, your report has now been forwarded to our guideline surveillance team who will review the UK Resuscitation Council’s 2021 guideline and consider if CG84 and other related NICE guidance need to be updated.” Source location 2022-0012-Response-from-NICE_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review relevant NICE guidance for alignment with the 2021 UK Resuscitation Council paediatric advanced life support guidance.
Verbatim wording from the response “Your report, which has been reviewed by our internal patient safety team and chief medical officer, states that the NICE guideline on the diagnosis and management of diarrhoea and vomiting caused by gastroenteritis in under 5s [CG84] is not in line with the UK Resuscitation Council’s 2021 guideline on paediatric advanced life support. Having reviewed the guidance, we agree that the volume of fluid bolus does not align and as a result of this being highlighted, we have also looked at our other guidance of relevance.” Source location 2022-0012-Response-from-NICE_Published
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 Balancing antibiotic risks in suspected sepsis is considered clinical judgement and cannot be addressed by a guideline.
Verbatim wording from the response “Finally, you also note the difficulty of treating a child with bacterial gastroenteritis who is suspected to have concomitant sepsis and ask if guidance on ‘how to weigh the balance of risk and who to involve in the decision-making process’ would be useful. Reflecting on the specific issue raised in your report, that ‘the administration of antibiotics may precipitate or worsen [haemolytic uraemic syndrome]’ and, if the child is subsequently found not to have sepsis, may inadvertently cause harm’, we consider this to be a matter of clinical judgement and not something that could be addressed by a guideline. Haemolytic uraemic syndrome is” Source location 2022-0012-Response-from-NICE_Published
Open published response
9 Nov 2021 Mollie Daisy DIMMOCK · Prevention of Future Deaths report Buckinghamshire
View report summary
Concerns raised 1 Lack of a clear national definition of large-for-gestational-age babies View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mollie Daisy DIMMOCK · 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
Mollie Daisy DIMMOCK died 34 minutes after delivery at Stoke Mandeville Hospital from perinatal asphyxia caused by hypoxia associated with umbilical cord compression during shoulder dystocia. The report identified uncertainty in national guidance because there is no definition of a large-for-gestational-age baby, creating variation in decisions about delivery mode and management of shoulder dystocia.
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 a clear national definition of large-for-gestational-age babies
Wider context from the report “NICE Guidance NG121 last updated 25 April 2019 relates to intrapartum care for women with existing medical conditions or obstetric complications and their babies.
Within this Guidance, whilst there is reference at paragraph 1.17 to guidance in respect mode of birth for large-for-gestational-age babies, there is no definition of a large-for-gestational-age baby in the Guidance.
There does not appear to be any national guidance or accepted definition of large-for-gestational-age such that application of the Guidance is open to interpretation and variation depending upon an NHS Trust's own policies and guidance , and, in turn, the interpretation of obstetricians and other clinicians advising potential parents in anticipation of delivery modes.
It is clear that NG121 is intended to provide guidance in relation to many potential scenarios which may impact upon care and mode of delivery decisions.
The uncertainty surrounding when section 1.17 of the Guidance should be relevant arises through the lack of a definition of a large-for-gestational-age baby.
Application of section 1.17 of the Guidance includes consideration of shoulder dystocia and options for continuing labour or caesarean section relevant to both the life of the mother and the baby.
” 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 No further action is required because introducing a cutoff could convey inappropriate certainty or reassurance despite diagnostic uncertainty.
Verbatim wording from the response “We believe that if the guideline were to provide a cut off it would be liable to convey inappropriate certainty, or reassurance if the cut off is not reached. As such, we do not believe that any action is required of NICE.” Source location 2021-0379-Response-from-NICE_Published
Open published response
Concerns raised 1 Lack of authoritative guidance for assessing diarrhoea and vomiting suspected to be caused by gastroenteritis in people over 70 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
Maureen Johnson · 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
Maureen Johnson became unwell with diarrhoea, vomiting and abdominal pain in late February 2021, later deteriorated with shortness of breath and was found to be seriously ill before dying at Stepping Hill Hospital on 13 March 2021. The report raises concern that authoritative guidance did not exist for assessing diarrhoea and vomiting suspected to be gastroenteritis in people over 70, including guidance on recognising dehydration and when face-to-face assessment is recommended.
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 authoritative guidance for assessing diarrhoea and vomiting suspected to be caused by gastroenteritis in people over 70
Wider context from the report “Given their physiological susceptibility to dehydration and its effects, it is a matter of concern that authoritative guidance does not currently exist as to the assessment of diarrhoea and vomiting suspected to be caused by gastroenteritis in the over 70s , as has previously been published in respect of children and infants younger than 5.
Such guidance might usefully provide a comprehensive overview of symptoms and signs of clinical dehydration in the over 70s, and give clinicians advice as to the circumstances in which a face-to-face assessment is recommended.
” 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 The existing Clinical Knowledge Summary provides appropriate gastroenteritis assessment advice, so no further action by NICE is required.
Verbatim wording from the response “While it is correct that we have not published a clinical guideline on gastroenteritis in adults, or children over the age of 5, there is a Clinical Knowledge Summary on gastroenteritis which we believe gives appropriate advice on the assessment of people who are suspected to have gastroenteritis, including questions that healthcare professionals should ask, the need to examine the person, the risk of dehydration, and symptoms to be aware of.” Source location Response from National Institute for Health and Care Excellence
Open published response
16 Jul 2021 Brian Jackson · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 2 Use of an inadequately effective CAM-ICU tool for delirium assessment View source Inconsistent recognition and diagnosis of delirium by hospital staff 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
Brian Jackson · 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
Following major heart surgery, Brian Jackson developed symptoms associated with post-operative delirium and, after transfer to a hospital ward, used a ligature to hang himself in a locked bathroom on 23 July 2020. He died at the scene despite prompt medical attention. Concerns included inconsistent recognition of delirium and reliance on the CAM-ICU assessment tool, which may fail to identify some patients at risk, including those presenting with paranoia or hypoactive symptoms.
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 Use of an inadequately effective CAM-ICU tool for delirium assessment
Wider context from the report “Following major heart surgery the Deceased spent a week on the Post-Operative Critical Care Unit, during which he presented intermittently with a range of symptoms which I was told in evidence constituted delirium, but were not consistently recognised or diagnosed as such by hospital staff. These symptoms were variously described as including confusion, agitation, severe paranoia and anxiety.
On a number of occasions the Deceased’s was assessed using the tool known as CAM-ICU, which I heard is a nationally recognised diagnostic tool, in widespread use across the country. On each occasion the result was negative for the purpose of delirium diagnosis, contradicting the view expressed in court to the effect that a diagnosis of delirium was appropriate.
The hospital had its own policy concerning the management of patients at risk of delirium, the use of which depended in large measure upon a diagnosis being made. My impression was that the CAM-ICU results relied too heavily upon whether the patient was orientated in time and place, without allowing for a more complex cocktails of presentational symptoms to be taken into account.
I was told by senior hospital staff that their investigation has revealed shortcomings in the efficacy of the CAM-ICU tool, notably in assessing the risk faced by patients with ‘hypo symptoms’ of delirium, or patients who produce a negative CAM-ICU result but present with evidence of paranoia .
I heard details of extensive changes made by the hospital in its local arrangements and also that the hospital had approached NICE to ask if the CAM-ICU tool itself could be modified to take account of the lessons it had learnt in this case. I was told that the response from NICE was that use of the tool (and NICE guidance around this subject) had only recently been reviewed, in 2019, and is not to be reviewed again for some time.
I am concerned that across the country an assessment tool remains in widespread use despite the problems identified and is likely to remain so for the indefinite future, meaning that patients at risk of delirium are not diagnosed or treated optimally . The outcome of this cases illustrates the gravity of the harm that can result.
” Open source report × Source evidence
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 recognition and diagnosis of delirium by hospital staff
Wider context from the report “Following major heart surgery the Deceased spent a week on the Post-Operative Critical Care Unit, during which he presented intermittently with a range of symptoms which I was told in evidence constituted delirium, but were not consistently recognised or diagnosed as such by hospital staff . These symptoms were variously described as including confusion, agitation, severe paranoia and anxiety.
On a number of occasions the Deceased’s was assessed using the tool known as CAM-ICU, which I heard is a nationally recognised diagnostic tool, in widespread use across the country. On each occasion the result was negative for the purpose of delirium diagnosis, contradicting the view expressed in court to the effect that a diagnosis of delirium was appropriate.
The hospital had its own policy concerning the management of patients at risk of delirium, the use of which depended in large measure upon a diagnosis being made. My impression was that the CAM-ICU results relied too heavily upon whether the patient was orientated in time and place, without allowing for a more complex cocktails of presentational symptoms to be taken into account.
I was told by senior hospital staff that their investigation has revealed shortcomings in the efficacy of the CAM-ICU tool, notably in assessing the risk faced by patients with ‘hypo symptoms’ of delirium, or patients who produce a negative CAM-ICU result but present with evidence of paranoia.
I heard details of extensive changes made by the hospital in its local arrangements and also that the hospital had approached NICE to ask if the CAM-ICU tool itself could be modified to take account of the lessons it had learnt in this case. I was told that the response from NICE was that use of the tool (and NICE guidance around this subject) had only recently been reviewed, in 2019, and is not to be reviewed again for some time.
I am concerned that across the country an assessment tool remains in widespread use despite the problems identified and is likely to remain so for the indefinite future, meaning that patients at risk of delirium are not diagnosed or treated optimally. The outcome of this cases illustrates the gravity of the harm that can result.
” 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 guideline CG103, focusing on delirium risk assessment and diagnosis, including in intensive care settings.
Verbatim wording from the response “Liverpool Heart and Chest Hospital informed us that they were undertaking a root cause analysis which was considering the ‘CAM/ISITIU – RASS delirium risk assessment’. We advised them that we had recently completed a review of CG103 and that we were going to update the guideline, focusing on the risk assessment and diagnosis of delirium, including in ICU settings. We also advised how they could engage with the development process and send evidence to us for consideration during the update.” Source location 2021-0246-Response-from-NICE_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the review of guideline CG103 on delirium prevention, diagnosis and management.
Verbatim wording from the response “Liverpool Heart and Chest Hospital informed us that they were undertaking a root cause analysis which was considering the ‘CAM/ISITIU – RASS delirium risk assessment’. We advised them that we had recently completed a review of CG103 and that we were going to update the guideline, focusing on the risk assessment and diagnosis of delirium, including in ICU settings. We also advised how they could engage with the development process and send evidence to us for consideration during the update.” Source location 2021-0246-Response-from-NICE_Published
Open published response
20 Jun 2021 Anne BRADLEY · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 2 Lack of a formal system for surgeons to provide endoscopists with information about tumour localisation errors and tattooing problems View source Failure to require or recommend equipment that increases tumour localisation accuracy in routine colonoscopies 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
Anne BRADLEY · 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
Anne Bradley underwent a colonoscopy that identified and tattooed a tumour, but the tumour was not located where expected during colectomy, requiring removal of a further section of colon. Post-operative complications led to bowel ischaemia and her death. Concerns included the lack of routine use of equipment that could improve tumour localisation and the absence of a formal system for sharing information about incorrect localisation or tattooing problems with endoscopists.
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 a formal system for surgeons to provide endoscopists with information about tumour localisation errors and tattooing problems
Wider context from the report “(2) Feedback to endoscopists at St Richards Hospital
I heard evidence that at St Richards Hospital surgeons do not necessarily feedback information regarding tattooing problems or incorrect localisation of tumours to endoscopists .
The concern that I therefore have is that there is no formal system at St Richards Hospital which requires surgeons to provide information about the incorrect localisation of tumours or tattooing problems which is then shared with endoscopists .
” Open source report × Source evidence
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 require or recommend equipment that increases tumour localisation accuracy in routine colonoscopies
Wider context from the report “(1) Use of scope guides/scope pilots
The colonoscopy was carried out without the use of a scope guide or scope pilot as none were available in the room used for Anne Bradley’s procedure. A scope guide or scope pilot is an additional piece of equipment which assists the endoscopist in carrying out a colonoscopy. I heard evidence from the endoscopist and 3 consultant colorectal surgeons who all agreed that the use of scope guides or scope pilots assist in accurately recording the location of a tumour.
The accuracy of this information is important in assisting the surgeons to locate the tumour especially during laparoscopic (keyhole) surgery with early stage tumours. I heard evidence that there are limited markers within the colon to assist the endoscopist to know the location and that tattoos used to mark the location of a tumour can, and in this case did, pierce through the colon and mark multiple areas.
Whilst St Richards Hospital explained that they have now equipped all rooms with scope guides or scope pilots I heard that use of such equipment is not required by quality assurance organisations.
The concern I have is that equipment which increases the accuracy of the localisation of a tumour is not required or recommended for use in routine colonoscopies.
” 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 Specific colonoscopy equipment, techniques and training fall outside the remit of clinical guidelines.
Verbatim wording from the response “While we have guidelines covering recognition and referral for suspected cancer [NG12], and the management of colorectal cancer [NG151], we have not made recommendations on colonoscopy. Guidance on specific equipment, techniques, and training are outside the remit of our clinical guidelines and it would be more appropriate for the professional societies, to whom I note you have also sent your report, to comment on this.” Source location 2021-0214-Response-from-NICE-_Published
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 societies are considered the appropriate bodies to comment on colonoscopy equipment, techniques and training.
Verbatim wording from the response “While we have guidelines covering recognition and referral for suspected cancer [NG12], and the management of colorectal cancer [NG151], we have not made recommendations on colonoscopy. Guidance on specific equipment, techniques, and training are outside the remit of our clinical guidelines and it would be more appropriate for the professional societies, to whom I note you have also sent your report, to comment on this.” Source location 2021-0214-Response-from-NICE-_Published
Open published response
2 Jun 2021 GEOFFREY WILLIAM HILL · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 3 Failure to undertake falls risk assessments for vulnerable and elderly A&E patients during prolonged stays View source Lack of national guidance for trolley rail assessments in A&E View source Lack of national guidelines for falls risk assessments in A&E departments 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
GEOFFREY WILLIAM HILL · 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
Geoffrey William Hill, aged 82, was admitted to hospital with Covid-19, reduced mobility and general illness, and fell from a trolley bed in the emergency department, sustaining a head injury. He later became unresponsive and died in hospital from a traumatic subdural haemorrhage. Concerns included the absence of a falls risk assessment, trolley rail assessment, advanced observations, mental test and therapy assessment, and the broader lack of national guidance for falls prevention in emergency departments.
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 undertake falls risk assessments for vulnerable and elderly A&E patients during prolonged stays
Wider context from the report “(7) I am concerned that vulnerable and elderly patients in A & E can spend long periods without any falls risk assessments being undertaken placing them at 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 for trolley rail assessments in A&E
Wider context from the report “(2) The inquest heard in evidence that there were no national guidelines on the use of falls risk assessments in A & E departments;
(3) The inquest heard in evidence there was no national requirements or guidance for a trolley rail assessment to be completed in A & E ;
(4) As Mr Hill did not present with a fall or recurrent falls there was no requirement for any generic or multi factorial risk assessment to be conducted;
” Open source report × Source evidence
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 for falls risk assessments in A&E departments
Wider context from the report “(2) The inquest heard in evidence that there were no national guidelines on the use of falls risk assessments in A & E departments ;
(3) The inquest heard in evidence there was no national requirements or guidance for a trolley rail assessment to be completed in A & E;
(4) As Mr Hill did not present with a fall or recurrent falls there was no requirement for any generic or multi factorial risk assessment to be conducted;
” 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 CG161 while considering issues raised in the report during scoping.
Verbatim wording from the response “We are about to update CG161 and the issues raised in your report will be considered as we scope out what needs to be considered in the update.” Source location 2021-0262-Response-from-NICE_Published
Open published response
21 May 2021 Dyllon Shaun Graham Milburn · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1 Lack of patient alerts for requesting and collecting repeat prescriptions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Dyllon Shaun Graham Milburn · 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
Dyllon Shaun Graham Milburn died on 8 October 2019 in the garden of his home in Manchester from asphyxiation using a ligature made from a scarf. He had been prescribed Sertraline and had periods of non-compliance. The report raised concern that the repeat-prescription system did not allow automated alerts to remind patients to request and collect their medication.
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 patient alerts for requesting and collecting repeat prescriptions
Wider context from the report “The system for repeat prescriptions does not currently allow for alerts to be sent to a patient to remind them to request and collect their repeat prescription to encourage compliance.
” 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 Changes to the EMIS system cannot be influenced by NICE.
Verbatim wording from the response “We have reflected on the circumstances surrounding Mr Milburn’s death, and the concerns raised in your report, in relation to NICE’s work. You suggest that an automated alert be added to the EMIS system to remind people to request and collect their repeat prescription to encourage compliance. While NICE is not able to influence changes to the EMIS system, the following NICE guidelines contain recommendations relevant to this report.” Source location 2021-0167-Response-from-NICE_Published
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 considers no action required because its implementation tools are put into practice locally.
Verbatim wording from the response “NICE produces tools to support implementation of our recommendations, but they are put into practice locally. Therefore, we do not consider that any action is required by NICE in response to your report.” Source location 2021-0167-Response-from-NICE_Published
Open published response
Concerns raised 1 Lack of national guidelines for monitoring and treating infants at risk of haemolytic disease of the newborn, including DCT-positive infants, after acute treatment and discharge View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Lola Sheldrake, also known as Lola Clarke · 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
Lola Sheldrake died aged 13 days on 23 December 2019 from severe anaemia caused by haemolytic disease of the newborn, which developed untreated after her discharge from hospital. The report raised concern that there were no national guidelines for monitoring and treating infants at risk, particularly following acute treatment after birth or discharge.
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 for monitoring and treating infants at risk of haemolytic disease of the newborn, including DCT-positive infants, after acute treatment and discharge
Wider context from the report “that there are no national guidelines in respect of the monitoring and treatment of infants at risk of haemolytic disease of the newborn/DCT positive infants and in particular no guidelines as to good practice following acute treatment immediately after birth and/or following discharge .
” Open source report
20 Apr 2021 Ella Adoo-Kissi-Debrah · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Insufficient undergraduate teaching on the health effects of air pollution View source Insufficient postgraduate education on the health effects of air pollution View source Insufficient detail and monitoring capacity for air quality information View source Insufficient professional guidance on communicating the health effects of air pollution View source Low public awareness of sources of national and local pollution information View source National Particulate Matter limits exceeding WHO guideline levels View source See 3 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
Ella Adoo-Kissi-Debrah · 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
Ella Adoo-Kissi-Debrah died aged 9 after an asthmatic episode led to cardiac arrest on 15 February 2013. The report states that air pollution, including exposure to nitrogen dioxide and particulate matter from traffic emissions, significantly contributed to her asthma and death. It also identifies concerns about pollution limits, public access to pollution information, and communication of air-pollution health risks by healthcare professionals.
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 undergraduate teaching on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” Open source report × Source evidence
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 postgraduate education on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” Open source report × Source evidence
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 detail and monitoring capacity for air quality information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government. The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors .
” Open source report × Source evidence
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 professional guidance on communicating the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” Open source report × Source evidence
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 Low public awareness of sources of national and local pollution information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government . The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors.
” Open source report × Source evidence
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 National Particulate Matter limits exceeding WHO guideline levels
Wider context from the report “(1) The national limits for Particulate Matter are set at a level far higher than the WHO guidelines. The evidence at the inquest was that there is no safe level for Particulate Matter and that the WHO guidelines should be seen as minimum requirements. Legally binding targets based on WHO guidelines would reduce the number of deaths from air pollution in the UK.
” 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 Amend the asthma guideline to acknowledge pollution-related asthma risks and include indoor and outdoor pollution exposure measures in personalised action plans.
Verbatim wording from the response “Following the inquest into Ella’s death, NICE carried out an exceptional surveillance review of its guideline on asthma to assess whether the link between air pollution and asthma was appropriately covered. As a result of this process, the decision was made to amend the NICE guideline on asthma: diagnosis, monitoring and chronic asthma management NICE guideline (NG80) to acknowledge the link between air pollution and asthma.” Source location 2021-0113-Response-from-National-Institute-for-Health-and-Care-Excellence-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete an exceptional surveillance review of the asthma guideline to assess coverage of the link between air pollution and asthma.
Verbatim wording from the response “Following the inquest into Ella’s death, NICE carried out an exceptional surveillance review of its guideline on asthma to assess whether the link between air pollution and asthma was appropriately covered. As a result of this process, the decision was made to amend the NICE guideline on asthma: diagnosis, monitoring and chronic asthma management NICE guideline (NG80) to acknowledge the link between air pollution and asthma.” Source location 2021-0113-Response-from-National-Institute-for-Health-and-Care-Excellence-Redacted
Open published response
Concerns raised 1 Failure to consider hormonal treatment and hormonal triggers when assessing depression in menopausal or perimenopausal women View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Sarah Jane Buckingham · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sarah Jane Buckingham died by hanging at her home on 12 August 2019 after a period of depression and a recent voluntary admission to a mental health hospital. The principal concern was that hormonal treatment or hormonal changes associated with perimenopause were not considered by the mental health clinicians treating her depressive illness, despite relevant previous episodes following childbirth.
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 consider hormonal treatment and hormonal triggers when assessing depression in menopausal or perimenopausal women
Wider context from the report “Sarah had been started on Hormone Replacement Therapy (HRT) by her GP in November 2017 as she was peri-menopausal. She began to experience and suffer from symptoms of depression once again in March 2019, and was clinically diagnosed with a depressive illness and anxiety.
It was only during a voluntary hospital admission between 28th – 30th July 2019 that Sarah had a blood test taken, which included a hormone profile. This was some four months into her illness and was only taken as 'routine'.
It transpired from the evidence at Sarah's Inquest that hormone treatment and/or hormonal triggers for depressive illness were not considered by the Mental Health Clinicians treating Sarah . I heard evidence that those treating Sarah relied on, and followed, NICE Guidelines but that NICE Guidance on Depression does not say anything about the routine monitoring of hormones, or that consideration be given to this potential contributory factor when treating menopausal or perimenopausal women . The significant impact of changing hormones was considered very early on in Sarah's treatment for PND, but was not considered at all during her last episode of depression ; with no justification or explanation as to why the impact of changing hormones was considered significant after birth, but not significant during menopause. I believe that an early consideration of these issues when treating a menopausal patient, and understanding of the potential interplay between hormonal changes and depression, may assist in formulating an effective treatment plan for patients such as Sarah.
” Open source report
27 Jan 2021 Michael Chahwanda · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 3 Lack of specific postnatal Vitamin D supplementation advice for attending Health Visitors View source Lack of directive for women at increased risk to take Vitamin D supplements View source Lack of Vitamin D provision to women and babies at increased risk of deficiency 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
Michael Chahwanda · 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
Michael Chahwanda was born on 19 September 2018 and died at Royal Manchester Children’s Hospital on 16 December 2018 after suffering a seizure at home. The report states that his death was associated with severe Vitamin D deficiency, with circulatory failure following an out-of-hospital cardiac arrest and cardiomyopathy associated with Vitamin D deficiency recorded at inquest. Concerns included the lack of specific postnatal Vitamin D supplementation advice in the Red Book and the absence of a directive for, or provision of supplements to, women and breast-fed babies at increased risk of deficiency.
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 specific postnatal Vitamin D supplementation advice for attending Health Visitors
Wider context from the report “1. To The Royal College of Paediatrics and Child Health and Department of Health and Social Care and The National Institute for Health and Care Excellence: To consider an amendment to the Red Book to include specific advice for Vitamin D supplementation in the postnatal period to be given by the attending Health Visitor . Such advice would be consistent with national 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 Lack of directive for women at increased risk to take Vitamin D supplements
Wider context from the report “2. To Department of Health and Social Care and The National Institute for Health and Care Excellence : To consider an amendment to the guidelines so that there is a directive for women (particularly those with an increased skin pigmentation and those who are breast-feeding) to take Vitamin D supplements . Also, to consider the provision of Vitamin D to women and babies who are at an increased risk of Vitamin D deficiency.
” Open source report × Source evidence
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 Vitamin D provision to women and babies at increased risk of deficiency
Wider context from the report “2. To Department of Health and Social Care and The National Institute for Health and Care Excellence : To consider an amendment to the guidelines so that there is a directive for women (particularly those with an increased skin pigmentation and those who are breast-feeding) to take Vitamin D supplements. Also, to consider the provision of Vitamin D to women and babies who are at an increased risk of Vitamin D deficiency .
” 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 postnatal care guideline to include a recommendation on vitamin D supplements for breastfeeding women.
Verbatim wording from the response “NICE also has a guideline on postnatal care up to 8 weeks after birth (CG37). This guideline includes advice on breastfeeding, and the management of common and serious health problems in women and their babies after the birth, and is currently in the process of being updated. The updated draft guideline includes the following new recommendation:” Source location 2021-0020-Response-from-NICE-Redacted
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 Further consider the issues raised by the report when the vitamin D guideline is next reviewed.
Verbatim wording from the response “We do not consider that PH56 needs to be amended as a result of your correspondence. However, the issues raised by your report will be further considered when the guideline is next considered for review.” Source location 2021-0020-Response-from-NICE-Redacted
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 Amendments to the Red Book’s vitamin D content should be considered by the RCPCH, which oversees the publication.
Verbatim wording from the response “The red book (Personal Child Health Record (PCHR)) is currently overseen by a multi-disciplinary group hosted by the Royal College of Paediatrics and Child Health (RCPCH). Therefore, we consider the RCPCH will be best placed to consider amendments to the current content of the publication with regards to vitamin D supplementation.” Source location 2021-0020-Response-from-NICE-Redacted
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 considers its current vitamin D guideline adequately addresses the identified risks and does not require amendment.
Verbatim wording from the response “We consider that NICE’s current guideline on vitamin D (PH56) appropriately highlights the increased risk of vitamin D deficiency and the need to take vitamin D supplements in the population groups you refer to.” Source location 2021-0020-Response-from-NICE-Redacted
Open published response
1 Dec 2020 Brandon-Robert William Collins-Hayward · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 2 Lack of national guidance for close monitoring of mothers and babies following discharge after birth View source Lack of national guidance for medical assessment of a baby when the mother is admitted to hospital with potential sepsis 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
Brandon-Robert William Collins-Hayward · 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
Brandon-Robert William Collins-Hayward was born on 29 May 2019 and died on 7 June 2019, aged 9 days, after developing reduced milk intake, a lip shiver, grumbling noises, jaundice, discharge and breathing difficulties. The principal concerns were the lack of national guidance for observations during early postnatal visits and for assessing a baby when the mother is admitted to hospital with infection or possible sepsis.
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 close monitoring of mothers and babies following discharge after birth
Wider context from the report “i. I am concerned that due to the lack of national guidance regarding close monitoring of mothers and babies following discharge after birth , and the fact that there is no national guidance for a medical assessment of a baby when the mother is admitted to hospital with potential sepsis, there could be a death 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 guidance for medical assessment of a baby when the mother is admitted to hospital with potential sepsis
Wider context from the report “i. I am concerned that due to the lack of national guidance regarding close monitoring of mothers and babies following discharge after birth, and the fact that there is no national guidance for a medical assessment of a baby when the mother is admitted to hospital with potential sepsis , there could be a death in the future.
” 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 postnatal care guidance to recommend assessing babies when mothers have confirmed or suspected puerperal sepsis.
Verbatim wording from the response “The concerns raised in your report surrounding the circumstances of Brandon-Robert’s death were, whether there is sufficient guidance relating to the monitoring of mothers and babies in the immediate time following discharge from hospital after birth, and the assessment of babies when the mother is admitted to hospital within 28 days of birth (especially when diagnosed with infection and at high risk of developing sepsis).” Source location Response from National Institute for Health and Care Excellence
Open published response
4 Sep 2020 Zoe Amanda Knight · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Overlap between aortic dissection and other cardiac-condition symptoms impeding or delaying diagnosis View source Failure to implement an ‘aortic pain’ discriminator for chest-pain triage 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
Zoe Amanda Knight · 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
Zoe Amanda Knight developed chest pain and other symptoms, was taken to hospital, and deteriorated after a brief seizure while being investigated for ischaemic heart disease and pulmonary embolism. A post-mortem examination concluded that she died from a dissecting aneurysm of the thoracic aorta. The report raised concerns about the overlap of symptoms with other cardiac conditions, delayed recognition of aortic dissection, and the apparent non-implementation of a recommendation to add “aortic pain” as a chest-pain triage discriminator.
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 Overlap between aortic dissection and other cardiac-condition symptoms impeding or delaying diagnosis
Wider context from the report “1. I heard from Dr ████████, a Consultant Cardiologist at Tameside general Hospital that aortic dissection is a well-recognised, but rare condition. It has some characteristic symptoms, but these are by no means definitively diagnostic.
2. There is an overlap of the symptoms of aortic dissection with other cardiac conditions, which can impede or delay the process of diagnosis. Rupture of the aorta following dissection as suffered by Mrs Knight is a catastrophic event.
3. Dr ████████ was aware of the recommendation made by the Healthcare Safety Investigation Branch – Delayed Recognition of Acute Aortic Dissection (Healthcare Safety Investigation I2017/002b – January 2020 Edition) which contained Safety recommendation R/2020/066:
“It is recommended that the Manchester Triage International Reference Group considers the addition of ‘aortic pain’ to the Manchester Triage System as a discriminator for chest pain, to raise awareness of acute aortic dissection as a potential cause.”
4. It does not appear that this recommendation has been implemented.
5. Dr ████████’s evidence was that awareness of aortic dissection was primarily through case-based learning but acknowledged that the recommendation from thee Healthcare Safety Investigation Report above would additionally raise awareness at the triage stage.
” Open source report × Source evidence
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 implement an ‘aortic pain’ discriminator for chest-pain triage
Wider context from the report “1. I heard from Dr ████████, a Consultant Cardiologist at Tameside general Hospital that aortic dissection is a well-recognised, but rare condition. It has some characteristic symptoms, but these are by no means definitively diagnostic.
2. There is an overlap of the symptoms of aortic dissection with other cardiac conditions, which can impede or delay the process of diagnosis. Rupture of the aorta following dissection as suffered by Mrs Knight is a catastrophic event.
3. Dr ████████ was aware of the recommendation made by the Healthcare Safety Investigation Branch – Delayed Recognition of Acute Aortic Dissection (Healthcare Safety Investigation I2017/002b – January 2020 Edition) which contained Safety recommendation R/2020/066:
“It is recommended that the Manchester Triage International Reference Group considers the addition of ‘aortic pain’ to the Manchester Triage System as a discriminator for chest pain, to raise awareness of acute aortic dissection as a potential cause.”
4. It does not appear that this recommendation has been implemented.
5. Dr ████████’s evidence was that awareness of aortic dissection was primarily through case-based learning but acknowledged that the recommendation from thee Healthcare Safety Investigation Report above would additionally raise awareness at the triage stage.
” 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 Follow up with relevant professional organisations to improve use of NICE guidance on aortic dissection.
Verbatim wording from the response “In terms of improving awareness and learning on this topic, the responsibility for the education and training of healthcare professionals rests with the relevant professional bodies, such as the Royal Colleges, the GMC and Health Education England. We regularly engage with these organisations to improve use of our guidelines, and we will follow up in relation to this issue.” Source location Response-from-NICE-2020-0168-Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete surveillance review of CG95, consulting experts and deciding whether additional aortic dissection guidance was needed.
Verbatim wording from the response “Reviewing this guideline” Source location Response-from-NICE-2020-0168-Redacted.pdf
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 decided not to add more detailed aortic dissection diagnosis guidance because topic experts considered this inappropriate.
Verbatim wording from the response “During this review, NICE also considered whether more detailed guidance on the diagnosis of aortic dissection (or acute aortic syndrome) should be included in the guideline.” Source location Response-from-NICE-2020-0168-Redacted.pdf
Open published response
Concerns raised 2 Omission of Lamotrigine self-harm or suicide risk from pharmacological information resources View source Failure to provide patients with information about Lamotrigine side effects View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Viktor John Anthony Scott-Brown · 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
Viktor John Anthony Scott-Brown, aged 23, was found hanging at his home overnight on 14/15 December 2018 and pronounced dead at the scene; the inquest concluded that his death was suicide. He had been prescribed Lamotrigine without being warned about its potential association with thoughts of self-harm or suicide, and concerns were raised that reputable prescribing resources were inconsistent or silent about this potential side effect.
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 Omission of Lamotrigine self-harm or suicide risk from pharmacological information resources
Wider context from the report “Mr Scott-Brown was prescribed Lamotrigine by an NHS Foundation Trust Consultant Psychiatrist. The prescribing consultant did not give Mr Scott-Brown a Trust information sheet about Lamotrigine and a Patient Information Leaflet about Lamotrigine from the drug manufacturer, GlaxoSmithKline. It was common ground that the consultant should have done so. Both documents record as a side effect of using Lamotrigine a risk that the patient may begin to experience thoughts of self-harm or suicide. Mr Scott-Brown was never given that information.
The consultant gave evidence that he was not aware of that particular side effect of Lamotrigine, and that his prescribing practice was informed by the British National Formulary and The Maudsley Prescribing Guidelines. Neither the online BNF viewable via the NICE website nor the 10th Edition of The Maudsley Guidelines (to which the court was referred) refer to that side effect in their respective entries for Lamotrigine.
Subsequent to the conclusion of the Inquest, I have learned from the Oxleas NHS Foundation Trust that when Mr Scott-Brown was prescribed Lamotrigine, then the current edition of the Maudsley Guidelines was the 13th Edition. The Inquest heard no evidence about the 13th Edition of the Maudsley Guidelines and information therein concerning Lamotrigine.
Quite apart from any issue regarding the consultant’s knowledge about Lamotrigine (and the existence of the 13th Edition of the Maudsley Guidelines) and his not having given Mr Scott-Brown the Trust’s prepared information about the drug and its side effects, I am concerned that two obviously reputable sources of pharmacological information are apparently silent, or have been silent, on a potentially significant side effect of this particular drug.
From a lay perspective, there is apparent potential for harm to patients depending upon which resources a prescriber consults before prescribing Lamotrigine. That potential for harm might be ameliorated were the advice about Lamotrigine consistent across all such resources.
” Open source report × Source evidence
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 patients with information about Lamotrigine side effects
Wider context from the report “Mr Scott-Brown was prescribed Lamotrigine by an NHS Foundation Trust Consultant Psychiatrist. The prescribing consultant did not give Mr Scott-Brown a Trust information sheet about Lamotrigine and a Patient Information Leaflet about Lamotrigine from the drug manufacturer, GlaxoSmithKline. It was common ground that the consultant should have done so. Both documents record as a side effect of using Lamotrigine a risk that the patient may begin to experience thoughts of self-harm or suicide. Mr Scott-Brown was never given that information.
The consultant gave evidence that he was not aware of that particular side effect of Lamotrigine, and that his prescribing practice was informed by the British National Formulary and The Maudsley Prescribing Guidelines. Neither the online BNF viewable via the NICE website nor the 10th Edition of The Maudsley Guidelines (to which the court was referred) refer to that side effect in their respective entries for Lamotrigine.
Subsequent to the conclusion of the Inquest, I have learned from the Oxleas NHS Foundation Trust that when Mr Scott-Brown was prescribed Lamotrigine, then the current edition of the Maudsley Guidelines was the 13th Edition. The Inquest heard no evidence about the 13th Edition of the Maudsley Guidelines and information therein concerning Lamotrigine.
Quite apart from any issue regarding the consultant’s knowledge about Lamotrigine (and the existence of the 13th Edition of the Maudsley Guidelines) and his not having given Mr Scott-Brown the Trust’s prepared information about the drug and its side effects, I am concerned that two obviously reputable sources of pharmacological information are apparently silent, or have been silent, on a potentially significant side effect of this particular drug.
From a lay perspective, there is apparent potential for harm to patients depending upon which resources a prescriber consults before prescribing Lamotrigine. That potential for harm might be ameliorated were the advice about Lamotrigine consistent across all such resources.
” 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 epilepsy guideline and consider incorporating the coroner’s concerns, including moving the suicidal-thoughts footnote into the recommendation.
Verbatim wording from the response “The guideline is currently in the process of being updated.” Source location 2020-0163-Response-from-NICE_Redacted.pdf
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 Reviewing the content of the British National Formulary is outside NICE’s role and authority.
Verbatim wording from the response “Although accessible from the NICE website, the BNF is a joint publication of the British Medical Association and the Royal Pharmaceutical Society. NICE manages the contract for the production of the BNF and BNF for Children (BNFC), but has no role in reviewing their content.” Source location 2020-0163-Response-from-NICE_Redacted.pdf
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 considering and acting on the BNF content concerns rests with its publishers.
Verbatim wording from the response “Your concerns have therefore been passed to the BNF publishers, in confidence, for their consideration and action, as appropriate. They have confirmed they will respond to the Regulation 28: Report directly to you, copying NICE into their response.” Source location 2020-0163-Response-from-NICE_Redacted.pdf
Open published response
Concerns raised 2 Lack of national guidance on managing and reducing pressure-ulcer risks in Emergency Departments View source Failure of Trust policies to recognise and respond appropriately to pressure-ulcer risk during prolonged Emergency Department stays View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Beryl Holland · 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
Beryl Holland sustained a fractured neck of femur after a fall at the care home where she resided, underwent surgery at Stepping Hill Hospital, continued to decline post-operatively, and died there on 7 July 2019. The concerns related to her prolonged stay in the Emergency Department while awaiting a ward bed, her vulnerability to pressure ulcers, and the absence of national guidance for managing pressure-ulcer risks in Emergency Department settings.
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 on managing and reducing pressure-ulcer risks in Emergency Departments
Wider context from the report “The inquest heard that Beryl Holland was in the Emergency Department of the Acute Hospital for a significant period of time before ultimately been transferred to a ward. This was due to awaiting a suitable bed. She was vulnerable and at high risk of developing pressure ulcers. The trust in question had identified gaps in its processes and taken steps to reduce the risk of pressure ulcers developing/worsening in the Emergency Department. The inquest was told that there is no national guidance relating to the management of/reducing the risks of pressure ulcers developing in an Emergency Department setting . As a result, Trusts will develop their own policies, which may not always recognise and react appropriately to the level of risk faced by those at risk of pressure ulcers particularly where there are prolonged periods of time in the Emergency Department.
” Open source report × Source evidence
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 Trust policies to recognise and respond appropriately to pressure-ulcer risk during prolonged Emergency Department stays
Wider context from the report “The inquest heard that Beryl Holland was in the Emergency Department of the Acute Hospital for a significant period of time before ultimately been transferred to a ward. This was due to awaiting a suitable bed. She was vulnerable and at high risk of developing pressure ulcers. The trust in question had identified gaps in its processes and taken steps to reduce the risk of pressure ulcers developing/worsening in the Emergency Department. The inquest was told that there is no national guidance relating to the management of/reducing the risks of pressure ulcers developing in an Emergency Department setting. As a result, Trusts will develop their own policies, which may not always recognise and react appropriately to the level of risk faced by those at risk of pressure ulcers particularly where there are prolonged periods of time in the Emergency Department .
” 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 Existing NICE guidance addresses pressure-ulcer risk assessment in emergency departments, so no further action is required at this time.
Verbatim wording from the response “The NICE guideline on the prevention and management of pressure sores (CG179) specifically provides advice to clinicians regarding patients receiving care in emergency department settings.” Source location 2020-0037-Response-from-NICE
Open published response
20 Feb 2020 Jon David JAMES · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 2 Rising deaths related to acute behavioural disturbance View source Lack of current NICE guidance on acute behavioural disturbance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jon David JAMES · 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
Jon David James died on 27 June 2017 after suffering cardiac arrest during restraint following an episode of acute behavioural disturbance associated with cocaine and anabolic steroid use. The principal concern was the absence of specific NICE guidance on acute behavioural disturbance, which the report states would benefit police, paramedics, emergency call handlers and medical professionals.
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 Rising deaths related to acute behavioural disturbance
Wider context from the report “1. Extensive evidence was received from a Consultant Forensic Pathologist and an expert who is a lead trainer for South Wales Police. They were both of the firm opinion that the publication of NICE guidance on the subject of Acute Behavioural Disturbance would be of vital benefit in preventing future deaths.
2. ABD is clearly a complex topic, with understanding ever-increasing. There have been other PFD reports from coroners seeking to implement national training and guidance on ABD, primarily for frontline police, emergency call handlers and paramedics. However, it is only the paramountcy of NICE guidance that would place ABD at the forefront of the national agenda. Critically, such guidance would be of enormous practical use not only to medical professionals, but also to police and any others who find themselves in the difficult position of having to respond to an individual exhibiting signs of ABD in either public places or clinical settings.
3. There is no current NICE guidance dealing specifically with ABD, and the number of deaths related to it is rising .
” Open source report × Source evidence
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 NICE guidance on acute behavioural disturbance
Wider context from the report “1. Extensive evidence was received from a Consultant Forensic Pathologist and an expert who is a lead trainer for South Wales Police. They were both of the firm opinion that the publication of NICE guidance on the subject of Acute Behavioural Disturbance would be of vital benefit in preventing future deaths.
2. ABD is clearly a complex topic, with understanding ever-increasing. There have been other PFD reports from coroners seeking to implement national training and guidance on ABD, primarily for frontline police, emergency call handlers and paramedics. However, it is only the paramountcy of NICE guidance that would place ABD at the forefront of the national agenda. Critically, such guidance would be of enormous practical use not only to medical professionals, but also to police and any others who find themselves in the difficult position of having to respond to an individual exhibiting signs of ABD in either public places or clinical settings.
3. There is no current NICE guidance dealing specifically with ABD , and the number of deaths related to it is rising.
” 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 Undertake the full NG10 update, including considering whether to extend its scope to ABD and clarify recommendation 1.5.5 terminology.
Verbatim wording from the response “Our guideline on violence and aggression (NG10) is due to undergo a full update in due course and your concerns have been noted for further consideration by the guidelines team as part of this work, including whether it is appropriate for the scope of NG10 to be extended to cover ABD, and any necessary clarification to the terminology in recommendation 1.5.5.” Source location 2020-0042-Response-from-NICE
Open published response
31 Jan 2020 Renee Simone Brooks · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Lack of UK guidance on the safe frequency of lipoedema-related liposuction procedures View source Lack of UK guidance on the amount of fluid to remove during lipoedema-related liposuction View source Lack of UK guidance on the amount of fluid to put into patients during lipoedema-related liposuction View source Lack of UK guidance on post-procedure patient recovery plans for lipoedema-related liposuction View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Renee Simone Brooks · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Renee Simone Brooks underwent a final large-volume liposuction procedure on 29 August 2019, suffered cardiac arrest during the procedure, and died in hospital on 30 August 2019. The inquest identified fat embolism syndrome as a recognised but rare complication, with pre-existing cardiac issues contributing. The principal concern was the absence of UK guidance on safe practice for lipoedema-related liposuction, including procedure frequency, fluid volumes, and post-procedure recovery planning.
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 UK guidance on the safe frequency of lipoedema-related liposuction procedures
Wider context from the report “Large volume liposuction is the recognised treatment for patients with lipoedema performed by a small number of specialist surgeons. UK guidance is limited to cosmetic procedures. There are no UK guidelines for lipoedema related liposuction and practices amongst surgeons vary considerably. I heard evidence from ████████ - consultant plastic and reconstruction surgeon, ████████ – Spire’s Group Clinical Director, and ████████ - investigation lead for Spire Parkway Hospital. All expressed concern about the absence of UK guidance relating to indications for safe practice . In particular, in relation to: (a) the frequency of procedures on a single patient , (b) the amount of fluid to put into the patient during the procedure, (c) the amount of fluid to remove from the patient during the procedure, and (d) the post procedure patient recovery plan. Spire Group have since the death of Mrs Brooks created their own internal standard guidance. The majority of procedures are performed on privately paying patients, although the NHS will refer a small number of patients for the procedure funded by the NHS.
My ongoing concern is that absence of UK guidance relating to indications for safe practice for lipoedema related liposuction is putting patients’ lives at risk. In my opinion there is a risk that future deaths will occur unless action is taken.
” Open source report × Source evidence
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 UK guidance on the amount of fluid to remove during lipoedema-related liposuction
Wider context from the report “Large volume liposuction is the recognised treatment for patients with lipoedema performed by a small number of specialist surgeons. UK guidance is limited to cosmetic procedures. There are no UK guidelines for lipoedema related liposuction and practices amongst surgeons vary considerably. I heard evidence from ████████ - consultant plastic and reconstruction surgeon, ████████ – Spire’s Group Clinical Director, and ████████ - investigation lead for Spire Parkway Hospital. All expressed concern about the absence of UK guidance relating to indications for safe practice . In particular, in relation to: (a) the frequency of procedures on a single patient, (b) the amount of fluid to put into the patient during the procedure, (c) the amount of fluid to remove from the patient during the procedure , and (d) the post procedure patient recovery plan. Spire Group have since the death of Mrs Brooks created their own internal standard guidance. The majority of procedures are performed on privately paying patients, although the NHS will refer a small number of patients for the procedure funded by the NHS.
My ongoing concern is that absence of UK guidance relating to indications for safe practice for lipoedema related liposuction is putting patients’ lives at risk. In my opinion there is a risk that future deaths will occur unless action is taken.
” Open source report × Source evidence
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 UK guidance on the amount of fluid to put into patients during lipoedema-related liposuction
Wider context from the report “Large volume liposuction is the recognised treatment for patients with lipoedema performed by a small number of specialist surgeons. UK guidance is limited to cosmetic procedures. There are no UK guidelines for lipoedema related liposuction and practices amongst surgeons vary considerably. I heard evidence from ████████ - consultant plastic and reconstruction surgeon, ████████ – Spire’s Group Clinical Director, and ████████ - investigation lead for Spire Parkway Hospital. All expressed concern about the absence of UK guidance relating to indications for safe practice . In particular, in relation to: (a) the frequency of procedures on a single patient, (b) the amount of fluid to put into the patient during the procedure , (c) the amount of fluid to remove from the patient during the procedure, and (d) the post procedure patient recovery plan. Spire Group have since the death of Mrs Brooks created their own internal standard guidance. The majority of procedures are performed on privately paying patients, although the NHS will refer a small number of patients for the procedure funded by the NHS.
My ongoing concern is that absence of UK guidance relating to indications for safe practice for lipoedema related liposuction is putting patients’ lives at risk. In my opinion there is a risk that future deaths will occur unless action is taken.
” Open source report × Source evidence
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 UK guidance on post-procedure patient recovery plans for lipoedema-related liposuction
Wider context from the report “Large volume liposuction is the recognised treatment for patients with lipoedema performed by a small number of specialist surgeons. UK guidance is limited to cosmetic procedures. There are no UK guidelines for lipoedema related liposuction and practices amongst surgeons vary considerably. I heard evidence from ████████ - consultant plastic and reconstruction surgeon, ████████ – Spire’s Group Clinical Director, and ████████ - investigation lead for Spire Parkway Hospital. All expressed concern about the absence of UK guidance relating to indications for safe practice . In particular, in relation to: (a) the frequency of procedures on a single patient, (b) the amount of fluid to put into the patient during the procedure, (c) the amount of fluid to remove from the patient during the procedure, and (d) the post procedure patient recovery plan . Spire Group have since the death of Mrs Brooks created their own internal standard guidance. The majority of procedures are performed on privately paying patients, although the NHS will refer a small number of patients for the procedure funded by the NHS.
My ongoing concern is that absence of UK guidance relating to indications for safe practice for lipoedema related liposuction is putting patients’ lives at risk. In my opinion there is a risk that future deaths will occur unless action is taken.
” 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 producing new guidance on liposuction for chronic lipoedema.
Verbatim wording from the response “In view of the safety concerns raised by this case, the IP team will consider whether:” Source location 2020-0260-Response-from-NICE_Redacted.pdf
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