27 Jan 2020 Shanté Andrée Marie TURAY-THOMAS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 21 Provision of incorrect advice that an adrenaline auto injector switch is only a brand substitution View source Failure to reconsider adrenaline auto injector dose after switching device View source Inadequate and incorrect national training content for 111 call handlers on adrenaline auto injectors View source Failure to identify patients at particularly high risk from allergies and asthma View source Lack of named accountability for allergy services and provision View source Failure to assess patients’ access to and understanding of adrenaline auto injector advice View source Failure of the Adastra system to update location information across screens in real time View source Failure to establish whether specialist allergy care was being provided View source Inconsistency in anaphylaxis ambulance categorisation between 999 and 111 services View source Failure to explain the need for sequential administration of two adrenaline auto injectors in acute anaphylaxis View source Failure of 111 call audits to identify all significant call-handling failings View source Rare provision of practical placebo-device adrenaline auto injector training View source Failure to provide healthcare-professional training after an adrenaline auto injector switch View source Failure to communicate device-specific training requirements for adrenaline auto injectors View source Failure of NHS Digital to retain and act on previously identified call-handling safety issues View source Failure of AAI leaflets to specify the need for device-specific healthcare-professional training View source Failure of the 999 service to safety-net inappropriate 111 categorisation View source Single-sale availability of Emerade adrenaline auto injectors View source Failure to record and emphasise the need to carry two adrenaline auto injector pens View source Failure to advise prescribers to reconsider adrenaline auto injector dose after a device switch View source Failure to display the advice to carry two adrenaline auto injectors on the outside of the box View source See 18 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Shanté Andrée Marie TURAY-THOMAS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Shanté Andrée Marie Turay-Thomas ate hazelnuts on 18 September 2018 and died soon afterwards from acute anaphylaxis. The report identifies concerns about inadequate allergy care, advice and training concerning adrenaline auto-injectors, prescribing and clinical communication, and errors in the NHS 111 response and ambulance categorisation.
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 Provision of incorrect advice that an adrenaline auto injector switch is only a brand substitution
Wider context from the report “7. The GPs relied upon the advice given by Enfield Clinical Commissioning Group (CCG) that the scriptswitch was simply the replacement of one branded product with another branded product of the same drug/device . This gave false reassurance. The CCG joint formulary committee introduced a new drug for GPs, but then gave the wrong advice to accompany this .
” Open source report × Source evidence
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 reconsider adrenaline auto injector dose after switching device
Wider context from the report “5. When Shanté’s AAI was changed from an EpiPen to an Emerade, her GPs failed to reconsider the prescription and to increase her dose from 300mgs to 500mcgs .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Inadequate and incorrect national training content for 111 call handlers on adrenaline auto injectors
Wider context from the report “17. In terms of national training for 111 call handlers, the NHS Digital distance learning pack contains advice that is in part inadequate and in part wrong . It does not give the crucial information that one dose of adrenaline, by whichever device it is administered, is very unlikely to be sufficient in the case of acute anaphylaxis . It contains a photograph to illustrate the use of an AAI, but in the photograph the device is held incorrectly .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to identify patients at particularly high risk from allergies and asthma
Wider context from the report “1. At the time of her death, Shanté was not receiving specialist care for her allergies. However, her general practitioners (GPs) failed to appreciate this. They assumed that she was being treated for her allergies at the transitional asthma clinic to which she had been referred following her paediatric discharge. This was an incorrect assumption.
The GPs had not identified Shanté (who had a high BMI and was severely allergic) as being at particularly high risk from her allergies and asthma, and had no awareness that they were the sole providers of Shanté’s allergy care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of named accountability for allergy services and provision
Wider context from the report “20. The issues within this prevention of future deaths report are predominantly national issues, but I heard at inquest that there is no person with named accountability for allergy services and allergy provision at NHS England or the Department of Health as a whole .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to assess patients’ access to and understanding of adrenaline auto injector advice
Wider context from the report “2. Shanté’s GPs knew that she should carry two adrenaline auto injector (AAI) pens at all times, and they may have mentioned this to her, but they failed to record this and they did not emphasise it to her.
They failed to emphasise to Shanté and her family that the reason for carrying two pens is primarily because in the event of severe acute anaphylaxis, the very strong likelihood is that both pens will need to be administered, one five minutes after the other, to keep the patient alive until the arrival of an emergency ambulance.
The GPs did not explore with Shanté the reason for her erratic requests for a pen . They did not explore with her where she kept her pens . They did not test her understanding of medical advice .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure of the Adastra system to update location information across screens in real time
Wider context from the report “14. When Shanté became ill following the ingestion of nuts, her mother rang NHS 111 and got through to the London Central & West (LCW) service. However, the call handler incorrectly recorded Shanté’s location: he failed to untick a box and so her grandmother’s address was recorded as her location, rather than her mother’s address where she was staying at the time.
In an example of good practice, this error was recognised by the clinician who later took over the call. However, what nobody at LCW realised was that the Adastra computer system would not then update in real time for any screens save that of the particular clinician inputting the information .
The staff at LCW have since been made aware of this and have been trained to walk over and look at the primary screen to check the address, but it is not clear to me that there is now a national understanding of that element of the system.
” Open source report × Source evidence
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 establish whether specialist allergy care was being provided
Wider context from the report “1. At the time of her death, Shanté was not receiving specialist care for her allergies. However, her general practitioners (GPs) failed to appreciate this . They assumed that she was being treated for her allergies at the transitional asthma clinic to which she had been referred following her paediatric discharge. This was an incorrect assumption.
The GPs had not identified Shanté (who had a high BMI and was severely allergic) as being at particularly high risk from her allergies and asthma, and had no awareness that they were the sole providers of Shanté’s allergy care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Inconsistency in anaphylaxis ambulance categorisation between 999 and 111 services
Wider context from the report “16. The individuals making these errors were working within the context of NHS Digital’s categorisation of anaphylaxis as needing a category 2 ambulance rather than a category 1 ambulance, on the Adastra computer system that supports the LCW 111 service.
This was the wrong categorisation and not the categorisation that the call would have received if 999 had been called and the London Ambulance Service contacted in the first instance. Acute anaphylaxis is immediately life threatening and must be treated as a category 1.
I heard at inquest that NHS Digital has since changed its categorisation. However, I also heard that for those areas (I think approximately half the country, though this is not completely clear to me), where the 999 service and the 111 service are supported by different computer systems rather than the same system being common to both services, there could remain inconsistencies of categorisation between 999 and 111 .
Even where there are inconsistencies in categorisation, the 999 service will not re-categorise following a 111 clinician’s categorisation, unless a 999 clinician has spoken to the patient, so inappropriate 111 categorisation will not be safety netted by the 999 service. This must be recognised and factored in.
” Open source report × Source evidence
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 explain the need for sequential administration of two adrenaline auto injectors in acute anaphylaxis
Wider context from the report “2. Shanté’s GPs knew that she should carry two adrenaline auto injector (AAI) pens at all times, and they may have mentioned this to her, but they failed to record this and they did not emphasise it to her.
They failed to emphasise to Shanté and her family that the reason for carrying two pens is primarily because in the event of severe acute anaphylaxis, the very strong likelihood is that both pens will need to be administered, one five minutes after the other , to keep the patient alive until the arrival of an emergency ambulance.
The GPs did not explore with Shanté the reason for her erratic requests for a pen. They did not explore with her where she kept her pens. They did not test her understanding of medical advice.
” Open source report × Source evidence
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 111 call audits to identify all significant call-handling failings
Wider context from the report “15. During the course of the 111 call, a number of errors were made. These were the errors of LCW individuals. When LCW audited the call in the first instance, the audit identified the problem with the address, but failed to recognise how badly the call had gone in other ways . Without effective audit and recognition of failings, it is difficult to see how there can be effective improvement .
” Open source report × Source evidence
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 Rare provision of practical placebo-device adrenaline auto injector training
Wider context from the report “13. I heard that the gold standard of training for use of any AAI is to give the patient the relevant pen (whichever that patient is prescribed) containing a placebo rather than adrenaline and, following appropriate instruction, ask the patient actually to administer a dose.
I heard at inquest that the incidence of this standard of training (in any setting) is rare . That may be for good reasons, but it seems that revisiting best practice training at a national level would be helpful.
” Open source report × Source evidence
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 healthcare-professional training after an adrenaline auto injector switch
Wider context from the report “6. Following the scriptswitch, the GPs failed to ask Shanté to come in to the surgery for training in use of the Emerade . This would also have presented an ideal opportunity to explore Shanté’s understanding of the use of her pens and to ensure that she understood she needed to carry two at all times.
” Open source report × Source evidence
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 device-specific training requirements for adrenaline auto injectors
Wider context from the report “9. The CCG failed to inform prescribers that the Emerade pen requires different training to the EpiPen because different AAIs do not operate in the same way. In fact, the CCG gave the opposite advice .
” Open source report × Source evidence
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 NHS Digital to retain and act on previously identified call-handling safety issues
Wider context from the report “19. One of the errors made by the first 111 call handler was a failure to ask to speak direct to the patient. This was the error of an individual.
However, this is not the first time that the issue has been brought to the attention of NHS Digital. At inquest, I asked the witness who appeared on behalf of NHS Digital, and indeed had been chosen by NHS Digital as the person best able to assist the court, if this had been an issue in the past. He said no. However, on 18 December 2018, Peter Harrowing, HM Assistant Coroner for Avon, sent a prevention of future deaths report to NHS Digital following the inquest touching the death of David Longden.
It was only when I asked the witness appearing on behalf of NHS Digital specifically about Coroner Harrowing’s report in respect of Mr Longden, pointing out that Coroner Harrowing had raised the need for NHS Digital to place greater emphasis on the call handler speaking to the patient, that the witness remembered that he had indeed seen that report.
I choose to characterise this as a memory lapse rather than as an intention wilfully to mislead the court. (A witness who lies whilst giving evidence on oath at inquest may be found in contempt of court and may even be prosecuted for the crime of perjury.) Nevertheless, if NHS Digital does not have a grasp of this sort of detail, specifically brought to its attention by a coroner in a prevention of future deaths report, it is difficult to see how there can be effective improvement .
” Open source report × Source evidence
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 AAI leaflets to specify the need for device-specific healthcare-professional training
Wider context from the report “12. The Emerade AAI (and I assume the EpiPen and JEXT) leaflet does not specifically advise that training from a healthcare professional is needed in how to use this particular AAI as opposed to any other .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure of the 999 service to safety-net inappropriate 111 categorisation
Wider context from the report “16. The individuals making these errors were working within the context of NHS Digital’s categorisation of anaphylaxis as needing a category 2 ambulance rather than a category 1 ambulance, on the Adastra computer system that supports the LCW 111 service.
This was the wrong categorisation and not the categorisation that the call would have received if 999 had been called and the London Ambulance Service contacted in the first instance. Acute anaphylaxis is immediately life threatening and must be treated as a category 1.
I heard at inquest that NHS Digital has since changed its categorisation. However, I also heard that for those areas (I think approximately half the country, though this is not completely clear to me), where the 999 service and the 111 service are supported by different computer systems rather than the same system being common to both services, there could remain inconsistencies of categorisation between 999 and 111.
Even where there are inconsistencies in categorisation, the 999 service will not re-categorise following a 111 clinician’s categorisation, unless a 999 clinician has spoken to the patient , so inappropriate 111 categorisation will not be safety netted by the 999 service . This must be recognised and factored in.
” Open source report × Source evidence
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 Single-sale availability of Emerade adrenaline auto injectors
Wider context from the report “4. The Emerade AAI is sold singly . It could be sold in boxes of two as the norm and only singly in the alternative.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to record and emphasise the need to carry two adrenaline auto injector pens
Wider context from the report “2. Shanté’s GPs knew that she should carry two adrenaline auto injector (AAI) pens at all times, and they may have mentioned this to her, but they failed to record this and they did not emphasise it to her .
They failed to emphasise to Shanté and her family that the reason for carrying two pens is primarily because in the event of severe acute anaphylaxis, the very strong likelihood is that both pens will need to be administered, one five minutes after the other, to keep the patient alive until the arrival of an emergency ambulance.
The GPs did not explore with Shanté the reason for her erratic requests for a pen. They did not explore with her where she kept her pens. They did not test her understanding of medical advice.
” Open source report × Source evidence
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 advise prescribers to reconsider adrenaline auto injector dose after a device switch
Wider context from the report “8. The CCG failed to draw prescribers’ attention to the need, following scriptswitch from EpiPen to Emerade, to reconsider the dose and to prescribe the higher dose of 500mcgs for patients at higher risk (which would have included Shanté).
” Open source report × Source evidence
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 display the advice to carry two adrenaline auto injectors on the outside of the box
Wider context from the report “3. The Emerade AAI accompanying leaflet does include the advice that two pens should be carried at all times, but the advice is not re-iterated on the outside of the box . Consideration will need to be given to whether this is the appropriate advice in all cases, but it seems worthwhile to review the issue as a whole.
” 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 how best to clarify in CG134 that two adrenaline auto-injectors should be prescribed and carried at all times.
Verbatim wording from the response “We do not consider it appropriate for us to duplicate the BNF advice referred to above. However, we will consider how best to make clear in CG134 the advice that 2 adrenaline auto-injectors should be prescribed, which patients should carry at all times.” Source location 2020-0124-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 Existing BNF and BNFc advice sufficiently covers adrenaline auto-injector doses, quantities and training, so NICE will not duplicate that advice.
Verbatim wording from the response “Having reviewed your concerns, we consider that the British National Formulary (BNF) and the BNF for Children (BNFc) already contain detailed advice on these aspects of care, including the following pieces of MHRA/CHM advice from 2017 and 2019, in the section on Adrenaline/Epinephrine (https://bnf.nice.org.uk/drug/adrenalineepinephrine.html):” Source location 2020-0124-Response-from-NICE_Redacted.pdf
Open published response
3 Jan 2020 James Thomas Wheeler · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to provide annual Care Act Reviews to eligible service users View source Lack of authoritative guidance on monitoring people with refractory epilepsy View source Insufficient resources for councils to undertake annual Care Act reviews View source Lack of guidance on the availability and use of assistive technology for monitoring people at high risk from seizures 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
James Thomas Wheeler · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Thomas Wheeler, who had refractory epilepsy alongside cerebral palsy and severe learning disability, was found unresponsive at Cheddle Lodge on 22 January 2018 and died shortly afterwards. The inquest concluded that he died following a nocturnal epileptic seizure while unobserved and not actively monitored. Concerns included the lack of authoritative UK guidance on monitoring people with refractory epilepsy and assistive technology, failures to provide required annual Care Act Reviews, and insufficient resources for local authorities to fulfil those duties.
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 annual Care Act Reviews to eligible service users
Wider context from the report “2. To Ms Pam Smith, Chief Executive, Stockport Metropolitan Borough Council
The court heard evidence that, notwithstanding the Local Authority’s statutory obligations under the Care Act 2014 in this regard, Mr Wheeler (and indeed many other eligible service users) did not receive annual Care Act Reviews as required by law .
Whilst the court heard evidence about the process of transformation of adult social care underway within the Local Authority, it is a matter of concern that the default position still appears to be that an obligatory Care Act Review will not take place , unless some exceptional circumstance is identified about the case.
” Open source report × Source evidence
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 on monitoring people with refractory epilepsy
Wider context from the report “1. To Sir Andrew Dillon, Chief Executive, National Institute of Health and Care Excellence
The court heard that there is currently an absence of authoritative guidance in the United Kingdom as to the monitoring of people with refractory epilepsy, both in hospital and community care settings .
A particular feature of this case was the absence of guidance as to the availability and use of assistive technology in monitoring individuals thought to be at high risk as a result of seizures.
” Open source report × Source evidence
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 resources for councils to undertake annual Care Act reviews
Wider context from the report “3. To Rt. Hon. Matt Hancock, Secretary of State for Health and Social Care
The court heard evidence that, whilst parliament had conferred on Local Authorities a statutory duty to undertake annual reviews pursuant to the Care Act 2014, insufficient resources had been made available to enable councils to discharge this duty alongside existing statutory obligations .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on the availability and use of assistive technology for monitoring people at high risk from seizures
Wider context from the report “1. To Sir Andrew Dillon, Chief Executive, National Institute of Health and Care Excellence
The court heard that there is currently an absence of authoritative guidance in the United Kingdom as to the monitoring of people with refractory epilepsy, both in hospital and community care settings.
A particular feature of this case was the absence of guidance as to the availability and use of assistive technology in monitoring individuals thought to be at high risk as a result of seizures .
” 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 Pass the stated concerns about monitoring refractory epilepsy and assistive technology to the guideline committee to inform its work.
Verbatim wording from the response “I have considered the circumstances surrounding Mr Wheeler’s death, and your concern that there is no national guidance on how to monitor people with refractory epilepsy (both in hospital and community care settings), including the use of assistive technology for those thought to be at high risk of seizures.” Source location 2020-0001-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 Update the epilepsy guideline by reviewing evidence on seizure-detection technologies, epilepsy-related mortality risk factors, and interventions reducing seizure-related mortality.
Verbatim wording from the response “This guideline (CG137) is currently in the early stages of being updated.” Source location 2020-0001-Response-from-NICE-Redacted
Open published response
30 Dec 2019 Maureen Waterfall · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Lack of a national protocol for timely anticoagulant antidote administration View source Lack of a clear target time for anticoagulant antidote administration View source Lack of national standard guidance for storage of anticoagulant antidote supplies View source Failure to share anticoagulant reversal risks with non-tertiary centres View source Unavailability of anticoagulant antidote supplies at the resuscitation unit View source Absence of a currently licensed antidote for Edoxaban View source Limited ability to monitor the effectiveness of anticoagulant antidotes View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Maureen Waterfall · 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 Waterfall fell at home on 12 July 2019 while taking the anticoagulant Edoxaban and sustained a head injury that led to a subdural haematoma. She died at Willow Wood Hospice on 26 July 2019. Concerns included the lack of a licensed specific antidote for Edoxaban, uncertainty about treatment effectiveness and timing, the absence of national guidance, and the storage of antidote supplies away from the resuscitation unit.
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 national protocol for timely anticoagulant antidote administration
Wider context from the report “2. The inquest was told that head injury patients who are prescribed Exodaban are at greater risk of continued bleeding to the brain than other patients as the absence of a specific antidote makes the reversal of the anticoagulant medication less certain. As with other newer anticoagulant drugs, there is little ability to monitor the effectiveness of the antidote. It was unclear if that understanding had been shared widely amongst non-tertiary centres to assist them in managing such patients.
The inquest was told that, at SRFT which is a tertiary centre for neuro surgery/ neurology they have taken steps to set a target for the use of anticoagulant antidote drugs at 90 minutes from presentation. It was unclear if this target was feeding into development of a national protocol . It was unclear how in the absence of national guidance that information was being shared with DGHs which rely on tertiary centres for expertise. At TGH there was no clear target time for the administration of anti-coagulations.
” Open source report × Source evidence
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 target time for anticoagulant antidote administration
Wider context from the report “2. The inquest was told that head injury patients who are prescribed Exodaban are at greater risk of continued bleeding to the brain than other patients as the absence of a specific antidote makes the reversal of the anticoagulant medication less certain. As with other newer anticoagulant drugs, there is little ability to monitor the effectiveness of the antidote. It was unclear if that understanding had been shared widely amongst non-tertiary centres to assist them in managing such patients.
The inquest was told that, at SRFT which is a tertiary centre for neuro surgery/ neurology they have taken steps to set a target for the use of anticoagulant antidote drugs at 90 minutes from presentation. It was unclear if this target was feeding into development of a national protocol. It was unclear how in the absence of national guidance that information was being shared with DGHs which rely on tertiary centres for expertise. At TGH there was no clear target time for the administration of anti-coagulations .
” Open source report × Source evidence
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 standard guidance for storage of anticoagulant antidote supplies
Wider context from the report “3. I heard that there is no national standard guidance about the storage of supplies of anticoagulant antidote drugs . As a result, as in this case at Tameside General Hospital Accident and Emergency Department they were not kept at the resuscitation unit, but rather they were kept in the haematology 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 to share anticoagulant reversal risks with non-tertiary centres
Wider context from the report “2. The inquest was told that head injury patients who are prescribed Exodaban are at greater risk of continued bleeding to the brain than other patients as the absence of a specific antidote makes the reversal of the anticoagulant medication less certain. As with other newer anticoagulant drugs, there is little ability to monitor the effectiveness of the antidote. It was unclear if that understanding had been shared widely amongst non-tertiary centres to assist them in managing such patients.
The inquest was told that, at SRFT which is a tertiary centre for neuro surgery/ neurology they have taken steps to set a target for the use of anticoagulant antidote drugs at 90 minutes from presentation. It was unclear if this target was feeding into development of a national protocol. It was unclear how in the absence of national guidance that information was being shared with DGHs which rely on tertiary centres for expertise. At TGH there was no clear target time for the administration of anti-coagulations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Unavailability of anticoagulant antidote supplies at the resuscitation unit
Wider context from the report “3. I heard that there is no national standard guidance about the storage of supplies of anticoagulant antidote drugs. As a result, as in this case at Tameside General Hospital Accident and Emergency Department they were not kept at the resuscitation unit, but rather they were kept in the haematology 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 Absence of a currently licensed antidote for Edoxaban
Wider context from the report “1. I heard evidence from ████████ Clinical Director of Neurosciences at Salford Royal Hospital. He told me that Edoxaban was one of the new anticoagulant drugs, but of those with which he is familiar, it is differentiated by the fact that there is no currently licensed antidote . He is aware of clinical trials being undertaken of such an antidote.
” Open source report × Source evidence
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 Limited ability to monitor the effectiveness of anticoagulant antidotes
Wider context from the report “2. The inquest was told that head injury patients who are prescribed Exodaban are at greater risk of continued bleeding to the brain than other patients as the absence of a specific antidote makes the reversal of the anticoagulant medication less certain. As with other newer anticoagulant drugs, there is little ability to monitor the effectiveness of the antidote . It was unclear if that understanding had been shared widely amongst non-tertiary centres to assist them in managing such patients.
The inquest was told that, at SRFT which is a tertiary centre for neuro surgery/ neurology they have taken steps to set a target for the use of anticoagulant antidote drugs at 90 minutes from presentation. It was unclear if this target was feeding into development of a national protocol. It was unclear how in the absence of national guidance that information was being shared with DGHs which rely on tertiary centres for expertise. At TGH there was no clear target time for the administration of anti-coagulations.
” Open source report
29 Nov 2019 Mrs Brenda McWilliams · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Failure to assess high-risk community patients for VTE prevention View source Failure to provide medication to minimise VTE risk for high-risk community patients 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
Mrs Brenda McWilliams · 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
Mrs Brenda McWilliams, who had Alzheimer's disease and remained immobile after discharge from hospital to a residential care home, died on 3 January 2019. A post-mortem examination found that she died from a pulmonary thromboembolism caused by a deep vein thrombosis associated with her immobility. The principal concern was that medication to minimise the risk of venous thromboembolism was not continued or prescribed after her hospital discharge despite her recognised high risk and the potentially life-threatening consequences.
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 assess high-risk community patients for VTE prevention
Wider context from the report “I am concerned that the various medical practitioners who attended upon Mrs McWilliams did not consider continuing prescribing Mrs McWilliams medication to minimise the risk of VTE after her discharge from hospital on 21st December 2018 despite recognising that:
(1) Mrs McWilliams remained at high risk of VTE and that the consequence of such an event was likely to be serious, even life threatening;
(2) it had been deemed appropriate to administer medication to Mrs McWilliams by means of daily injections whilst in hospital; and
(3) there were no other suitable means identified and/or adopted to minimise this risk.
I understand that NICE has published the following guidance:
• Guideline NG89 “VTE in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism”
• Quality Standard QS29 “VTE in adults: diagnosis and management”
I was told that QS29 does not include recommendations for the prevention of VTE.
The evidence that I heard suggested that medical practitioners have interpreted the NICE guidance as saying that it is not necessary/appropriate to prescribe medication to minimise the VTE risk for patients who are living in the community unless they have been discharged from hospital with short term immobility (for example with their leg in a cast following a fracture).
Whilst I recognise that the decision to prescribe medication is a multi-factoral clinical decision I am concerned that the evidence I heard suggests that some patients living in the community who are at high risk of VTE (who may not have been admitted to hospital whilst at high risk of VTE) are not being assessed and treated with medication to minimise the risk of VTE, which if it develops can be a life-threatening condition.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to provide medication to minimise VTE risk for high-risk community patients
Wider context from the report “I am concerned that the various medical practitioners who attended upon Mrs McWilliams did not consider continuing prescribing Mrs McWilliams medication to minimise the risk of VTE after her discharge from hospital on 21st December 2018 despite recognising that:
(1) Mrs McWilliams remained at high risk of VTE and that the consequence of such an event was likely to be serious, even life threatening;
(2) it had been deemed appropriate to administer medication to Mrs McWilliams by means of daily injections whilst in hospital; and
(3) there were no other suitable means identified and/or adopted to minimise this risk.
I understand that NICE has published the following guidance:
• Guideline NG89 “VTE in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism”
• Quality Standard QS29 “VTE in adults: diagnosis and management”
I was told that QS29 does not include recommendations for the prevention of VTE.
The evidence that I heard suggested that medical practitioners have interpreted the NICE guidance as saying that it is not necessary/appropriate to prescribe medication to minimise the VTE risk for patients who are living in the community unless they have been discharged from hospital with short term immobility (for example with their leg in a cast following a fracture).
Whilst I recognise that the decision to prescribe medication is a multi-factoral clinical decision I am concerned that the evidence I heard suggests that some patients living in the community who are at high risk of VTE (who may not have been admitted to hospital whilst at high risk of VTE) are not being assessed and treated with medication to minimise the risk of VTE, which if it develops can be a life-threatening condition.
” Open source report
28 Nov 2019 Thomas Wedrychowski · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 2 Failure to share relevant physical healthcare check results between primary and secondary healthcare providers View source Failure to provide more frequent diabetes monitoring for individuals at higher risk 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 Wedrychowski · 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 Wedrychowski had paranoid schizophrenia and had been prescribed antipsychotic medication for a number of years. Expert evidence indicated that the medication caused diabetes and contributed to morbid obesity; the medical cause of death was recorded as diabetic ketoacidosis and medication-induced diabetes mellitus. Concerns included whether higher-risk patients should receive more frequent diabetes monitoring and whether physical healthcare findings were adequately shared between primary and secondary care providers.
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 share relevant physical healthcare check results between primary and secondary healthcare providers
Wider context from the report “At both primary and secondary health levels it appeared to have been the view that following initial titration and a period of regular checks, annual monitoring for signs of the development of diabetes should be carried out annually as recommended in NICE guideline CG178. However, expert evidence at the inquest suggested that in cases of individuals with a higher risk of developing diabetes, more regular checks were called for. Further there was evidence to the effect that the results of relevant physical healthcare checks had not been shared between primary and secondary healthcare providers . Thus:
(1) I draw to the attention of the National Institute for Health and Care Excellence their guidance CG178 and specifically clause 1.3.6.4 thereof and ask them to consider whether to the directive for an annual test of inter alia HbA1c, there might be added the words:
“or more frequently in those who have a higher baseline risk for the development of diabetes”.
(2) I draw to the attention of Avon and Wiltshire Mental Health Partnership NHS Trust with reference to their planned review of their document entitled “Medicines Guideline: Monitoring psychotropic medication” my first paragraph addressed to the National Institute for Health and Care Excellence and ask them to consider adding similar wording to their recommendations with regard to annual review appearing at page 4 of the present document.
Secondly, I ask the Trust to consider adding advice in the document to the effect that when a patient is prescribed anti-psychotic medication contact be made with the patient’s GP practice (a) informing them of this fact (b) requesting communication thereafter of any physical health findings that might indicate serious side-effects or potential side-effects of the drugs and (c) communicating any relevant physical health findings to the GP practice as well as mental health findings.
” Open source report × Source evidence
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 more frequent diabetes monitoring for individuals at higher risk
Wider context from the report “At both primary and secondary health levels it appeared to have been the view that following initial titration and a period of regular checks, annual monitoring for signs of the development of diabetes should be carried out annually as recommended in NICE guideline CG178. However, expert evidence at the inquest suggested that in cases of individuals with a higher risk of developing diabetes, more regular checks were called for . Further there was evidence to the effect that the results of relevant physical healthcare checks had not been shared between primary and secondary healthcare providers. Thus:
(1) I draw to the attention of the National Institute for Health and Care Excellence their guidance CG178 and specifically clause 1.3.6.4 thereof and ask them to consider whether to the directive for an annual test of inter alia HbA1c, there might be added the words:
“or more frequently in those who have a higher baseline risk for the development of diabetes”.
(2) I draw to the attention of Avon and Wiltshire Mental Health Partnership NHS Trust with reference to their planned review of their document entitled “Medicines Guideline: Monitoring psychotropic medication” my first paragraph addressed to the National Institute for Health and Care Excellence and ask them to consider adding similar wording to their recommendations with regard to annual review appearing at page 4 of the present document.
Secondly, I ask the Trust to consider adding advice in the document to the effect that when a patient is prescribed anti-psychotic medication contact be made with the patient’s GP practice (a) informing them of this fact (b) requesting communication thereafter of any physical health findings that might indicate serious side-effects or potential side-effects of the drugs and (c) communicating any relevant physical health findings to the GP practice as well as mental health findings.
” Open source report
22 Nov 2019 MAUREEN MILTON · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 2 Lack of awareness of petrol-based emollient fire risks View source Fire ignition of clothing impregnated with petrol-based emollient cream View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
MAUREEN MILTON · 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 Milton, aged 74, died after her clothing caught fire while she was attempting to light a cigarette with a long match; petrol-based emollient cream on her clothing likely accelerated the fire, and she was pronounced dead at the scene. The principal concern was a lack of awareness among medical professionals, carers, victims and families about the fire risks associated with petrol-based emollients.
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 awareness of petrol-based emollient fire risks
Wider context from the report “Evidence given by fire investigators was that they are increasingly attending fires involving (mostly) the elderly where there is evidence of petrol based emollient cream in use. The petrol base is found in a significant number of prescribed creams and creams (such as moisturisers) which are readily available over the counter. This cream impregnates clothing and is not washed away during a normal washing programme. In the event of a fire the victim is rapidly engulfed by flames with little chance of survival. The cause of death is generally burns, not inhalation of smoke. The concern is the lack of awareness of this problem by medical professionals, carers, victims and their families. It is felt appropriate heighten awareness of this growing problem amongst health professionals and others who work in the field of prescribing such creams and those caring for patients using petrol based emollients.
” Open source report × Source evidence
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 Fire ignition of clothing impregnated with petrol-based emollient cream
Wider context from the report “Evidence given by fire investigators was that they are increasingly attending fires involving (mostly) the elderly where there is evidence of petrol based emollient cream in use. The petrol base is found in a significant number of prescribed creams and creams (such as moisturisers) which are readily available over the counter. This cream impregnates clothing and is not washed away during a normal washing programme. In the event of a fire the victim is rapidly engulfed by flames with little chance of survival. The cause of death is generally burns, not inhalation of smoke. The concern is the lack of awareness of this problem by medical professionals, carers, victims and their families. It is felt appropriate heighten awareness of this growing problem amongst health professionals and others who work in the field of prescribing such creams and those caring for patients using petrol based emollients.
” 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 Oversight of medicine and medical-product safety and product labelling falls outside the respondent’s role.
Verbatim wording from the response “NICE does not have a role in overseeing the safety of medicines and medical products, or in ensuring appropriate warnings on the labels of such products. In the UK, this is the responsibility of the Medicines and Healthcare products Regulatory Agency (MHRA). In addition, NICE does not have a role in running safety awareness or educational campaigns aimed at professionals or patients and carers. The responsibility for this would rest with organisations such as the MHRA and other healthcare regulators, professional bodies and voluntary organisations and charities.” Source location 2019-0396-Response-by-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 prescriber information and warnings about emollient fire risks are considered adequate, leaving nothing specifically to add.
Verbatim wording from the response “We consider that appropriate information and warnings are available to prescribers regarding the risks of fire associated with the use of paraffin-based emollient products, and that there is nothing specifically NICE can do to add to this. As explained above, an awareness or educational campaign for professionals, patients or carers on this important issue would not fall within our role.” Source location 2019-0396-Response-by-NICE
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The MHRA is responsible for medicine and medical-product safety oversight and ensuring appropriate product warnings.
Verbatim wording from the response “NICE does not have a role in overseeing the safety of medicines and medical products, or in ensuring appropriate warnings on the labels of such products. In the UK, this is the responsibility of the Medicines and Healthcare products Regulatory Agency (MHRA). In addition, NICE does not have a role in running safety awareness or educational campaigns aimed at professionals or patients and carers. The responsibility for this would rest with organisations such as the MHRA and other healthcare regulators, professional bodies and voluntary organisations and charities.” Source location 2019-0396-Response-by-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 Safety-awareness and educational campaigns are the responsibility of the MHRA, healthcare regulators, professional bodies, voluntary organisations and charities.
Verbatim wording from the response “NICE does not have a role in overseeing the safety of medicines and medical products, or in ensuring appropriate warnings on the labels of such products. In the UK, this is the responsibility of the Medicines and Healthcare products Regulatory Agency (MHRA). In addition, NICE does not have a role in running safety awareness or educational campaigns aimed at professionals or patients and carers. The responsibility for this would rest with organisations such as the MHRA and other healthcare regulators, professional bodies and voluntary organisations and charities.” Source location 2019-0396-Response-by-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 Running safety-awareness or educational campaigns for professionals, patients and carers falls outside the respondent’s role.
Verbatim wording from the response “NICE does not have a role in overseeing the safety of medicines and medical products, or in ensuring appropriate warnings on the labels of such products. In the UK, this is the responsibility of the Medicines and Healthcare products Regulatory Agency (MHRA). In addition, NICE does not have a role in running safety awareness or educational campaigns aimed at professionals or patients and carers. The responsibility for this would rest with organisations such as the MHRA and other healthcare regulators, professional bodies and voluntary organisations and charities.” Source location 2019-0396-Response-by-NICE
Open published response
6 Nov 2019 Stuart Clarke · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1 Lack of national referral guidelines for patients with known valvular disease View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stuart 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
Stuart Clarke presented with breathlessness in February 2018 and underwent a TAVI procedure on 25 June 2019 after a prolonged pathway to treatment. He did not recover following the procedure and died at Wythenshawe Hospital on 27 June 2019. The principal concern was the absence of national guidelines for referral between primary, secondary and tertiary care for patients with known valvular disease, alongside concern about the timeliness of intervention.
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 referral guidelines for patients with known valvular disease
Wider context from the report “However, I was concerned that there remain no national guidelines for referral from primary care to secondary care and/or from secondary care to tertiary care for patients with known valvular disease .
” 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 Highlight the reported referral concerns to the guideline developers for consideration in specifying referral urgency factors.
Verbatim wording from the response “Details of the concerns you have raised have been highlighted to the guideline developers, so they can consider indicating which factors merit more and less urgent referral, where the evidence is available.” Source location 2019-0366-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 Develop a clinical guideline on adult heart valve disease, including indications for referral and TAVI.
Verbatim wording from the response “NICE is at the early stages of developing a clinical guideline on heart valve disease presenting in adults: investigation and management. One of the issues to be covered by this guideline are the indications for patient referral from primary care to a specialist. The draft guidance is expected to go out for consultation with stakeholders in November 2020, and we expect to publish our final guideline to the NHS on 20 May 2021.” Source location 2019-0366-Response-from-NICE
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The guideline is unlikely to cover secondary-to-tertiary pathways because TAVI is commissioned by NHS England.
Verbatim wording from the response “This guideline will also be considering the indications for TAVI, and its clinical effectiveness and cost effectiveness. However, we are unlikely to cover issues relating to the patient pathway from secondary to tertiary care, as TAVI is commissioned by NHS England (as outlined within their publication titled ‘Clinical Commissioning Policy Transcatheter Aortic Valve Implantation (TAVI) For Aortic Stenosis’).” Source location 2019-0366-Response-from-NICE
Open published response
18 Sep 2019 Graham Martin SAFFERY · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 1 Failure of the BNF to provide caution and monitoring guidance for simultaneous amitriptyline and oxycodone prescribing 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
Graham Martin SAFFERY · 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
Graham Martin SAFFERY was found deceased at home on 19 June 2018 after taking prescribed oxycodone and amitriptyline. The inquest conclusion stated that the combination carried a risk of sudden death and that his prescription remained unchanged despite signs of over-sedation. A substantive concern was that the BNF did not appear to provide the caution and monitoring advice given by other pharmacological guidance for simultaneous prescribing of these medicines.
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 the BNF to provide caution and monitoring guidance for simultaneous amitriptyline and oxycodone prescribing
Wider context from the report “Although other pharmacological guidance such as Medscape Drug Interaction Checker and Stockley’s Interaction Checker recommend the need for both caution and monitoring when prescribing amitriptyline and oxycodone simultaneously, such advice does not appear to be provided by the BNF which is regularly consulted and relied upon by GPs.
” Open source report
24 Jul 2019 Xander Curran-Pass · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 10 Lack of guidance on pethidine use with significant reduced fetal movement View source Inconsistent fundal-height measurement and recording View source Lack of national provision for sharing maternity induction-of-labour learning View source Poor quality of admission documentation View source Failure to require obstetrician review on admission with reduced fetal movement and delayed induction of labour View source Lack of clear guidance for managing a prolonged episode of reduced fetal movement View source Inconsistent and unclear diarising, prioritisation and management of induction of labour View source Failure to closely observe a concerning cardiotocograph View source Failure to review cardiotocography after induction of labour commenced View source Failure to advise return to triage for further monitoring during ongoing reduced fetal movement View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Xander Curran-Pass · 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
Xander Curran-Pass was delivered by category C Caesarean Section on 15 September 2018 after reduced fetal movement, delayed induction of labour, and concerning CTG findings. Resuscitation was unsuccessful and he died; post-mortem examination identified poor placental function associated with chronic villitis and thrombotic vasculopathy. The substantive concerns included delays in review and delivery, inadequate monitoring and documentation, and unclear or inconsistent processes for managing induction of labour and reduced fetal movement.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on pethidine use with significant reduced fetal movement
Wider context from the report “6. Xander's mother was given pethidine. There was no guidance on issues to be considered in terms of advisability of pethidine where there was already significant reduced fetal movement ;
” Open source report × Source evidence
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 fundal-height measurement and recording
Wider context from the report “5.Xander had his fundal height measured by tape measure by midwives in the community. There was a significant discrepancy between the recorded measurements of two different midwives , which altered where he was on the centile chart significantly ;
” Open source report × Source evidence
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 provision for sharing maternity induction-of-labour learning
Wider context from the report “1.The inquest was told that there was a growing challenge to maternity units from the rise in Induction of Labour and the pressure to ensure that timescales set out in NICE guidance were met. In this case and since the death of Xander the trust have taken steps to reconfigure their IOL process to reduce risk but no provision to share such learning nationally existed ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Poor quality of admission documentation
Wider context from the report “7. The quality of documentation on admission was poor ;
” Open source report × Source evidence
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 obstetrician review on admission with reduced fetal movement and delayed induction of labour
Wider context from the report “4. A review by an obstetrician did not take place on admission despite RFM and delayed IOL . The trust guidance did not require such a review . Such a review may have identified growing concern about condition of Xander;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance for managing a prolonged episode of reduced fetal movement
Wider context from the report “2.In the inquest reference was made to the guidance from the Royal College on reduced fetal movement. The guidance references individual episodes of RFM but does not give clear guidance on the approach to be taken where in effect there is one prolonged episode rather than multiple episodes of RFM ;
” Open source report × Source evidence
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 and unclear diarising, prioritisation and management of induction of labour
Wider context from the report “8. The triage and IOL diary were poorly kept and used in different ways by staff . The trust has since changed the way records are kept to ensure consistency and improved its audit process. It is unclear if nationally there is clarity on the way in which IOLs are diarised, prioritised and managed ;
” Open source report × Source evidence
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 closely observe a concerning cardiotocograph
Wider context from the report “9. The CTG at 07.09 was concerning from the early stages but the evidence suggested that it was not closely observed ;
” Open source report × Source evidence
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 review cardiotocography after induction of labour commenced
Wider context from the report “10. The second CTG after IOL commenced was not reviewed .
” Open source report × Source evidence
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 advise return to triage for further monitoring during ongoing reduced fetal movement
Wider context from the report “3. Xander's mother was not told it would be advisable to return to triage for further monitoring in light of the ongoing reduced fetal movement. The inquest was told that this would have been advisable given the prolonged nature and the fact that it was unclear when she would be offered a slot for IOL;
” Open source report
19 Jun 2019 James William Francis · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 14 Failure to provide paramedics with basic patient information View source Unavailability of an instantly transferable key-information patient document View source Failure of staff to understand relevant patient medical history and implanted-device function View source Delays in seeking out-of-hours medical advice and requesting GP review View source NICE guidelines inadequately addressing slow intracranial bleeding after falls in elderly patients View source Failure to place an incapacitated patient in a position that protects the airway View source Failure to document key patient-care events and sickness details View source Failure of management records and checks to verify required observations View source Inadequate shift handover documentation for highlighting concerns and increased observations View source Failure to provide complete information about patient history and deterioration to the GP View source Failure to communicate required increased observations during shift handover View source Failure to consider NHS 111 advice for a deteriorating patient View source Failure of care staff to recognise and respond to head injury in anticoagulated patients View source Lack of current basic first-aid training for care staff View source See 11 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James William Francis · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James William Francis, who had a history of falls and balance difficulties, suffered an unwitnessed fall at his care home on 9 April 2017 and later developed repeated vomiting and deterioration. He was admitted to hospital with a large subdural haematoma and died on 11 April 2017. The principal concerns included failures in shift handover and monitoring, delays in seeking medical advice, inadequate information provided to paramedics, the patient’s positioning, staff training, and whether relevant guidelines sufficiently addressed this type of injury in elderly patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to provide paramedics with basic patient information
Wider context from the report “They reported that they found Mr Francis on the floor leaning up against the dining room chair and over to his right side. They accepted that they were assertive but felt this was born from a frustration to find a time critical patient in such a position and staff were unable to answer basic questions about past medical history, allergies, mobility, communications for current medication .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Unavailability of an instantly transferable key-information patient document
Wider context from the report “In addition, the paramedic suggested that other care homes have a key document that can be instantly handed over to them to speed up the handover procedure and ensure that clinical staff have a full history key information. This is often called a Hospital Passport and uses simple traffic light alerts to highlight key information. There was no evidence of this kind of simple document in this case
” Open source report × Source evidence
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 staff to understand relevant patient medical history and implanted-device function
Wider context from the report “In addition one of the team leaders confirmed that she knew Mr Francis had a VP shunt in place but she was not aware of his past medical history or indeed what shunt did . This raises concerns about basic aspects of patient care and the adequacy of staff training
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Delays in seeking out-of-hours medical advice and requesting GP review
Wider context from the report “I heard evidence that when Mr Francis was sick three times during the late afternoon and early evening of the day of his fall, no action was taken to seek out of hours medical advice
In addition, despite a significant deterioration in Mr Francis condition later in the day of his fall and more significantly the following morning and after five separate referrals by the day support worker to the team leader, there was a five hour delay in making a simple telephone call to request a GP visit . Further, there does not appear to have been any thought given to making a call to NHS 111 for advice. It was also unclear exactly what information was given to the GP surgery to stress the history and deterioration in Mr Francis condition
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation NICE guidelines inadequately addressing slow intracranial bleeding after falls in elderly patients
Wider context from the report “The suggestion was that the existing guidelines may not sufficiently address the fact that this type of slow bleed fall in the elderly also needs to be considered i.e non-traumatic head injury leading to a shearing effect on the brain. The suggestion was that this type of slow bleed may take significantly longer to manifest in terms of observable symptoms such as a change in alertness or persistent vomiting. It certainly seems that the care home staff did not make the connection
As a result, this raises concerns as to whether this type of incident which must be frequent in the elderly is adequately taken into account in relevant NICE guidelines
” Open source report × Source evidence
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 place an incapacitated patient in a position that protects the airway
Wider context from the report “It would seem the care home staff had not considered placing Mr Francis on the floor into the recovery position until requested to do so by the 999 operator. From reading the transcript it suggests that when the operator asked the staff to do this, efforts were made to comply and then ensure Mr Francis head was tilted to keep the airway clear and his breathing became a little less shallow. Conversely, the ambulance crew were both very clear that their immediate concern on entering the room was the poor position of Jim in a seated/slumped position that may have compromised his airway
” Open source report × Source evidence
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 key patient-care events and sickness details
Wider context from the report “Again, it took some time to obtain all the details of the fall and sickness details
Finally, when leaving the building to get the stretcher trolley one of the paramedic crew heard care home staff arguing about the sickness details that had not been documented . This evidence raises considerable concern regarding the adequacy of documenting key events in a patient’s care such as a fall event if the patient indicates there was no acute trauma particularly when the patient is elderly and has a complicated past medical history
” Open source report × Source evidence
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 management records and checks to verify required observations
Wider context from the report “Related to item 1 above, is the fact there seem to be a failure of appropriate management records and checks to ensure that if 30 minute observations were required that these were undertaken at regular intervals
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Inadequate shift handover documentation for highlighting concerns and increased observations
Wider context from the report “I heard evidence from several staff members at different grades including two support workers responsible for Mr Francis’s daily care, a senior support worker and a team leader that they were unaware of Mr Francis recent fall or the fact that 30 minute observations needed to be carried out. In particular, both key support workers who knew Mr Francis best failed to carry out the 30 minute observations during the morning and afternoon shifts and on balance of probabilities it was likely that neither support worker was told either during the handover meeting or by the senior staff on duty that this was a requirement that day. However, it certainly seems that both support workers observed Mr Francis on a regular basis throughout the day and took appropriate action to report his condition and any change to senior staff. In another patient, this lack of handing on of vital information to key members of staff could be crucial
I was shown a shift handover form but this is basic and contains no additional guidance or method to highlight particular concerns or need for increased observations
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to provide complete information about patient history and deterioration to the GP
Wider context from the report “I heard evidence that when Mr Francis was sick three times during the late afternoon and early evening of the day of his fall, no action was taken to seek out of hours medical advice
In addition, despite a significant deterioration in Mr Francis condition later in the day of his fall and more significantly the following morning and after five separate referrals by the day support worker to the team leader, there was a five hour delay in making a simple telephone call to request a GP visit. Further, there does not appear to have been any thought given to making a call to NHS 111 for advice. It was also unclear exactly what information was given to the GP surgery to stress the history and deterioration in Mr Francis condition
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate required increased observations during shift handover
Wider context from the report “I heard evidence from several staff members at different grades including two support workers responsible for Mr Francis’s daily care, a senior support worker and a team leader that they were unaware of Mr Francis recent fall or the fact that 30 minute observations needed to be carried out. In particular, both key support workers who knew Mr Francis best failed to carry out the 30 minute observations during the morning and afternoon shifts and on balance of probabilities it was likely that neither support worker was told either during the handover meeting or by the senior staff on duty that this was a requirement that day . However, it certainly seems that both support workers observed Mr Francis on a regular basis throughout the day and took appropriate action to report his condition and any change to senior staff. In another patient, this lack of handing on of vital information to key members of staff could be crucial
I was shown a shift handover form but this is basic and contains no additional guidance or method to highlight particular concerns or need for increased observations
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to consider NHS 111 advice for a deteriorating patient
Wider context from the report “I heard evidence that when Mr Francis was sick three times during the late afternoon and early evening of the day of his fall, no action was taken to seek out of hours medical advice
In addition, despite a significant deterioration in Mr Francis condition later in the day of his fall and more significantly the following morning and after five separate referrals by the day support worker to the team leader, there was a five hour delay in making a simple telephone call to request a GP visit. Further, there does not appear to have been any thought given to making a call to NHS 111 for advice . It was also unclear exactly what information was given to the GP surgery to stress the history and deterioration in Mr Francis condition
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure of care staff to recognise and respond to head injury in anticoagulated patients
Wider context from the report “I heard evidence from a number of staff members that they had received no training at all or it was some time (up to 3 years) since they had had any basic first aid training. In addition, the paramedics indicated that when the care home staff were asked what their protocol and understanding was of a head injury with someone who was prescribed anticoagulant, it seemed the staff could not answer . Nor could they spot the signs and symptoms of head injury even though this is basic first-aid
” Open source report × Source evidence
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 basic first-aid training for care staff
Wider context from the report “I heard evidence from a number of staff members that they had received no training at all or it was some time (up to 3 years) since they had had any basic first aid training . In addition, the paramedics indicated that when the care home staff were asked what their protocol and understanding was of a head injury with someone who was prescribed anticoagulant, it seemed the staff could not answer. Nor could they spot the signs and symptoms of head injury even though this is basic first-aid
” 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 Publish the final surveillance review decision in September 2019.
Verbatim wording from the response “The guideline is currently undergoing a surveillance review exercise to determine whether it should be updated. As a result of your report, the review is likely to conclude that an update is required so that it is clearer that the guideline applies to indirect head injury (for example, by making the definition more accessible to users). A final surveillance review decision is due to be published in September 2019.” Source location 2019-0202-Response-by-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 Conduct the ongoing surveillance review of the head injury guideline to determine whether it requires updating.
Verbatim wording from the response “The guideline is currently undergoing a surveillance review exercise to determine whether it should be updated. As a result of your report, the review is likely to conclude that an update is required so that it is clearer that the guideline applies to indirect head injury (for example, by making the definition more accessible to users). A final surveillance review decision is due to be published in September 2019.” Source location 2019-0202-Response-by-NICE
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing NICE head-injury guidance already applies to injuries caused by both direct and indirect trauma.
Verbatim wording from the response “We have considered the circumstances surrounding Mr Francis’ death and the concerns raised in your report and in particular the concerns that existing NICE guidance on head injury may not be appropriate for instances where a person experiences a non-direct head trauma.” Source location 2019-0202-Response-by-NICE
Open published response
17 Jun 2019 Oliver Hall · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 3 Failure to transfer the NHS 111 Service’s original disposition information to ambulance crews and treating clinicians View source Lack of clear and consistent guidance on heart-rate criteria triggering urgent sepsis treatment in sick six-year-old children View source Failure to inform medical professionals of ambulance delays of 39 minutes or less View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Oliver Hall · 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
Oliver Hall, a six-year-old boy, became acutely unwell on 23 October 2017 and died in the early hours of 24 October 2017 after developing meningococcal septicaemia. The report identified concerns about NHS 111 disposition information not being transferred to ambulance and treating clinicians, delays in ambulance availability information, and conflicting guidance about the significance of his heart rate.
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 transfer the NHS 111 Service’s original disposition information to ambulance crews and treating clinicians
Wider context from the report “1. It is apparent that there is a failure in the process of the transfer information regarding a patient's original disposition by the NHS 111 Service to the ambulance service and the treating clinicians on the ground .
In Oliver’s case a non-clinician NHS Pathway Advisor using the NHS Pathway algorithms identified a ‘severe illness and a rash suggestive of septicaemia’ following a 5-minute phone call with his mother. As identified at inquest meningococcal septicaemia was Oliver’s actual cause of death and the NHS 111 Service identified this as a possible risk at 13.00, some 5 hours 45 minutes before it was diagnosed by a medical clinician.
In response to their algorithms the NHS 111 Service implemented a disposition of ‘emergency ambulance response for septicaemia’ and an automatic referral was made to the 999 service. This disposition and a ‘severe illness and a rash suggestive of septicaemia’ were included in the information transferred to the East of England Ambulance Service.
However, it was then identified that the current East of England Ambulance Service system does not provide the ambulance crew (and therefore in this case subsequently the GP’s) with that information .
The message made available to the crew simply read ‘headache/abdo-pain/fever- no access issues, patient not alone 38.8’.
Both the ambulance crew and GP’s stated in their evidence that had they known the original disposition from the NHS 111 Service had been suggestive of septicaemia it would have informed their decision-making processes and may have changed their clinical management of Oliver.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of clear and consistent guidance on heart-rate criteria triggering urgent sepsis treatment in sick six-year-old children
Wider context from the report “3. It was apparent from the evidence given by both the ambulance crew and treating doctors that there was some lack of clarity over the current National Institute for Health Care Excellence guidance on the treatment of sepsis and the guidance provided by the Joint Royal Colleges Ambulance Liaison Committee .
This lack of clarity centred around the heart rate which should trigger a medical treatment response in a sick six-year-old child .
Evidence heard stated that a heart rate of 120 beats per minute was given in some guidance as being at the top end of the normal range for a six-year-old child. The health professionals involved in Oliver’s case said they had relied on this guidance.
However, in other guidance a heart rate of 120 beats per minute in a six-year-old child is considered to be a high-risk criteria in cases of suspected sepsis requiring an urgent response . The health professionals involved in Oliver’s case said they were either unaware of this guidance, or they were aware of it but placed their reliance on the ‘normal range’ guidance above.
Therefore, it is apparent that the significance of Oliver’s heart rate of 120 beats per minute was not identified as being a symptom of his meningococcal septicaemia by the health professionals responsible for his treatment , likely to be due to the nature of the conflicting guidance as detailed above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to inform medical professionals of ambulance delays of 39 minutes or less
Wider context from the report “2. It was heard in evidence that since this incident the East of England Ambulance Service have introduced a system whereby if a medical professional calls requesting an ambulance and one is not available (due to pressure on the service exceeding capacity) they will inform the medical professional if the anticipated response time is outside the key performance times for the category of call.
It was identified, that in a septicaemia case similar to Oliver’s (or indeed any case where time is of the essence to transport a patient to hospital to commence life saving treatment) the correct category for the ambulance response would be Category 2.
As such, any medical professional who calls for an ambulance will only be told there will be a delay if it is anticipated that delay would be longer than 40 minutes (40 minutes being the Category 2 aimed response time in 9 out of 10 cases).
Therefore, under the current system, a medical professional requesting an ambulance will not be told if the delay is 39 minutes or less .
Evidence was heard, that in a patient with meningococcal septicaemia the bacterial loading in their system will have almost doubled in that 39 minute time period and the patient’s condition would have rapidly deteriorated.
As such, under the current system of a medical professional being told of the delay if it is only 40 minutes or more (in a Category 2 case), that attending medical professional will be unable to make an informed judgement as to whether waiting for an ambulance or using another form of transport is the right course of action for the patient they are treating .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and amend the CKS Meningitis topic to align with NICE sepsis guidance.
Verbatim wording from the response “In addition to NICE guidance, our website provides access to Clinical Knowledge Summaries (CKS) which set out the current evidence base and best practice on more than 360 common and significant primary care presentations. These summaries are commissioned by NICE, but they are not formal NICE guidelines. They are authored by an external contractor using a development process that has been accredited by NICE.” Source location 2019-0198-Response-by-NICE
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NICE disputes that its sepsis guidance lacks clarity, citing defined heart-rate thresholds for children aged 6–7 years.
Verbatim wording from the response “We have considered the circumstances surrounding Oliver’s death and the concerns raised in your report. In particular, the concerns raised regarding the NICE guidance on treatment of sepsis and a perceived lack of clarity over the heart rate which should trigger a medical treatment response in an unwell 6 year old child.” Source location 2019-0198-Response-by-NICE
Open published response
2 May 2019 Alexander James Davidson · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Delays in updating electronic patient records with NHS 111 triage documents View source Failure to adapt NHS 111 telephone triage questions and wording for young and vulnerable patients View source Variation in admission for observation of paediatric patients returning to the Emergency Department View source Unclear NHS Pathways algorithm for exploring ‘soil’ or ‘coffee ground’ vomit during telephone triage View source Lack of standard lipase/amylase testing for patients under 18 with relevant abdominal symptoms View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alexander James Davidson · 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
Alexander James Davidson became suddenly unwell with abdominal pain, vomiting and diarrhoea, and died at the Queens Medical Centre on 26 February 2018 after developing an infected and necrotic pancreatic pseudocyst caused by gallstone pancreatitis. The report raised concerns about NHS 111 telephone triage for young or vulnerable patients, the clarity and transfer of triage information, testing for pancreatitis in young people, and the management of unscheduled returns to 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 Delays in updating electronic patient records with NHS 111 triage documents
Wider context from the report “(3) The NHS 111 telephone triage service provides an electronic copy of the patient triage notes to the patient’s GP within minutes of the call ending. There was a delay of 7 days in the GP surgery uploading the 111 triage document to Alex’s patient record. This prevented Alex’s GP from reviewing the triage note prior to his consultation with the patient. There is no guidance as to expected practise with regards to the timely updating of electronic patient records, and as a result delays are all too frequent.
” Open source report × Source evidence
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 adapt NHS 111 telephone triage questions and wording for young and vulnerable patients
Wider context from the report “(1) The NHS 111 telephone triage service uses the NHS Pathways computer system to triage patients via pre-determined question/answer based algorithms. The pre-determined questions are the same whether the caller is an adult or a child. Alex struggled to comprehend some of the medical terminology used during these calls. Call handlers are not permitted to deviate from the prescribed wording of the pre-determined questions, and this created confusion and inconsistency in the patient’s answers. Consideration should be given as to how young and/or vulnerable patients can be assisted to provide accurate information about their symptoms.
” Open source report × Source evidence
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 Variation in admission for observation of paediatric patients returning to the Emergency Department
Wider context from the report “(5) Patients who make an unscheduled return to the Emergency Department within 72 hours of discharge are required to have a review undertaken by an ED Consultant, or a ST4 trainee or above in the absence of a Consultant on the ‘shop floor’: RCEM Guidance June 2016. Some hospitals will admit returning paediatric patients for observation but practise seems to vary doctor-to-doctor and across Trusts. Consideration ought to be given to a national approach.
” Open source report × Source evidence
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 Pathways algorithm for exploring ‘soil’ or ‘coffee ground’ vomit during telephone triage
Wider context from the report “(2) The NHS Pathways algorithm for triaging vomiting and diarrhoea symptoms is unclear as patients may fail to understand what is meant by ‘soil’ or ‘coffee ground’ vomit . Consideration should be given to how this important diagnostic feature can be explored during telephone triage, especially when the patient is young and/or vulnerable.
” Open source report × Source evidence
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 standard lipase/amylase testing for patients under 18 with relevant abdominal symptoms
Wider context from the report “(4) Adults presenting to their GP or Emergency Department with abdominal symptoms receive a lipase and/or amylase blood test as part of the standard package of blood testing. The levels of each of these enzymes can be used to diagnose pancreatitis. Patients under the age of 18 years are not offered this testing as standard , on the basis that pancreatitis is rare in paediatric patients. I heard anecdotal evidence of some doctors at Kingsmill Hospital now add this test to the standard admission bloods for older teenage patients who present with non-specific abdominal symptoms but the NICE guidance (September 2018) is not explicit in this regard . I heard evidence as to the increasing prevalence of gallstone pancreatitis in young people, in line with an increase in childhood obesity. Consideration ought to be given to a national approach for lipase/amylase testing in young people with relevant symptoms.
” 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 Reconsider the scope of the pancreatitis guideline at its next review, including whether it should address lipase or amylase testing accuracy in young people.
Verbatim wording from the response “Our guideline on pancreatitis (NG104) notes (in section 1.2) that “Diagnosis of acute pancreatitis is confirmed by testing blood lipase or amylase levels, which are usually raised. If raised levels are not found, abdominal CT may confirm pancreatic inflammation”. However, because the purpose of the guideline is to recommend treatments following diagnosis of acute pancreatitis, the accuracy of lipase or amylase in young people is not considered in it. Nevertheless, in the light of your letter, we’ll reconsider the scope of the guideline when it is next reviewed.” Source location 2019-0149-Response-by-NICE
Open published response
29 Mar 2019 Colin Bailey · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to undertake CT brain/head scans after falls with head impact in patients taking anticoagulant medication View source Lack of national guidance on CT scanning after falls with head impact in patients taking different types of anticoagulant medication 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
Colin Bailey · 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
Colin Bailey was admitted to hospital following a stroke and later transferred for rehabilitation. After falling and hitting his head while taking anticoagulant medication, he suffered an extensive subarachnoid haemorrhage and died at Tameside General Hospital on 10 April 2018. The concern was that national guidance did not require a CT scan in this situation for all types of anticoagulant medication, although clinicians indicated that scanning should be undertaken regardless of the type used.
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 CT brain/head scans after falls with head impact in patients taking anticoagulant medication
Wider context from the report “The inquest heard that Mr Bailey fell and hit his head whilst an in-patient at Stepping Hill hospital. No CT scan of the brain/head was undertaken despite Mr Bailey taking anti-coagulant medication because NICE guideline recommended a scan is undertaken if the patient has fallen, struck their head and is taking warfarin but that is not the guidance if the anticoagulant medication is one of the other types of anticoagulant medications used. The clinicians attending the Inquest indicated that a CT scan in this scenario should be undertaken whatever the type of anti-coagulant medication and that is the Trust's own policy going forwards. There was concern that this ought to be 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 national guidance on CT scanning after falls with head impact in patients taking different types of anticoagulant medication
Wider context from the report “The inquest heard that Mr Bailey fell and hit his head whilst an in-patient at Stepping Hill hospital. No CT scan of the brain/head was undertaken despite Mr Bailey taking anti-coagulant medication because NICE guideline recommended a scan is undertaken if the patient has fallen, struck their head and is taking warfarin but that is not the guidance if the anticoagulant medication is one of the other types of anticoagulant medications used . The clinicians attending the Inquest indicated that a CT scan in this scenario should be undertaken whatever the type of anti-coagulant medication and that is the Trust's own policy going forwards. There was concern that this ought to be national guidance .
” Open source report
6 Mar 2018 Georgia Polydorou · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to communicate the significance of post-fall deterioration signs to patients’ interpreters or carers View source Failure to provide timely CT scanning after falls in elderly patients taking blood-thinning medications View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Georgia Polydorou · 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
Georgia Polydorou was an in-patient being treated for congestive cardiac failure when she fell while going to the toilet on 10 July 2017. She later became unresponsive and was found to have a large acute subdural haematoma; after surgery and a prolonged period on a ventilator, she died on 18 September 2017. Concerns included the decision not to perform a CT scan within eight hours of the fall despite concurrent use of aspirin, clopidogrel and enoxaparin, the delayed presentation of head-injury signs in elderly patients, and communication difficulties relating to her limited English and the significance of headache after the fall.
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 communicate the significance of post-fall deterioration signs to patients’ interpreters or carers
Wider context from the report “(3) Mrs Polydorou’s first language was Greek. Witnesses described her ability to converse in English as “basic”. Whilst in A&E, her son acted as an interpreter in order to obtain a reliable history . Following the fall, it was decided that Mrs Polydorou would have a CT scan if she showed signs of deterioration such as headache, bleeding, dizziness or vomiting. Mrs Polydorou’s son, ████████ was told that his mother had fallen but was not told of the significance that may indicate that her condition was deteriorating. During a visit on 10 July, Mrs Polydorou told her son that she had a headache but he did not realise the potential significance of this. Mrs Polydorou did not report her headache to medical staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely CT scanning after falls in elderly patients taking blood-thinning medications
Wider context from the report “(1) Mrs Polydorou did not receive a CT scan within 8 hours of her fall because she had a Glasgow Coma Scale of 15/15, she did not have any abnormal neurological observations and was not taking Warfarin. Mrs Polydorou was concurrently taking aspirin, clopidogrel and enoxaparin during her hospital admission. All of which have the effect of thinning the blood.
(2) Evidence from a consultant neurosurgeon established that there can be a significant delay in elderly patients showing signs of head injury following a fall, particularly where they are taking blood thinning medications.
” 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 Take the issues into account when the relevant guideline areas are next reviewed.
Verbatim wording from the response “Following our considerations, we believe both guidelines appropriately reflect the available evidence and do not need to be amended at this time. Nevertheless, the issues have been logged with the NICE guideline surveillance team, and will be taken into account when the guideline areas are next considered for review.” Source location 2018-0079-Response-by-N.I.C.E
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 Log the concerns with the NICE guideline surveillance team for consideration in ongoing surveillance.
Verbatim wording from the response “Following our considerations, we believe both guidelines appropriately reflect the available evidence and do not need to be amended at this time. Nevertheless, the issues have been logged with the NICE guideline surveillance team, and will be taken into account when the guideline areas are next considered for review.” Source location 2018-0079-Response-by-N.I.C.E
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 VTE and head-injury guidelines appropriately reflect available evidence and do not require amendment at this time.
Verbatim wording from the response “We also have a guideline on the assessment and early management of head injury (CG176). This guideline includes recommendations on performing CT head scans in patients on warfarin (who have no other indications for CT head scan), reflecting the available evidence. The guideline developers considered there to be limited evidence regarding patients using other antiplatelet or anticoagulant drugs within studies deriving or validating clinical decision rules for determining which patients need CT head scans - particularly, evidence in determining whether they are at increased risk of intracranial haemorrhage. The guideline developers therefore made a research recommendation on this issue.” Source location 2018-0079-Response-by-N.I.C.E
Open published response
Concerns raised 2 Lack of local guidance setting out the pathway for surgery following diagnosis of gallstone pancreatitis View source Failure to prioritise the timing of cholecystectomy after diagnosis of gallstone pancreatitis 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
Terrence Denis George · 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
Terrence Denis George was admitted with gallstone pancreatitis in August 2015 and later died on 7 January 2016 after a further episode of severe pancreatitis, before the planned gallstone surgery had been scheduled. The report identified inadequate systems at the treating hospital for ensuring timely gallstone surgery and identifying patients whose operations had not occurred within recommended timescales. It also raised concern that few responding acute NHS trusts had local guidance for the surgical pathway and that the timing of surgery had not been prioritised by Trust management.
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 local guidance setting out the pathway for surgery following diagnosis of gallstone pancreatitis
Wider context from the report “At inquest the Coroner was reassured that the treating hospital (The Royal Cornwall Hospitals NHS Trust) had put in place measures to ensure an adequate system for ensuring the timeliness of gallstone surgery and to identify when patients had not had their operations within the recommended guidelines following the death of Mr George (see attached letter dated 26/07/2017).
At the request of the Coroner, Royal Cornwall Hospital wrote to 12 acute NHS Trusts within the South West and only 2 of the 9 Trusts who had replied had any local guidance in place which sets out the pathway for surgery following diagnosis of gallstone pancreatitis . Although the treating doctors were aware of The International Association of Pancreatology (IAP) and the British Society of Gastroenterology (BSG) recommendation that a cholecystectomy should take place urgently after diagnosis of gallstone pancreatitis the Trust Management had not prioritised this due to other competing demands on Trust resources.
It was considered that if there were NICE guidelines with regards to the timing of surgery after diagnosis of gallstone pancreatitis then Trusts would prioritise the timing of such surgery.
” Open source report × Source evidence
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 prioritise the timing of cholecystectomy after diagnosis of gallstone pancreatitis
Wider context from the report “At inquest the Coroner was reassured that the treating hospital (The Royal Cornwall Hospitals NHS Trust) had put in place measures to ensure an adequate system for ensuring the timeliness of gallstone surgery and to identify when patients had not had their operations within the recommended guidelines following the death of Mr George (see attached letter dated 26/07/2017).
At the request of the Coroner, Royal Cornwall Hospital wrote to 12 acute NHS Trusts within the South West and only 2 of the 9 Trusts who had replied had any local guidance in place which sets out the pathway for surgery following diagnosis of gallstone pancreatitis. Although the treating doctors were aware of The International Association of Pancreatology (IAP) and the British Society of Gastroenterology (BSG) recommendation that a cholecystectomy should take place urgently after diagnosis of gallstone pancreatitis the Trust Management had not prioritised this due to other competing demands on Trust resources .
It was considered that if there were NICE guidelines with regards to the timing of surgery after diagnosis of gallstone pancreatitis then Trusts would prioritise the timing of such surgery.
” Open source report
Concerns raised 25 Failure to assess current asthma control using recommended tests View source Failure to assess underlying asthma severity and prescribed medication level View source Failure to recognise high-risk asthma status View source Failure to manage asthma exacerbations as part of the child’s chronic condition View source Failure to record inhaler technique checks View source Failure to analyse acute asthma episodes in the context of chronic asthma View source Failure to refer high-risk asthma patients to tertiary respiratory services View source Resource constraints affecting chronic asthma care View source Deficiencies in strategies for long-term prevention of recurrent uncontrolled asthma attacks View source Lack of a long-term asthma management and care plan View source Failure to provide and document a Personal Asthma Action Plan View source Lack of a co-ordinating record of asthma exacerbations View source Lack of effective communication between primary and secondary care View source Failure to measure lung function when indicated View source Failure to standardise chronic asthma care nationally View source Persistent missed opportunities and poor asthma care practice View source Failure to complete formal referral to a tertiary respiratory service View source Failure to record frequency of reliever use View source Lack of understanding of recurrent chronic asthma management View source Failure to recognise deterioration in asthma View source Failure to optimise asthma medication despite poor control View source Failure to recognise risk factors for near-fatal or fatal asthma View source Failure to share asthma-care learning continuously across medical professionals View source Failure to assign overall management responsibility for care View source Deficiencies in training for asthma care and treatment View source See 22 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Uriely · 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 Uriely had asthma from early childhood, which deteriorated and was uncontrolled in the seven months before his death. The report identified missed opportunities in the management of his asthma, including a lack of coordinated overall responsibility and long-term care planning, failure to assess and optimise treatment consistently, poor communication between services, and failure to refer him to a specialist respiratory service.
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 assess current asthma control using recommended tests
Wider context from the report “6) The assessment and management of Michael’s chronic asthma condition was not in accordance with the BTS/SIGN Guidelines. In particular: lung function (peak expiratory flow/ PEF or spirometry) was not always measured when indicated; his medication was not optimised despite poor control; current asthma control was not always assessed using one of the tests recommended ; Michael’s frequency of use of relievers was never recorded; inhaler technique checking was not recorded; and there was no evidence in the GP or hospital records that a Personal Asthma Action Plan (PAAP) detailing the use of medication, recognising danger and how and when to call for help, had been issues to Michael.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to assess underlying asthma severity and prescribed medication level
Wider context from the report “2) There was:-
i) No co-ordinating record of these occasions.
ii) No analysis of the acute episodes in context with his chronic asthma condition.
iii) No appreciation of the underlying severity and analysis of the level of medication prescribed.
iv) No appreciation of the risk factors of near fatal or fatal asthma evident in this child.
v) No appreciation of the deteriorating nature of his asthma.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise high-risk asthma status
Wider context from the report “10) Following the NRAD recommendations published in May 2014, and widely publicised in local and national media, and GP Press, Michael’s high risk status was not recognised which should have prompted a referral to a difficult or severe asthma service run by a paediatric respiratory specialist.
” Open source report × Source evidence
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 manage asthma exacerbations as part of the child’s chronic condition
Wider context from the report “1) The care management and treatment of this child during his final year of life with exacerbations of asthma was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning him to the care of his family.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to record inhaler technique checks
Wider context from the report “6) The assessment and management of Michael’s chronic asthma condition was not in accordance with the BTS/SIGN Guidelines. In particular: lung function (peak expiratory flow/ PEF or spirometry) was not always measured when indicated; his medication was not optimised despite poor control; current asthma control was not always assessed using one of the tests recommended; Michael’s frequency of use of relievers was never recorded; inhaler technique checking was not recorded ; and there was no evidence in the GP or hospital records that a Personal Asthma Action Plan (PAAP) detailing the use of medication, recognising danger and how and when to call for help, had been issues to Michael.
” Open source report × Source evidence
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 analyse acute asthma episodes in the context of chronic asthma
Wider context from the report “2) There was:-
i) No co-ordinating record of these occasions.
ii) No analysis of the acute episodes in context with his chronic asthma condition.
iii) No appreciation of the underlying severity and analysis of the level of medication prescribed.
iv) No appreciation of the risk factors of near fatal or fatal asthma evident in this child.
v) No appreciation of the deteriorating nature of his asthma.
” Open source report × Source evidence
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 refer high-risk asthma patients to tertiary respiratory services
Wider context from the report “7) Two further areas of concern presented, inter related but independently significant and critical in this matter:
A) Michael’s mother readily presented her child for care in and out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment.
B) Evidence was also received of the failure to refer this child to a tertiary respiratory service which may have resulted in a different approach to his treatment which may have prevented his death, by:
i) The general practitioners who failed to recognise the severity of his condition and that referral to a tertiary unit could have been considered.
ii) The A&E and inpatient service at the local hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Resource constraints affecting chronic asthma care
Wider context from the report “13) There are undoubtedly resource issues implicated in this matter but a demonstration of resolve and an effective lead given by the Department of Health and those involved in the provision of Health Service guidance and education nationally would demonstrate a universal resolve to standardise the care of chronic asthma patients and to make paediatric asthma death a “never event”.
” Open source report × Source evidence
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 Deficiencies in strategies for long-term prevention of recurrent uncontrolled asthma attacks
Wider context from the report “11) The conclusions of the Review would not of themselves have impacted on the events leading to Michael’s death but in the context of seeking to avoid future deaths, the Review and the evidence of Michael’s Inquest identify a need by both national and local agencies to revisit the recommendations of the Review, the formal substance of training identified as appropriate for the care and treatment of Asthma, the nature of that disease and the strategies essential for the long term management, care and prevention of uncontrolled re-occurring attacks .
” Open source report × Source evidence
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 long-term asthma management and care plan
Wider context from the report “4) In the absence of no one individual assuming responsibility for his care there was no plan directed towards his long term management and care identifying the chronic nature of his condition, seeking a sustained and balanced level of treatment, control.
” Open source report × Source evidence
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 and document a Personal Asthma Action Plan
Wider context from the report “6) The assessment and management of Michael’s chronic asthma condition was not in accordance with the BTS/SIGN Guidelines. In particular: lung function (peak expiratory flow/ PEF or spirometry) was not always measured when indicated; his medication was not optimised despite poor control; current asthma control was not always assessed using one of the tests recommended; Michael’s frequency of use of relievers was never recorded; inhaler technique checking was not recorded; and there was no evidence in the GP or hospital records that a Personal Asthma Action Plan (PAAP) detailing the use of medication, recognising danger and how and when to call for help, had been issues to Michael .
” Open source report × Source evidence
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 co-ordinating record of asthma exacerbations
Wider context from the report “2) There was:-
i) No co-ordinating record of these occasions.
ii) No analysis of the acute episodes in context with his chronic asthma condition.
iii) No appreciation of the underlying severity and analysis of the level of medication prescribed.
iv) No appreciation of the risk factors of near fatal or fatal asthma evident in this child.
v) No appreciation of the deteriorating nature of his asthma.
” Open source report × Source evidence
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 effective communication between primary and secondary care
Wider context from the report “7) Two further areas of concern presented, inter related but independently significant and critical in this matter:
A) Michael’s mother readily presented her child for care in and out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment .
B) Evidence was also received of the failure to refer this child to a tertiary respiratory service which may have resulted in a different approach to his treatment which may have prevented his death, by:
i) The general practitioners who failed to recognise the severity of his condition and that referral to a tertiary unit could have been considered.
ii) The A&E and inpatient service at the local hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to measure lung function when indicated
Wider context from the report “6) The assessment and management of Michael’s chronic asthma condition was not in accordance with the BTS/SIGN Guidelines. In particular: lung function (peak expiratory flow/ PEF or spirometry) was not always measured when indicated ; his medication was not optimised despite poor control; current asthma control was not always assessed using one of the tests recommended; Michael’s frequency of use of relievers was never recorded; inhaler technique checking was not recorded; and there was no evidence in the GP or hospital records that a Personal Asthma Action Plan (PAAP) detailing the use of medication, recognising danger and how and when to call for help, had been issues to Michael.
” Open source report × Source evidence
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 standardise chronic asthma care nationally
Wider context from the report “13) There are undoubtedly resource issues implicated in this matter but a demonstration of resolve and an effective lead given by the Department of Health and those involved in the provision of Health Service guidance and education nationally would demonstrate a universal resolve to standardise the care of chronic asthma patients and to make paediatric asthma death a “never event”.
” Open source report × Source evidence
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 Persistent missed opportunities and poor asthma care practice
Wider context from the report “9) The National Review of Asthma Death (NRAD) 2011-2014 was published in a report entitles ‘Why Asthma Kills’ on the 6th May 2014. The Review’s evidence based conclusions and recommendations exemplify and underline the same missed opportunities and poor practice which led to Michael’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to complete formal referral to a tertiary respiratory service
Wider context from the report “8) Michael was never formally referred to a tertiary respiratory service .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to record frequency of reliever use
Wider context from the report “6) The assessment and management of Michael’s chronic asthma condition was not in accordance with the BTS/SIGN Guidelines. In particular: lung function (peak expiratory flow/ PEF or spirometry) was not always measured when indicated; his medication was not optimised despite poor control; current asthma control was not always assessed using one of the tests recommended; Michael’s frequency of use of relievers was never recorded ; inhaler technique checking was not recorded; and there was no evidence in the GP or hospital records that a Personal Asthma Action Plan (PAAP) detailing the use of medication, recognising danger and how and when to call for help, had been issues to Michael.
” Open source report × Source evidence
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 understanding of recurrent chronic asthma management
Wider context from the report “5) In and of itself the death of this child demonstrates a profound and woeful indication of the lack of understanding of how this condition, its recurring nature can and should be managed by someone with the proper training and understanding of this chronic respiratory disease.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise deterioration in asthma
Wider context from the report “2) There was:-
i) No co-ordinating record of these occasions.
ii) No analysis of the acute episodes in context with his chronic asthma condition.
iii) No appreciation of the underlying severity and analysis of the level of medication prescribed.
iv) No appreciation of the risk factors of near fatal or fatal asthma evident in this child.
v) No appreciation of the deteriorating nature of his asthma.
” Open source report × Source evidence
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 optimise asthma medication despite poor control
Wider context from the report “6) The assessment and management of Michael’s chronic asthma condition was not in accordance with the BTS/SIGN Guidelines. In particular: lung function (peak expiratory flow/ PEF or spirometry) was not always measured when indicated; his medication was not optimised despite poor control ; current asthma control was not always assessed using one of the tests recommended; Michael’s frequency of use of relievers was never recorded; inhaler technique checking was not recorded; and there was no evidence in the GP or hospital records that a Personal Asthma Action Plan (PAAP) detailing the use of medication, recognising danger and how and when to call for help, had been issues to Michael.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise risk factors for near-fatal or fatal asthma
Wider context from the report “2) There was:-
i) No co-ordinating record of these occasions.
ii) No analysis of the acute episodes in context with his chronic asthma condition.
iii) No appreciation of the underlying severity and analysis of the level of medication prescribed.
iv) No appreciation of the risk factors of near fatal or fatal asthma evident in this child.
v) No appreciation of the deteriorating nature of his asthma.
” Open source report × Source evidence
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 share asthma-care learning continuously across medical professionals
Wider context from the report “12) It is right to acknowledge that the local Trust in this matter have responded to the criticism directed towards them and sought to identify better practices for the future, their experience needs to be shared by and with other medical care professionals on a continuing bases , and their resolve to do so, evidence of their commitment that lessons have been learned.
” Open source report × Source evidence
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 assign overall management responsibility for care
Wider context from the report “3) Despite the presence of a significant number of health care professionals involved in his care, no single individual assumed management for his care overall .
” Open source report × Source evidence
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 Deficiencies in training for asthma care and treatment
Wider context from the report “11) The conclusions of the Review would not of themselves have impacted on the events leading to Michael’s death but in the context of seeking to avoid future deaths, the Review and the evidence of Michael’s Inquest identify a need by both national and local agencies to revisit the recommendations of the Review, the formal substance of training identified as appropriate for the care and treatment of Asthma , the nature of that disease and the strategies essential for the long term management, care and prevention of uncontrolled re-occurring attacks.
” 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 Produce and publish a quality standard covering diagnosis and management of asthma in adults and children.
Verbatim wording from the response “We have produced a quality standard on asthma that covers diagnosing and managing asthma in adults and children (aged 12 months and over). NICE quality standards describe high-priority areas for quality improvement in a defined care or service area. Each standard consists of a prioritised set of specific, concise and measurable statements. They draw on existing guidance, which provides an underpinning, comprehensive set of recommendations, and are designed to support the measurement of improvement.” Source location Uriely-Response2
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and, where appropriate, update the asthma quality standard after the related guidelines are published.
Verbatim wording from the response “Both guidelines are due to be published in October 2017. Once published, our quality standard will be reviewed and updated where appropriate, in line with our recommendations.” Source location Uriely-Response2
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 Develop guidelines on asthma diagnosis, monitoring and management, excluding severe asthma and acute asthma attacks.
Verbatim wording from the response “In addition to our published quality standard on asthma, we are currently developing guidelines on the diagnosis and monitoring of asthma and on asthma management. However, the scope of these guidelines do not cover managing severe asthma or acute asthma attacks.” Source location Uriely-Response2
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 Produce tools and resources supporting NHS implementation of the recommendations.
Verbatim wording from the response “We will be producing tools and resources to help support the NHS to implement the recommendations, and we are working with NHS England on implementation of the guidance.” Source location Uriely-Response2
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The guidelines under development do not cover management of severe asthma or acute asthma attacks.
Verbatim wording from the response “In addition to our published quality standard on asthma, we are currently developing guidelines on the diagnosis and monitoring of asthma and on asthma management. However, the scope of these guidelines do not cover managing severe asthma or acute asthma attacks.” Source location Uriely-Response2
Open published response
31 Oct 2016 Frederick Squires · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 1 Lack of guidance on when to recommence Warfarin after head injury View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Frederick Squires · 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
Frederick Squires was involved in a low-impact road traffic collision, sustained a head injury, and was discharged home after his warfarin and other medications were stopped. He was later found unwell, diagnosed with an acute ischaemic stroke, and died on 30 December 2014. The principal concern was the lack of guidance for clinicians on when warfarin should be recommenced after a head injury.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on when to recommence Warfarin after head injury
Wider context from the report “(1) That there is no guidance available to clinicians as to when Warfarin should be recommenced for a patient who has suffered a head injury . If clear guidance is not available it will lead to confusion amongst clinicians and the patient with the result that it is commenced too soon and the patient develops a bleed or too late and the patient suffers a stroke.
” 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 extending the head-injury guideline’s scope to examine evidence and develop recommendations on restarting warfarin during the 2017 update.
Verbatim wording from the response “We have a guideline on the assessment and early management of head injury (accessible from our website: www.nice.org.uk/cg176), which includes recommendations regarding discharging patients. However, we believe that to examine the available evidence and make specific recommendations on when to restart Warfarin would require the guideline’s scope to be extended. We will consider the case for doing so, when we consider the guideline for updating in 2017.” 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 Specific recommendations on restarting Warfarin after head injury cannot be made without extending the guideline’s scope.
Verbatim wording from the response “We have a guideline on the assessment and early management of head injury (accessible from our website: www.nice.org.uk/cg176), which includes recommendations regarding discharging patients. However, we believe that to examine the available evidence and make specific recommendations on when to restart Warfarin would require the guideline’s scope to be extended. We will consider the case for doing so, when we consider the guideline for updating in 2017.” Source location Response from National Institute for Health and Care Excellence
Open published response
7 Sep 2016 Dildar Shariff · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Failure to incorporate the significance of head injury in patients undergoing haemodialysis or with significant uraemia due to renal failure into relevant NICE guidelines View source Lack of awareness within the medical profession of haemorrhage risk after head injury in patients undergoing haemodialysis or with significant uraemia due to renal failure View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Dildar Shariff · 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
Dildar Shariff died at Fairfield General Hospital on 10 May 2016 after a cardiac arrest, following a fall, head pain and vomiting. An intracerebral haemorrhage was confirmed, and the report states that his haemodialysis placed him at increased risk of haemorrhage. The principal concern was that this risk was not widely recognised or referred to in the relevant NICE guidelines, potentially creating a risk to other 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 to incorporate the significance of head injury in patients undergoing haemodialysis or with significant uraemia due to renal failure into relevant NICE guidelines
Wider context from the report “Evidence was given that patients who are undergoing haemodialysis or with significant uraemia due to renal failure, such as Mr Shariff, are at increased risk of a haemorrhage and that this is not commonly known within the medical profession or referred to in the relevant NICE guidelines. This lack of awareness could create a risk that other deaths will continue to exist or occur in the future and whilst I am satisfied that the Trust have taken this matter very seriously, in that they have implemented appropriate measures to reduce the risk of this occurring in the future, I am concerned with the National procedures as I am mindful that it may take some time for the significance of a head injury within patients with undergoing haemodialysis or with significant uraemia due to renal failure to be incorporated into the NICE guidelines .
” Open source report × Source evidence
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 awareness within the medical profession of haemorrhage risk after head injury in patients undergoing haemodialysis or with significant uraemia due to renal failure
Wider context from the report “Evidence was given that patients who are undergoing haemodialysis or with significant uraemia due to renal failure, such as Mr Shariff, are at increased risk of a haemorrhage and that this is not commonly known within the medical profession or referred to in the relevant NICE guidelines. This lack of awareness could create a risk that other deaths will continue to exist or occur in the future and whilst I am satisfied that the Trust have taken this matter very seriously, in that they have implemented appropriate measures to reduce the risk of this occurring in the future, I am concerned with the National procedures as I am mindful that it may take some time for the significance of a head injury within patients with undergoing haemodialysis or with significant uraemia due to renal failure to be incorporated into the NICE guidelines.
” 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 Log the concerns with the guideline surveillance team for consideration when the head injury guidance is next reviewed.
Verbatim wording from the response “While we believe that our guideline does not need to be amended as a result of your report, your concerns have been logged with our guideline surveillance team, for their information when the guidance is next considered for update in 2017.” Source location 2016-0321-Response-by-N.I.C.E
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing head injury guideline does not need amendment because its bleeding-disorder risk factor and CT assessment recommendations already address the concern.
Verbatim wording from the response “We have noted the circumstances around Mr Shariff’s death and the concerns you have raised, in relation to our existing guideline on the assessment and early management of head injury (accessible from our website: www.nice.org.uk/cg176).” Source location 2016-0321-Response-by-N.I.C.E
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 Clinicians are widely aware that renal failure, uraemia and haemodialysis increase bleeding risk, contrary to the report’s concern about lack of awareness.
Verbatim wording from the response “You explain in your report that you consider there to be a lack of awareness within the medical profession that people undergoing haemodialysis, or those with significant uremia due to renal failure, are at increased risk of a haemorrhage. Subsequently, you’ve asked for the significance of a head injury in such people to be incorporated into NICE guidelines.” Source location 2016-0321-Response-by-N.I.C.E
Open published response
30 Jun 2016 baby Dominic Smith · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 14 Failure to act on early warning scores View source Failure to carry out maternal observations after delivery despite a temperature spike View source Failure to recognise signs and symptoms of neonatal deterioration View source Inadequate clinical communication and handover View source Inadequate preceptorship for newly qualified and part-time midwives View source Failure of midwives to escalate to or consult with relevant specialist clinicians View source Failure to carry out speculum examination to establish rupture of membranes View source Failure to document rationale for clinical discretion View source Failure to carry out neonatal observations after material change in condition View source Failure to routinely offer intrapartum prophylactic antibiotics to women with current or previous positive GBS tests View source Failure of staff to follow clinical protocols and guidance View source Failure to routinely offer antenatal GBS screening to pregnant women during the final weeks of pregnancy View source Miscalculation of early warning scores View source Inadequate clinical record keeping View source See 11 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
baby Dominic Smith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Baby Dominic Smith was born on 2 June 2015 after a prolonged labour and died at approximately 18 hours of life following a collapse. The report describes pneumonia as the cause of death and identifies concerns including failure to recognise possible rupture of membranes and infection risk, inadequate maternal and neonatal observations, failure to escalate deterioration, delayed antibiotic treatment, and communication and record-keeping problems.
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 act on early warning scores
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon ;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
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 carry out maternal observations after delivery despite a temperature spike
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature ;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise signs and symptoms of neonatal deterioration
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed ;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Inadequate clinical communication and handover
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Inadequate preceptorship for newly qualified and part-time midwives
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives .
” Open source report × Source evidence
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 midwives to escalate to or consult with relevant specialist clinicians
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
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 carry out speculum examination to establish rupture of membranes
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes . The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
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 rationale for clinical discretion
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion ;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
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 carry out neonatal observations after material change in condition
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition . Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely offer intrapartum prophylactic antibiotics to women with current or previous positive GBS tests
Wider context from the report “Department of Health, NIHCE and the Royal Colleges:
1. I previously completed a PFD 13 month ago in relation to a neonatal GBS death. At that time I raised the following concerns:
- That antenatal screening for GBS was not being routinely offered by the NHS to all pregnant women during the final weeks of pregnancy,
- That prophylaxis intrapartum antibiotics were not routinely offered to all women who test positive for GBS (or have done so in the past)
&
- That given the seriousness of the illness, in the absence of a national screening and prophylactic treatment programme, babies were potentially being put at risk of harm/death.
During the course of the inquest into Baby Smith’s death the evidence suggested that no further action has been taken in this regard, despite the responses received in relation to the last PFD action.
I therefore raise the issues again as a concern.
” Open source report × Source evidence
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 staff to follow clinical protocols and guidance
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely offer antenatal GBS screening to pregnant women during the final weeks of pregnancy
Wider context from the report “Department of Health, NIHCE and the Royal Colleges:
1. I previously completed a PFD 13 month ago in relation to a neonatal GBS death. At that time I raised the following concerns:
- That antenatal screening for GBS was not being routinely offered by the NHS to all pregnant women during the final weeks of pregnancy ,
- That prophylaxis intrapartum antibiotics were not routinely offered to all women who test positive for GBS (or have done so in the past)
&
- That given the seriousness of the illness, in the absence of a national screening and prophylactic treatment programme, babies were potentially being put at risk of harm/death.
During the course of the inquest into Baby Smith’s death the evidence suggested that no further action has been taken in this regard, despite the responses received in relation to the last PFD action.
I therefore raise the issues again as a concern.
” Open source report × Source evidence
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 Miscalculation of early warning scores
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated , ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Inadequate clinical record keeping
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping ;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report
6 Mar 2016 Edward Paddon-Bramley · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Inconsistent use of intrapartum antibiotics View source Inconsistent treatment guidance and practice for prolonged rupture of membranes View source Inconsistent GBS screening practice during pregnancy 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
Edward Paddon-Bramley · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Edward Paddon-Bramley was born following prolonged rupture of membranes and developed severe infection, including Group B Streptococcus infection. Despite neonatal care, he died aged 9 days. The report identified differing practices and opinions regarding the treatment of prolonged rupture of membranes and whether pregnant women should be screened for Group B Streptococcus and given intrapartum antibiotics.
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 Inconsistent use of intrapartum antibiotics
Wider context from the report “Evidence was provided to the Court by way of National guidelines (NICE 2008, Induction of labour), Trust guidelines (more than one Trust), The Royal College (Green-top guideline no 36) and by Consultants.
Trust guidelines as to the treatment of prolonged rupture of membranes (PROM) differed from those provided by NICE and the use of anti-biotics, after varying times of rupture, irrespective of the clinical picture.
Consultants views as to the best practice for treating PROM and whether women should be screened for GBS during pregnancy differed from those provided by NICE.
In conclusion, evidence was given at the inquest that there is a difference of opinion and practice in the treatment of mothers (and their babies) who suffer from ROM of a prolonged period. Both clinicians and Trusts appear to be at odds with NICE.
There also appears to be arguable opinion that GBS screening in pregnant women together with the use of intra-partum anti-biotics ought to re-viewed.
” Open source report × Source evidence
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 treatment guidance and practice for prolonged rupture of membranes
Wider context from the report “Evidence was provided to the Court by way of National guidelines (NICE 2008, Induction of labour), Trust guidelines (more than one Trust), The Royal College (Green-top guideline no 36) and by Consultants.
Trust guidelines as to the treatment of prolonged rupture of membranes (PROM) differed from those provided by NICE and the use of anti-biotics, after varying times of rupture, irrespective of the clinical picture.
Consultants views as to the best practice for treating PROM and whether women should be screened for GBS during pregnancy differed from those provided by NICE.
In conclusion, evidence was given at the inquest that there is a difference of opinion and practice in the treatment of mothers (and their babies) who suffer from ROM of a prolonged period. Both clinicians and Trusts appear to be at odds with NICE.
There also appears to be arguable opinion that GBS screening in pregnant women together with the use of intra-partum anti-biotics ought to re-viewed.
” Open source report × Source evidence
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 GBS screening practice during pregnancy
Wider context from the report “Evidence was provided to the Court by way of National guidelines (NICE 2008, Induction of labour), Trust guidelines (more than one Trust), The Royal College (Green-top guideline no 36) and by Consultants.
Trust guidelines as to the treatment of prolonged rupture of membranes (PROM) differed from those provided by NICE and the use of anti-biotics, after varying times of rupture, irrespective of the clinical picture.
Consultants views as to the best practice for treating PROM and whether women should be screened for GBS during pregnancy differed from those provided by NICE.
In conclusion, evidence was given at the inquest that there is a difference of opinion and practice in the treatment of mothers (and their babies) who suffer from ROM of a prolonged period. Both clinicians and Trusts appear to be at odds with NICE.
There also appears to be arguable opinion that GBS screening in pregnant women together with the use of intra-partum anti-biotics ought to re-viewed.
” Open source report
Concerns raised 1 Failure of the head injury pathway to include Clopidogrel as a CT scan trigger 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
Thelma Doris Clarkson · 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
Thelma Doris Clarkson fell at home on 10 February 2015, sustained head injuries, and died in hospital the following day after her condition deteriorated and an inoperable head injury was identified. The concern was that the NICE Head Injury Pathway did not treat Clopidogrel use as a trigger for a CT scan in the same way as Warfarin, despite the risk of increased bleeding from head trauma.
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 the head injury pathway to include Clopidogrel as a CT scan trigger
Wider context from the report “Prior to her fall, Mrs Clarkson has for some time been prescribed and was taking the drug Clopidogrel for long-standing heart disease. The British National Formulary warns that patients taking Clopidogrel are at risk of increased bleeding from trauma. However, I was told in evidence at the Inquest that under the NICE Head Injury Pathway which was in use at the time at Gosport War Memorial Hospital, had Mrs Clarkson been taking Warfarin she would have been sent to a larger hospital to have a CT scan of her head but the Pathway did not include Clopidogrel as a similar trigger for a CT scan - notwithstanding the risk of increased bleeding from head trauma. I was also told that, had Mrs Clarkson been sent from Gosport War Memorial Hospital for a CT scan, there is a strong possibility it would have revealed the extent of her head injury and her treatment - and its potential outcome - may have been different. I am therefore concerned that the NICE should consider whether its Head Injury Pathway should be amended to include taking Clopidogrel as a trigger for a CT scan in the same way as Warfarin presently does.
” Open source report
Concerns raised 9 Failure to provide longitudinal management of recurring asthma exacerbations View source Failure to recognise deterioration in respiratory condition View source Failure to enable appropriate referrals to the tertiary paediatric service View source Failure to ensure understanding of the purpose and limits of asthma plans View source Lack of a long-term management plan for chronic asthma View source Lack of effective communication between primary and secondary care services View source Lack of a coordinating record of recurrent asthma presentations View source Failure to assign overall clinical management responsibility View source Failure to refer paediatric asthma patients to tertiary respiratory specialists View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Tamara Mills · 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
Tamara Mills, who had longstanding asthma and repeated acute exacerbations, developed breathing difficulties during the night of 10th/11th April 2015 and died after paramedics were called. The principal concerns were fragmented care, inadequate coordination and communication, insufficient recognition of her deteriorating chronic respiratory condition, and the absence of a long-term management plan.
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 longitudinal management of recurring asthma exacerbations
Wider context from the report “1. The care management and treatment of this child on the innumerable occasions she presented with an exacerbation of asthma, was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family .
2. There was :-
i) No co-ordinating record of these occasions
ii) No analysis of the frequency or circumstances of the events
iii) No analysis of the medication or level of medication prescribed
iv) No determination of its effectiveness the frequency or regularity of its use
v) No appreciation of the deteriorating nature of her respiratory condition
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise deterioration in respiratory condition
Wider context from the report “1. The care management and treatment of this child on the innumerable occasions she presented with an exacerbation of asthma, was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family.
2. There was :-
i) No co-ordinating record of these occasions
ii) No analysis of the frequency or circumstances of the events
iii) No analysis of the medication or level of medication prescribed
iv) No determination of its effectiveness the frequency or regularity of its use
v) No appreciation of the deteriorating nature of her respiratory condition
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to enable appropriate referrals to the tertiary paediatric service
Wider context from the report “8. Two further areas of concern presented, inter related but independently significant and critical in this matter :
A) Tamara’s mother readily presented her child for care in an out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment.
B) Evidence was also received of the development of a Tertiary service designed to improve medical care in the area of paediatrics.
i) There was a singular lack of understanding by practitioners of how referrals to the service were to be made and once made an anxiety that the receiving trust not be seen to be acquiring a patient at the expense of the referring trust . The net result of this inhibition a further fragmentation in the care and management of the patient.
ii) Within this service there were and indeed are specialist Respiratory Physicians who because of their level of expertise could and did demonstrate their ability to make a difference if they had been permitted in one instance to assume long term management of the child’s care
and
iii) More tragically in another because she was referred to the hospital but not to the service and therefore not to the Tertiary Specialists, managed only as an acute presentation
9. Tamara was never formally referred to this level of service.
” Open source report × Source evidence
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 understanding of the purpose and limits of asthma plans
Wider context from the report “3. Despite the presence of a significant number of health care professional involved in her care and some frequently, no single individual assumed management for her care overall
4. In the absence of no one individual assuming responsibility for her care, there was no plan directed towards her long term management and care identifying the chronic nature of her condition, seeking a sustained and balanced level of treatment, control and resolution of the recurring episodes.
5. Insofar as planning occurred it was in the last six months of her life and was in the form of an emergency plan directed towards the next and apparently accepted inevitable acute event, but not as a part of the necessary strategy to control and avoid such events.
6. Not only did those advised of such a plan fail to understand its limited objective they misinterpreted its purpose and consoled themselves in the false belief there was a purposeful strategy designed to protect this child in the long term.
” Open source report × Source evidence
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 long-term management plan for chronic asthma
Wider context from the report “3. Despite the presence of a significant number of health care professional involved in her care and some frequently, no single individual assumed management for her care overall
4. In the absence of no one individual assuming responsibility for her care, there was no plan directed towards her long term management and care identifying the chronic nature of her condition, seeking a sustained and balanced level of treatment, control and resolution of the recurring episodes .
5. Insofar as planning occurred it was in the last six months of her life and was in the form of an emergency plan directed towards the next and apparently accepted inevitable acute event, but not as a part of the necessary strategy to control and avoid such events.
6. Not only did those advised of such a plan fail to understand its limited objective they misinterpreted its purpose and consoled themselves in the false belief there was a purposeful strategy designed to protect this child in the long term.
” Open source report × Source evidence
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 effective communication between primary and secondary care services
Wider context from the report “8. Two further areas of concern presented, inter related but independently significant and critical in this matter :
A) Tamara’s mother readily presented her child for care in an out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment .
B) Evidence was also received of the development of a Tertiary service designed to improve medical care in the area of paediatrics.
i) There was a singular lack of understanding by practitioners of how referrals to the service were to be made and once made an anxiety that the receiving trust not be seen to be acquiring a patient at the expense of the referring trust. The net result of this inhibition a further fragmentation in the care and management of the patient.
ii) Within this service there were and indeed are specialist Respiratory Physicians who because of their level of expertise could and did demonstrate their ability to make a difference if they had been permitted in one instance to assume long term management of the child’s care
and
iii) More tragically in another because she was referred to the hospital but not to the service and therefore not to the Tertiary Specialists, managed only as an acute presentation
9. Tamara was never formally referred to this level of service.
” Open source report × Source evidence
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 coordinating record of recurrent asthma presentations
Wider context from the report “1. The care management and treatment of this child on the innumerable occasions she presented with an exacerbation of asthma, was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family.
2. There was :-
i) No co-ordinating record of these occasions
ii) No analysis of the frequency or circumstances of the events
iii) No analysis of the medication or level of medication prescribed
iv) No determination of its effectiveness the frequency or regularity of its use
v) No appreciation of the deteriorating nature of her respiratory condition
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to assign overall clinical management responsibility
Wider context from the report “3. Despite the presence of a significant number of health care professional involved in her care and some frequently, no single individual assumed management for her care overall
4. In the absence of no one individual assuming responsibility for her care, there was no plan directed towards her long term management and care identifying the chronic nature of her condition, seeking a sustained and balanced level of treatment, control and resolution of the recurring episodes.
5. Insofar as planning occurred it was in the last six months of her life and was in the form of an emergency plan directed towards the next and apparently accepted inevitable acute event, but not as a part of the necessary strategy to control and avoid such events.
6. Not only did those advised of such a plan fail to understand its limited objective they misinterpreted its purpose and consoled themselves in the false belief there was a purposeful strategy designed to protect this child in the long term.
” Open source report × Source evidence
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 refer paediatric asthma patients to tertiary respiratory specialists
Wider context from the report “8. Two further areas of concern presented, inter related but independently significant and critical in this matter :
A) Tamara’s mother readily presented her child for care in an out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment.
B) Evidence was also received of the development of a Tertiary service designed to improve medical care in the area of paediatrics.
i) There was a singular lack of understanding by practitioners of how referrals to the service were to be made and once made an anxiety that the receiving trust not be seen to be acquiring a patient at the expense of the referring trust. The net result of this inhibition a further fragmentation in the care and management of the patient.
ii) Within this service there were and indeed are specialist Respiratory Physicians who because of their level of expertise could and did demonstrate their ability to make a difference if they had been permitted in one instance to assume long term management of the child’s care
and
iii) More tragically in another because she was referred to the hospital but not to the service and therefore not to the Tertiary Specialists, managed only as an acute presentation
9. Tamara was never formally referred to this level of service .
” Open source report
23 Oct 2015 Hireiti Kufletsion · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Inadequate frequency of anti-factor Xa review for pregnant women with mechanical valves View source Failure of clinicians managing pregnant women with mechanical heart valves to understand the thrombosis risk and anticoagulation implications View source Insufficient clexane dosing for pregnant women with mechanical valves 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
Hireiti Kufletsion · 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
Hireiti Kufletsion died at Queen Elizabeth Hospital Birmingham on 20 November 2014 from thrombosis of a mechanical mitral valve during the first trimester of pregnancy. The report identified failures to adequately investigate the valve, seek specialist cardiology advice and prescribe adequate doses of clexane, with concerns that pregnant women with mechanical heart valves may be at risk from insufficient anticoagulation and inadequate clinical understanding of the associated thrombosis risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Inadequate frequency of anti-factor Xa review for pregnant women with mechanical valves
Wider context from the report “(1) In giving evidence ████████ stated that from time to time she does see at her Obstetric/Cardiac clinic pregnant patients with mechanical valves who have had their warfarin changed to clexane at other hospitals in the region on too low a dose of clexane (i.e. not a twice daily 60mg/kg dose). Likewise she is aware that review of anti-factor Xa may not be arranged to occur with adequate frequency (once a week) . Therefore pregnant women with mechanical valves may be at risk from being prescribed insufficient doses of clexane with insufficient review of their anti-factor Xa .
” Open source report × Source evidence
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 clinicians managing pregnant women with mechanical heart valves to understand the thrombosis risk and anticoagulation implications
Wider context from the report “(2) It was apparent from evidence given by clinicians at the Birmingham Heartlands Hospital that they did not understand the extent and gravity of the increased risk of thrombosis to pregnant women with mechanical heart valves and this affected the course of investigations into the deceased’s condition ultimately resulting in a delay in diagnosis until it was too late. Whilst this issue has now been brought to the full attention of all departments within the Birmingham Heartlands Hospital, it is reasonable to assume that there are haematologists, cardiologists and obstetricians without specialist cardio-obstetric knowledge across the country that do not appreciate the implications during pregnancies of patients with a mechanical heart valve for anti-coagulation therapy but maybe involved in the management and care of such patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Insufficient clexane dosing for pregnant women with mechanical valves
Wider context from the report “(1) In giving evidence ████████ stated that from time to time she does see at her Obstetric/Cardiac clinic pregnant patients with mechanical valves who have had their warfarin changed to clexane at other hospitals in the region on too low a dose of clexane (i.e. not a twice daily 60mg/kg dose) . Likewise she is aware that review of anti-factor Xa may not be arranged to occur with adequate frequency (once a week). Therefore pregnant women with mechanical valves may be at risk from being prescribed insufficient doses of clexane with insufficient review of their anti-factor Xa.
” Open source report
Concerns raised 1 Lack of accessible sharing of relevant clinical information across NHS record silos 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
Naiya Diarra · 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
Naiya Diarra died aged 9 months on 25 June 2015 from dilated cardiomyopathy arising from severe Vitamin D deficiency. Vitamin supplementation was provided but was ultimately insufficient, and the significance of her sibling’s Vitamin D deficiency was not recognised, resulting in missed opportunities to address this. The report also raised concerns about relevant information being held in disparate record silos and not being accessible to clinicians, particularly the reviewing psychiatric team.
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 accessible sharing of relevant clinical information across NHS record silos
Wider context from the report “(1) Multiple pieces of relevant information regarding ████████ current illness were contained in disparate record ‘silos’. It was difficult for clinicians to access this information and, as such, it was not available to the reviewing psychiatric team, in particular.
I am concerned that the previous focus on access to medical records, which was to occur through the NHS Programme for IT, has been lost and that the new focus on patient access to GP records will not address the risks posed by the current state of record sharing within the NHS .
” Open source report
23 Jul 2015 Lynn POYSER · Prevention of Future Deaths report South Lincolnshire
View report summary
Concerns raised 2 Insufficient guidance on care and caution when co-prescribing ACEI drugs and Spironolactone View source Insufficient guidance to take a holistic view of patients' best interests when co-prescribing ACEI drugs and Spironolactone 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
Lynn POYSER · 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
Lynn POYSER had impaired kidney function and was prescribed Lisinopril while already taking Spironolactone. She was admitted to hospital with severe hyperkalaemia and suffered a cardiac arrest from which she could not be resuscitated. The principal concern was whether guidance on co-prescribing these medicines sufficiently emphasised caution, review, and monitoring of renal function and electrolytes.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Insufficient guidance on care and caution when co-prescribing ACEI drugs and Spironolactone
Wider context from the report “1: Evidence was presented at the inquest to the effect that the interaction between Lisinopril and Spironolactone is well known, and that Lisinopril can precipitate deterioration in a patient's renal function. NICE published guidelines on initiation of Angiotensin converting enzyme inhibitor therapy indicates that patients should be reviewed one to two weeks after initiation of therapy and have their renal function and electrolyte status checked 10 – 14 days after initiation of ACEI therapy. This is re-iterated in LCHS guidance. The expert evidence at the inquest pointed out that, following a report of a trial in 1999 "The Randomised Aldactone Evaluation Study", there was an increase in the co-prescription of Spironolactone and Lisinopril in heart failure, immediately followed by an increase in hospital admissions and subsequent deaths associated with hyperkalaemia.
Those to whom I make this report may wish to consider whether or not the current guidance relating to the co-prescription of ACEI drugs, such as Lisinopril, and Spironolactone draws sufficient attention to the need for care and caution and the need to take a holistic view of the best interests of the patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Insufficient guidance to take a holistic view of patients' best interests when co-prescribing ACEI drugs and Spironolactone
Wider context from the report “1: Evidence was presented at the inquest to the effect that the interaction between Lisinopril and Spironolactone is well known, and that Lisinopril can precipitate deterioration in a patient's renal function. NICE published guidelines on initiation of Angiotensin converting enzyme inhibitor therapy indicates that patients should be reviewed one to two weeks after initiation of therapy and have their renal function and electrolyte status checked 10 – 14 days after initiation of ACEI therapy. This is re-iterated in LCHS guidance. The expert evidence at the inquest pointed out that, following a report of a trial in 1999 "The Randomised Aldactone Evaluation Study", there was an increase in the co-prescription of Spironolactone and Lisinopril in heart failure, immediately followed by an increase in hospital admissions and subsequent deaths associated with hyperkalaemia.
Those to whom I make this report may wish to consider whether or not the current guidance relating to the co-prescription of ACEI drugs, such as Lisinopril, and Spironolactone draws sufficient attention to the need for care and caution and the need to take a holistic view of the best interests of the patient .
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations