Concerns raised 2 Lack of a clear clinical basis for overriding a GP request for patient assessment View source Failure to undertake adequate clinical inquiry and mental health assessment before making a clinical determination 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
Karen O’Brien · 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
Karen O’Brien suffered from chronic pain and depression and had disclosed thoughts of self-harm. After a mental health referral, SEPT determined that a face-to-face assessment was not required; she later jumped into the path of an underground train, and the inquest concluded that she killed herself, with multiple injuries as the medical cause of death. The principal concerns were the lack of further inquiry or face-to-face assessment and the basis on which SEPT overrode the GP’s request, including its interpretation of NICE guidance.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear clinical basis for overriding a GP request for patient assessment
Wider context from the report “It is difficult to understand how there can be a clinical determination by SEPT without more inquiry and, preferably, some face-to-face assessment of the patient by a mental health professional.
The NICE guidance is stated to be a recommendation. It must therefore be presumed not to be applied slavishly without careful assessment. The patient’s GP had asked for her to be seen. On what basis did SEPT decide to override the GP’s request?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 adequate clinical inquiry and mental health assessment before making a clinical determination
Wider context from the report “It is difficult to understand how there can be a clinical determination by SEPT without more inquiry and, preferably, some face-to-face assessment of the patient by a mental health professional.
The NICE guidance is stated to be a recommendation. It must therefore be presumed not to be applied slavishly without careful assessment. The patient’s GP had asked for her to be seen. On what basis did SEPT decide to override the GP’s request?
” Open source report
7 May 2015 Baby Olsberg · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3 Risk of serious harm or death to babies from GBS infection View source Failure to routinely offer prophylactic intrapartum antibiotics to women with current or previous positive GBS tests View source Failure to routinely offer antenatal GBS screening to all pregnant women during the final weeks of pregnancy View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Baby Olsberg · 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 Olsberg was born on 23 December 2013 and developed worsening symptoms in the hours after birth. Despite medical treatment and transfer to tertiary care, he suffered three cardiac arrests and died on 24 December 2013; blood cultures confirmed GBS infection. The concerns identified were the lack of routine antenatal GBS screening and routine prophylactic intrapartum antibiotics, and the resulting potential risk of serious harm or death to babies.
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 Risk of serious harm or death to babies from GBS infection
Wider context from the report “3. That GBS infection is a very serious illness and in the absence of a national screening and prophylactic treatment programme, babies are potentially being put at risk of harm/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 routinely offer prophylactic intrapartum antibiotics to women with current or previous positive GBS tests
Wider context from the report “2. That prophylactic intrapartum antibiotics are not routinely offered to all women who test positive for GBS (or have done so in the past) .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 all pregnant women during the final weeks of pregnancy
Wider context from the report “1. That antenatal screening for GBS is not routinely offered by the NHS, to all pregnant women, during the final weeks of pregnancy .
” 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 evidence and consult stakeholders to assess whether the antenatal GBS guideline requires updating.
Verbatim wording from the response “We most recently reviewed the evidence in 2014, and after consulting with stakeholders, we decided that there was not enough new evidence to justify updating the guideline.” Source location 2015-0177-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 Encourage research into the clinical and cost effectiveness of intrapartum antibiotic prophylaxis guided by routine antenatal GBS screening.
Verbatim wording from the response “You may also be interested in our clinical guideline on Antibiotics for early-onset neonatal infection (CG149, 2012). The guideline provides a framework outlining risk factors and clinical indicators that may be used to direct antibiotic management decisions. Once again, we have encouraged further research into the clinical and cost effectiveness of intrapartum antibiotic prophylaxis targeting group B streptococcus and guided by routine antenatal screening. Further information is available on our website at: www.nice.org.uk/CG149.” Source location 2015-0177-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 Encourage further research into GBS screening during pregnancy.
Verbatim wording from the response “As you are aware, our guideline does not recommend routine screening for GBS. This is because there was insufficient evidence to support a positive recommendation. However, we have encouraged more research to be carried out in this area and we will keep our recommendations under review, pending new evidence emerging. Our consideration of the evidence informing this recommendation is available in the full guideline which is available on our website: www.nice.org.uk/cg62. Screening for GBS is discussed in section 10.9.” Source location 2015-0177-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 Keep recommendations on antenatal GBS screening under review pending new evidence.
Verbatim wording from the response “As you are aware, our guideline does not recommend routine screening for GBS. This is because there was insufficient evidence to support a positive recommendation. However, we have encouraged more research to be carried out in this area and we will keep our recommendations under review, pending new evidence emerging. Our consideration of the evidence informing this recommendation is available in the full guideline which is available on our website: www.nice.org.uk/cg62. Screening for GBS is discussed in section 10.9.” Source location 2015-0177-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 Routine GBS screening was not recommended because evidence was insufficient, and later review found insufficient new evidence to update the guideline.
Verbatim wording from the response “As you are aware, our guideline does not recommend routine screening for GBS. This is because there was insufficient evidence to support a positive recommendation. However, we have encouraged more research to be carried out in this area and we will keep our recommendations under review, pending new evidence emerging. Our consideration of the evidence informing this recommendation is available in the full guideline which is available on our website: www.nice.org.uk/cg62. Screening for GBS is discussed in section 10.9.” Source location 2015-0177-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 Local clinicians and organisations are responsible for deciding the best approach to care, using evidence and guidance provided.
Verbatim wording from the response “I should point out that our role is to provide the evidence for decisions to be made by local clinicians and organisations on the best approach to care by providing guidance on treatments and other forms of practice. In developing the recommendations in our clinical guideline on antenatal care (CG62, 2008), we referred to the evidence-based recommendations of the UK National Screening Committee (NSC), which is part of Public Health England.” Source location 2015-0177-Response-by-N.I.C.E
Open published response
22 Apr 2015 Eliza Rebecca Bowen · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 1 Failure to perform regular blood glucose testing for patients with diabetes risk factors 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
Eliza Rebecca Bowen · 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
Eliza Bowen, a resident of Springfield House Care Home with complex medical needs, became suddenly unwell on 15 November 2014 and died after developing markedly raised blood glucose, acute kidney injury and metabolic imbalances. The inquest concluded that she died from hyperosmolar non-ketotic coma, a natural cause of death. The principal concerns were that regular blood glucose testing might have identified diabetes sooner and that guidance on diabetes screening and management for patients with relevant risk factors should be available to medical staff.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to perform regular blood glucose testing for patients with diabetes risk factors
Wider context from the report “1. A simple blood glucose test done on a regular basis may have identified the diabetes sooner and the condition managed.
2. Although the patient wasn’t identified as a diabetic she presented with some of the key associated risk factors including BMI greater than 30 and immobility due to her medical condition .
” Open source report
Concerns raised 1 Lack of guidance for thromboprophylaxis management in patients with restricted mobility who are not in casts View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Andrew Bladen · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Andrew Bladen ruptured his right quadriceps tendon after falling down stairs and underwent reconstructive surgery. He received thromboprophylaxis during and shortly after surgery but no extended treatment after discharge, and died on 2 September 2014 from a massive pulmonary embolism. The principal concern was the absence of clear guidance on optimum thromboprophylaxis for patients with restricted mobility due to a brace rather than a cast.
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 for thromboprophylaxis management in patients with restricted mobility who are not in casts
Wider context from the report “(1) Absence of guidance for optimum thromboprophylaxis management in patients who are not in casts but still have restriction of mobility eg. due to a brace.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the clinical guideline and prepare a new scope through the routine surveillance process.
Verbatim wording from the response “As part of our routine surveillance process, this guideline is to be updated and a new scope will be prepared as part of the process. We have not yet scheduled this project into our work programme, however I will make arrangements for a copy of your report to be forwarded to guideline developers at the appropriate time so that they are aware of the circumstances around this case and your concerns about the lack of specific guidance for patients in a brace. Please let me know if you or Mr Bladen’s family would prefer that this information should not be shared.” Source location 2015-0079-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 Forward the report to guideline developers so they can consider the concerns about guidance for patients in braces.
Verbatim wording from the response “As part of our routine surveillance process, this guideline is to be updated and a new scope will be prepared as part of the process. We have not yet scheduled this project into our work programme, however I will make arrangements for a copy of your report to be forwarded to guideline developers at the appropriate time so that they are aware of the circumstances around this case and your concerns about the lack of specific guidance for patients in a brace. Please let me know if you or Mr Bladen’s family would prefer that this information should not be shared.” Source location 2015-0079-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 Available evidence does not warrant a specific prophylaxis recommendation for patients in braces.
Verbatim wording from the response “As you are aware we make a specific recommendation on pharmacological VTE prophylaxis to patients with lower limb casts, however there was no evidence to indicate that a specific recommendation on prophylaxis for patients in a brace was warranted.” Source location 2015-0079-Response-by-NICE
Open published response
17 Nov 2014 Mrs Gladys Smith · Prevention of Future Deaths report West Yorkshire (East)
View report summary
Concerns raised 16 Failure to fully record wound dimensions and presenting features on each District Nurse visit View source Failure to regularly and fully record residents' weights View source Lack of Care Home staff knowledge of dementia care View source Lack of comprehensive national guidance on prevention and treatment of impact-injury wounds and ulcers View source Delays in District Nurse referrals to the Tissue Viability Nurse Service View source Failure to regularly monitor residents' weights View source Failure to body map residents' bruises View source Failure to complete turning and repositioning charts View source Omission of guidance on when District Nurses should refer patients to the Tissue Viability Nurse Service View source Failure to implement nutrition charts for residents with significant weight loss View source Failure to proactively seek medical practitioners' care advice for residents with recognised medical conditions View source Failure to undertake regular falls assessments for residents View source Delays in seeking medical advice after apparent impact injury bruising View source Failure to implement medical practitioners' advice and instruction on resident turning and repositioning View source Failure to consider the appropriate location of residents' rooms View source Delays in seeking medical advice after significant resident weight loss View source See 13 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
Mrs Gladys 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
Mrs Gladys Smith died while resident at a care home; the supplied text does not provide further circumstances of her death. The concerns included failures in repositioning, bruise and wound monitoring, falls assessment, weight and nutrition monitoring, dementia care, and delays or gaps in district nursing wound documentation and referral. The report also identified a lack of comprehensive national guidance on wounds and ulcers caused by impact injuries.
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 fully record wound dimensions and presenting features on each District Nurse visit
Wider context from the report “(a) Members of the District Nursing Team who attended upon Mrs Smith did not, upon each visit, fully record and document the dimensions and presenting features of the wound . In the circumstances, the Trust should ensure District Nurses do record and document all bruises and/or wounds, in particular the dimensions of the same together with a detailed description as to all presenting features;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 regularly and fully record residents' weights
Wider context from the report “(e) Between January and June 2012 Mrs Smith lost a total of 28lbs in weight. Mrs Smith's weight was neither regularly monitored nor regularly and fully recorded . In the circumstances, Care Home staff should ensure that there is regular monitoring and appropriate recording of residents' weights';
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 Care Home staff knowledge of dementia care
Wider context from the report “(g) Mrs Smith suffered from vascular dementia and had done so since the commencement of her residency at the Care Home. A number of other residents suffer from dementia. Care Assistants at the said Care Home have little or no knowledge of dementia and, consequently, how to care for residents suffering from such a condition . In the circumstances, all Care Home staff should undergo more indepth training in relation to dementia;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 comprehensive national guidance on prevention and treatment of impact-injury wounds and ulcers
Wider context from the report “(a) There are no NICE guidelines which provide any comprehensive guidance to Medical Practitioners in relation to the prevention and treatment of wounds and ulcers caused by impact injuries . Clinical Guideline 29 – The prevention and treatment of pressure ulcers, does not give guidance in respect of wounds/ulcers caused by impact injuries . In the circumstances there should be national guidelines which deal with such
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 District Nurse referrals to the Tissue Viability Nurse Service
Wider context from the report “(b) Mrs Smith was referred to the Tissue Viability Nurse Service on or around 25 June 2012, some 12 days after a referral ought to have been made according to expert evidence adduced in the course of the Inquest. In the circumstances, the Trust should ensure District Nurses make referrals to the Tissue Viability Nurse Service timeously;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 regularly monitor residents' weights
Wider context from the report “(e) Between January and June 2012 Mrs Smith lost a total of 28lbs in weight. Mrs Smith's weight was neither regularly monitored nor regularly and fully recorded. In the circumstances, Care Home staff should ensure that there is regular monitoring and appropriate recording of residents' weights';
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 body map residents' bruises
Wider context from the report “(b) None of the bruises sustained by Mrs Smith, in particular the one which was noticed on the 25 May 2012, were body mapped by Care Home staff. In the circumstances, staff should ensure that all bruises sustained by residents are carefully body mapped at the first available opportunity;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 turning and repositioning charts
Wider context from the report “(a) Advice and instruction given to Care Home staff as to the turning and repositioning of Mrs Smith was not followed and repositioning charts were not completed . In the circumstances, all Care Home staff should ensure that all advice and instruction given by medical practitioners, that is to say by General Practitioners and District Nurses, in relation to residents is appropriately implemented and that turning/repositioning charts are completed;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Omission of guidance on when District Nurses should refer patients to the Tissue Viability Nurse Service
Wider context from the report “(c) The Trusts Clinical Guidelines for Wound Management in Adults and Children omits to provide guidance as to when District Nurses should refer patients to the Tissue Viability Nurse Service . In the circumstances, the Trust should amend the said Clinical Guidelines in order to provide comprehensive guidance as to when such a referral to the said Service should be made
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to implement nutrition charts for residents with significant weight loss
Wider context from the report “(f) Despite the aforesaid weight loss experienced by Mrs Smith, at no time was a nutrition chart implemented in order to monitor Mrs Smith's nutritional intake . Moreover, medical advice in relation to Mrs Smith's weight loss was only sought a number of weeks after the commencement of the said weight loss. In the circumstances, Care Home staff should ensure nutrition charts are completed in respect of any resident whose weight falls significantly and should ensure appropriate medical advice is sought at the first available opportunity following such a fall in weight;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 proactively seek medical practitioners' care advice for residents with recognised medical conditions
Wider context from the report “(h) Care Home staff do not proactively enquire of medical practitioners as to how to care for residents with certain medical conditions – for example, hiatus hernias, dementia. In the circumstances, Care Home staff should ensure proactive enquiries are made of relevant medical practitioners at the earliest opportunity as to the appropriate care for residents suffering from recognised medical conditions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 regular falls assessments for residents
Wider context from the report “(d) Falls assessments in respect of Mrs Smith whilst a resident at the Care Home were not regularly undertaken and no consideration was at any time given by Care Home staff as to the most appropriate location for Mrs Smith's room within the Care Home. In the circumstances, falls assessments should be regularly undertaken in respect of all residents and regular consideration should be given as to the appropriate location of residents' rooms within the Care Home;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 medical advice after apparent impact injury bruising
Wider context from the report “(c) On or around 25 May 2012 bruising on the left side of Mrs Smith's bottom cheek was noted by a Care Home staff together with a blister. However, District Nurse attendance in respect of an open area on Mrs Smith's bottom on her left side took place 7 (seven) days later on 11 June 2012. In the circumstances, Care Home staff should ensure appropriate medical advice is sought at the first available opportunity upon noticing a bruise to a resident following an apparent impact injury;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to implement medical practitioners' advice and instruction on resident turning and repositioning
Wider context from the report “(a) Advice and instruction given to Care Home staff as to the turning and repositioning of Mrs Smith was not followed and repositioning charts were not completed. In the circumstances, all Care Home staff should ensure that all advice and instruction given by medical practitioners, that is to say by General Practitioners and District Nurses, in relation to residents is appropriately implemented and that turning/repositioning charts are completed;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 the appropriate location of residents' rooms
Wider context from the report “(d) Falls assessments in respect of Mrs Smith whilst a resident at the Care Home were not regularly undertaken and no consideration was at any time given by Care Home staff as to the most appropriate location for Mrs Smith's room within the Care Home . In the circumstances, falls assessments should be regularly undertaken in respect of all residents and regular consideration should be given as to the appropriate location of residents' rooms within the Care Home;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 medical advice after significant resident weight loss
Wider context from the report “(f) Despite the aforesaid weight loss experienced by Mrs Smith, at no time was a nutrition chart implemented in order to monitor Mrs Smith's nutritional intake. Moreover, medical advice in relation to Mrs Smith's weight loss was only sought a number of weeks after the commencement of the said weight loss . In the circumstances, Care Home staff should ensure nutrition charts are completed in respect of any resident whose weight falls significantly and should ensure appropriate medical advice is sought at the first available opportunity following such a fall in weight;
” Open source report
12 Nov 2014 Patricia Ann Mellor · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 6 Failure to include warnings about cardiac arrest risks in inhalational anaesthetic product information for patients with LQTS View source Failure to update guidance to require specific examination of the QTc interval in all pre-operative ECGs View source Failure to update pre-operative assessment guidance to require consideration of drug-induced LQTS before omitting a 12 lead ECG View source Failure to include warnings about cardiac arrest risks in product information for other drugs used during inhalational anaesthesia in patients with LQTS View source Failure to update guidance to require 12 lead ECG recording and QTc examination for patients receiving drugs at high or intermediate risk of inducing cardiac arrest in LQTS View source Failure to highlight issues involving antidepressant agents and LQTS in regular agency bulletins View source See 3 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
Patricia Ann Mellor · 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
Patricia Ann Mellor suffered a cardiac arrest during general anaesthesia in 2004, resulting in a hypoxic brain injury and severe disability. She died from aspiration pneumonia on 24 January 2014. The investigation identified acquired Long QT Syndrome associated with a combination of citalopram, nortriptyline and ranitidine, and concerns were raised about the need to identify and manage this risk before anaesthesia.
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 include warnings about cardiac arrest risks in inhalational anaesthetic product information for patients with LQTS
Wider context from the report “There were further communications with the MHRA suggesting that;
· The product information for inhalational anaesthetic agents should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS
· The product information for other drugs such as 5HT₃ anti-emetics should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS during inhalational anaesthesia
· The particular issues with antidepressant agents and LQTS should be highlighted in the regular bulletins from the Agency
Furthermore, ████████ reported that recommendations be sent to NICE updating guideline CG3 to;
· Instruct anaesthetists to consider drug-induced LQTS in their pre-operative assessment before following the recommendation not to perform a 12 lead ECG
· Instruct anaesthetists to specifically examine the QTc interval in all pre-operative ECGs performed for any indication
· To require a 12 lead ECG to be recorded and the QTc to be specifically examined in all patients receiving aged deemed to be of “high” and “intermediate” risk of inducing cardiac arrest in LQTS
· ████████ advised that despite the above notifications and recommendations, no action has been taken by these agencies .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 update guidance to require specific examination of the QTc interval in all pre-operative ECGs
Wider context from the report “There were further communications with the MHRA suggesting that;
· The product information for inhalational anaesthetic agents should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS
· The product information for other drugs such as 5HT₃ anti-emetics should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS during inhalational anaesthesia
· The particular issues with antidepressant agents and LQTS should be highlighted in the regular bulletins from the Agency
Furthermore, ████████ reported that recommendations be sent to NICE updating guideline CG3 to;
· Instruct anaesthetists to consider drug-induced LQTS in their pre-operative assessment before following the recommendation not to perform a 12 lead ECG
· Instruct anaesthetists to specifically examine the QTc interval in all pre-operative ECGs performed for any indication
· To require a 12 lead ECG to be recorded and the QTc to be specifically examined in all patients receiving aged deemed to be of “high” and “intermediate” risk of inducing cardiac arrest in LQTS
· ████████ advised that despite the above notifications and recommendations, no action has been taken by these agencies .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 update pre-operative assessment guidance to require consideration of drug-induced LQTS before omitting a 12 lead ECG
Wider context from the report “There were further communications with the MHRA suggesting that;
· The product information for inhalational anaesthetic agents should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS
· The product information for other drugs such as 5HT₃ anti-emetics should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS during inhalational anaesthesia
· The particular issues with antidepressant agents and LQTS should be highlighted in the regular bulletins from the Agency
Furthermore, ████████ reported that recommendations be sent to NICE updating guideline CG3 to;
· Instruct anaesthetists to consider drug-induced LQTS in their pre-operative assessment before following the recommendation not to perform a 12 lead ECG
· Instruct anaesthetists to specifically examine the QTc interval in all pre-operative ECGs performed for any indication
· To require a 12 lead ECG to be recorded and the QTc to be specifically examined in all patients receiving aged deemed to be of “high” and “intermediate” risk of inducing cardiac arrest in LQTS
· ████████ advised that despite the above notifications and recommendations, no action has been taken by these agencies .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to include warnings about cardiac arrest risks in product information for other drugs used during inhalational anaesthesia in patients with LQTS
Wider context from the report “There were further communications with the MHRA suggesting that;
· The product information for inhalational anaesthetic agents should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS
· The product information for other drugs such as 5HT₃ anti-emetics should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS during inhalational anaesthesia
· The particular issues with antidepressant agents and LQTS should be highlighted in the regular bulletins from the Agency
Furthermore, ████████ reported that recommendations be sent to NICE updating guideline CG3 to;
· Instruct anaesthetists to consider drug-induced LQTS in their pre-operative assessment before following the recommendation not to perform a 12 lead ECG
· Instruct anaesthetists to specifically examine the QTc interval in all pre-operative ECGs performed for any indication
· To require a 12 lead ECG to be recorded and the QTc to be specifically examined in all patients receiving aged deemed to be of “high” and “intermediate” risk of inducing cardiac arrest in LQTS
· ████████ advised that despite the above notifications and recommendations, no action has been taken by these agencies .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 update guidance to require 12 lead ECG recording and QTc examination for patients receiving drugs at high or intermediate risk of inducing cardiac arrest in LQTS
Wider context from the report “There were further communications with the MHRA suggesting that;
· The product information for inhalational anaesthetic agents should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS
· The product information for other drugs such as 5HT₃ anti-emetics should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS during inhalational anaesthesia
· The particular issues with antidepressant agents and LQTS should be highlighted in the regular bulletins from the Agency
Furthermore, ████████ reported that recommendations be sent to NICE updating guideline CG3 to;
· Instruct anaesthetists to consider drug-induced LQTS in their pre-operative assessment before following the recommendation not to perform a 12 lead ECG
· Instruct anaesthetists to specifically examine the QTc interval in all pre-operative ECGs performed for any indication
· To require a 12 lead ECG to be recorded and the QTc to be specifically examined in all patients receiving aged deemed to be of “high” and “intermediate” risk of inducing cardiac arrest in LQTS
· ████████ advised that despite the above notifications and recommendations, no action has been taken by these agencies .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 highlight issues involving antidepressant agents and LQTS in regular agency bulletins
Wider context from the report “There were further communications with the MHRA suggesting that;
· The product information for inhalational anaesthetic agents should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS
· The product information for other drugs such as 5HT₃ anti-emetics should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS during inhalational anaesthesia
· The particular issues with antidepressant agents and LQTS should be highlighted in the regular bulletins from the Agency
Furthermore, ████████ reported that recommendations be sent to NICE updating guideline CG3 to;
· Instruct anaesthetists to consider drug-induced LQTS in their pre-operative assessment before following the recommendation not to perform a 12 lead ECG
· Instruct anaesthetists to specifically examine the QTc interval in all pre-operative ECGs performed for any indication
· To require a 12 lead ECG to be recorded and the QTc to be specifically examined in all patients receiving aged deemed to be of “high” and “intermediate” risk of inducing cardiac arrest in LQTS
· ████████ advised that despite the above notifications and recommendations, no action has been taken by these agencies .
” Open source report
11 Nov 2014 Beryl WALTERS · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 1 Unnecessary use of Cyclizine in severe heart failure despite cardiac 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
Beryl WALTERS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Beryl Walters presented to A&E with atypical chest pain and a posterior myocardial infarction. After receiving Cyclizine for nausea, she became hypotensive and tachycardic and suffered a cardiac arrest from which she could not be resuscitated; the substantive concern was the use of Cyclizine in acute coronary events despite an available alternative antiemetic and evidence advising against its use in these circumstances.
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 Unnecessary use of Cyclizine in severe heart failure despite cardiac risk
Wider context from the report “(1) The British National Formulary states in the cautions part of the section on Cyclizine “severe heart failure; may counteract haemodynamic benefits of opioids,... ”
(2) The paper attached, whilst itself drawing the reader’s attention to the possible non-transferability of the findings to the emergency department, and the limited group of patients the original 1988 study was based on, makes a recommendation not to use Cyclizine in these circumstances .
(3) The availability of an alternative antiemetic, Metoclopramide, which does not appear to share the same cardiac risk profile, would seem to suggest that the use of Cyclizine is an unnecessary risk in these circumstances .
” Open source report
24 Oct 2014 Isa Riaz Mushtaq · Prevention of Future Deaths report Manchester (City)
View report summary
Concerns raised 2 Unavailability of fetal blood sampling for antenatal CTG assessment View source Lack of detailed national guidance on antepartum CTG assessment and management 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
Isa Riaz Mushtaq · 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
Isa Riaz Mushtaq was delivered by emergency caesarean section after reduced fetal movement, a suspicious antenatal CTG and fetal bradycardia. He did not recover from the bradycardia/asystole episode, developed severe hypoxic ischaemic encephalopathy and died on the third neonatal day. The principal concern was the absence of detailed national guidance for interpreting and managing abnormal antenatal CTGs, including when urgent delivery is required.
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 Unavailability of fetal blood sampling for antenatal CTG assessment
Wider context from the report “In clinical practice the fetal CTG continues to be a source of problems, both in interpretation and in what degree of action should be taken. This is particularly the case for antenatal (non labour) CTG’s since there has not been the same clarification that was provided for electronic intrapartum fetal monitoring by specific NICE guidance. Currently there is no detailed national guidance on antepartum CTG assessment and therefore no guidance as to the circumstances in which CTG changes or abnormalities require urgent delivery. For example, the following problems with antenatal CTG interpretation may arise:-
(i) Should change of position or intravenous fluids be used in the same way as in labour
(ii) What role can be given to iced water drinks or dietary intake to stimulate fetal changes
(iii) At what stage should intervention should be made and with what urgency in the absence of decelerations.
(iv) What significance should be attached to reduced variability and what action should be taken in the absence of decelerations
(v) What significance should be attached to the absence of accelerations where there is reduced variability.
Reliance on the NICE guidance for intrapartum CTG monitoring to interpret antenatal CTG features is of limited value because:
(i) It is not intended for such use and therefore such practice is arguably not evidence based
(ii) It is much more common for fetal heart traces not to look normal during labour (in the region 20 -30 % outwith normal parameters) therefore the significance of such abnormal traces may not be the same in labour as compared to when identified antenatally.
(iii) Only a very small percentage of antenatal CTG’s are not normal.
(iv) There is no recourse to fetal blood sampling for an antenatal CTG, so that if suspicions persist about lack of fetal well-being there is no way of assessing fetal acid-base balance.
St Mary’s Hospital has now developed its own local guidance for the management of suspected abnormal antenatal CTG in order to mitigate risk. In the absence of uniform, detailed national guidance on antepartum CTG abnormalities St Mary’s hospital has implemented a procedure of early consultant involvement where there are persisting features of unusual CTG.
There should be a review to consider whether national guidance on antepartum CTG monitoring and interpretation where there are abnormalities or unusual features would lead to safer, evidence based management of such cases.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 detailed national guidance on antepartum CTG assessment and management
Wider context from the report “In clinical practice the fetal CTG continues to be a source of problems, both in interpretation and in what degree of action should be taken. This is particularly the case for antenatal (non labour) CTG’s since there has not been the same clarification that was provided for electronic intrapartum fetal monitoring by specific NICE guidance . Currently there is no detailed national guidance on antepartum CTG assessment and therefore no guidance as to the circumstances in which CTG changes or abnormalities require urgent delivery . For example, the following problems with antenatal CTG interpretation may arise:-
(i) Should change of position or intravenous fluids be used in the same way as in labour
(ii) What role can be given to iced water drinks or dietary intake to stimulate fetal changes
(iii) At what stage should intervention should be made and with what urgency in the absence of decelerations.
(iv) What significance should be attached to reduced variability and what action should be taken in the absence of decelerations
(v) What significance should be attached to the absence of accelerations where there is reduced variability.
Reliance on the NICE guidance for intrapartum CTG monitoring to interpret antenatal CTG features is of limited value because:
(i) It is not intended for such use and therefore such practice is arguably not evidence based
(ii) It is much more common for fetal heart traces not to look normal during labour (in the region 20 -30 % outwith normal parameters) therefore the significance of such abnormal traces may not be the same in labour as compared to when identified antenatally.
(iii) Only a very small percentage of antenatal CTG’s are not normal.
(iv) There is no recourse to fetal blood sampling for an antenatal CTG, so that if suspicions persist about lack of fetal well-being there is no way of assessing fetal acid-base balance.
St Mary’s Hospital has now developed its own local guidance for the management of suspected abnormal antenatal CTG in order to mitigate risk. In the absence of uniform, detailed national guidance on antepartum CTG abnormalities St Mary’s hospital has implemented a procedure of early consultant involvement where there are persisting features of unusual CTG.
There should be a review to consider whether national guidance on antepartum CTG monitoring and interpretation where there are abnormalities or unusual features would lead to safer, evidence based management of such cases.
” Open source report
Concerns raised 12 Failure to monitor physiological trends over time View source Failure to share and act promptly on nursing staff concerns View source Failure to prioritise children’s cases appropriately for timely assessment View source Reluctance to involve other hospital disciplines in paediatric care View source Unclear guidance on pre-hospital antibiotics for suspected meningitis View source Incomplete handovers between primary and secondary care providers View source Difficulties in internal communication during evolving emergencies View source Unavailability of consultant advice to registrars when needed View source Exclusion of nursing colleagues from team debriefs View source Failure to transfer patients to hospital by ambulance when required View source Delays in treating raised intracranial pressure while awaiting diagnosis View source Failure to retain meningitis as a differential diagnosis View source See 9 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
Thomas George 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
Thomas George Smith, aged 13, developed symptoms including headache, neck pain and vomiting before being admitted to hospital, where he later became unresponsive and died after suspected meningitis and raised intracranial pressure. The report identified concerns about delays in recognising and treating meningitis and raised intracranial pressure, communication and handover, responding to nursing concerns, monitoring physiological trends, and the transfer of the patient to hospital.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor physiological trends over time
Wider context from the report “(1) The inquest revealed the importance of observing physiological trends in the patient’s condition, rather than observing readings on a “snap shot” basis . The Coroner considers that comprehensive time series data would have provided clinicians with a sounder platform for assessing Thomas. Can the Chief Executive confirm that this will be the practice at PCH?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 and act promptly on nursing staff concerns
Wider context from the report “(2) The inquest revealed a somewhat fragmented approach to patient care, with nursing staff concerns not being acted on promptly by doctors . One expert highlighted the importance of a “whole team approach” where information could be freely shared and acted upon by nursing staff professionals . The Coroner suggests that this should be the correct approach. The Coroner noted with concern that at PCH nursing colleagues are not involved in a team debrief. The Coroner considers that they always should be involved.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise children’s cases appropriately for timely assessment
Wider context from the report “(2) The Coroner noted that it was only by chance that Thomas was seen more quickly than usual (because the case was “modified” and removed from the pool). Given the greater susceptibility of children to deteriorate in health the Coroner would like to see children’s cases be given a greater “weighting” so that they can be seen more quickly than adult cases if these can safely be delayed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Reluctance to involve other hospital disciplines in paediatric care
Wider context from the report “(3) Similarly the expert commented that there appeared to be a reluctance on the paediatric ward to bring in other disciplines from the hospital where this might be
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Unclear guidance on pre-hospital antibiotics for suspected meningitis
Wider context from the report “The Coroner notes the guidance at page 61 of the June 2010 publication “Bacterial meningitis and meningococcal septicaemia” to the effect that “the available evidence does not allow any conclusion to be drawn about whether or not pre-hospital parenteral antibiotics affect mortality or morbidity ”. This is however contradicted by the evidence heard at inquest from eminent experts ████████ who gave their empirical conclusions that the literature suggested that antibiotics should be given sooner rather than later in cases of meningitis. In the event of primary care doctors being involved in a remote location there might be a delay of some hours before transfer to secondary care . The Coroner also noted the Guidelines issued by the Scientific Advisory Committee of HPSF (Eire) which recommended that primary care providers administer antibiotics in cases of suspected meningitis (at page 17) “all GPs and advanced paramedics should have benzylpenicillin available when attending patients and should be ready to administer it without delay to patients with a systemic febrile illness and a petechial or purpuric rash”. The Coroner would recommend that the existing guidance is revisited.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Incomplete handovers between primary and secondary care providers
Wider context from the report “(1) No criticism is made of the actions of the Out of Hours Doctor ████████. The inquest however revealed the importance of full and accurate handover between primary and secondary care providers. Such handovers should record full observations and details of any medication already given (for instance painkillers may mask fever). Can the clinical director confirm OOH doctors observe this practice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Difficulties in internal communication during evolving emergencies
Wider context from the report “(4) The expert recommends a “stress testing of ward management” through a clinical scenario simulation of emergencies within ward areas. This could also test how to improve communication during times of evolving emergencies. Given the difficulties in internal communication as revealed by this inquest the Coroner suggests this would be a valuable exercise.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 consultant advice to registrars when needed
Wider context from the report “(6) There was a divergence of evidence at the hearing between ████████ and ████████ – with the former suggesting that at one point in the afternoon that he could not find ████████ while ████████ said he had been in his office all the time. While the resolution of this conflict was not necessary for the purposes of the inquest it does reveal a situation where (for whatever reason) a registrar was not able to obtain the advice of the consultant when he needed it . It appeared to the Coroner to be archaic for the Registrar to have to physically go looking for the Consultant on the ward – there must be modern telecommunication means to ensure that the consultant is always available for advice even if remotely .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Exclusion of nursing colleagues from team debriefs
Wider context from the report “(2) The inquest revealed a somewhat fragmented approach to patient care, with nursing staff concerns not being acted on promptly by doctors. One expert highlighted the importance of a “whole team approach” where information could be freely shared and acted upon by nursing staff professionals. The Coroner suggests that this should be the correct approach. The Coroner noted with concern that at PCH nursing colleagues are not involved in a team debrief . The Coroner considers that they always should be involved.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer patients to hospital by ambulance when required
Wider context from the report “(3) In this case Thomas was transferred to hospital by his mother. Although he suffered no ill effects from this the experts agreed that such a transfer should have been undertaken by ambulance . The Coroner suggests this should be the standard 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 Delays in treating raised intracranial pressure while awaiting diagnosis
Wider context from the report “(4) It appeared at the inquest if the clinicians had adopted an “exclusionary focus” to rule out meningitis rather than an “inclusionary focus” so as to be able to adopt a diagnosis of meningitis as a differential diagnosis. The Coroner considers that the inclusionary approach is appropriate where a patient presents with some of the signs of meningitis. It should be standard practice at PCH for raised Intracranial pressure to be treated without delay even if a diagnosis is awaited on the underlying 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 retain meningitis as a differential diagnosis
Wider context from the report “(4) It appeared at the inquest if the clinicians had adopted an “exclusionary focus” to rule out meningitis rather than an “inclusionary focus” so as to be able to adopt a diagnosis of meningitis as a differential diagnosis. The Coroner considers that the inclusionary approach is appropriate where a patient presents with some of the signs of meningitis. It should be standard practice at PCH for raised Intracranial pressure to be treated without delay even if a diagnosis is awaited on the underlying condition.
” Open source report
11 Jun 2014 Bridget May CAHILL · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 2 Failure to individualise maximum morphine doses to body weight, comorbidities and other relevant factors View source Failure to account for morphine buildup during long-term therapy 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
Bridget May CAHILL · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Bridget May CAHILL died in hospital from a morphine overdose after being admitted with unresponsiveness and receiving treatment including naloxone. The principal concern was how a patient prescribed and receiving less than the maximum permitted morphine dose could nevertheless suffer an overdose, including whether dosing should account for factors such as body weight, comorbidities, and possible accumulation during long-term therapy.
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 individualise maximum morphine doses to body weight, comorbidities and other relevant factors
Wider context from the report “The evidence I heard was that Mrs. Cahill was admitted to Walsall Manor Hospital on 10th September 2013. She had a one day history of unresponsiveness, had a background of Parkinson’s disease, dementia and chronic backache. She lived in a residential home. On admission she had pinpoint pupils suggesting morphine overdose which was partially reversed with an antidote. Blood tests showed high calcium levels suggestive of dehydration, or possibly a tumour and there was a suggestion of possible ongoing infection. She had treatment with IV fluids, IV antibiotics and Naloxone, but she deteriorated and died. She was on morphine night and morning and also oral morphine during the day if and when required. The maximum dose of Oramorph was 20 millilitres per day, 5 millilitres at a time, dosages to be 4 to 6 hours apart. The evidence I heard was that at no time prior to her death did she have the maximum permitted dose.
My concern relates to how it is that a person who is prescribed morphine and who has less than the amount prescribed for them, can nevertheless suffer an overdose. I write to enquire whether attention needs to be given to the maximum dose that can be recommended and whether it is, or should be, subject to factors such as body weight, any co morbidities and any other factors and whether attention should be directed towards the possible buildup of morphine in the body for those involved in long-term therapy.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure to account for morphine buildup during long-term therapy
Wider context from the report “The evidence I heard was that Mrs. Cahill was admitted to Walsall Manor Hospital on 10th September 2013. She had a one day history of unresponsiveness, had a background of Parkinson’s disease, dementia and chronic backache. She lived in a residential home. On admission she had pinpoint pupils suggesting morphine overdose which was partially reversed with an antidote. Blood tests showed high calcium levels suggestive of dehydration, or possibly a tumour and there was a suggestion of possible ongoing infection. She had treatment with IV fluids, IV antibiotics and Naloxone, but she deteriorated and died. She was on morphine night and morning and also oral morphine during the day if and when required. The maximum dose of Oramorph was 20 millilitres per day, 5 millilitres at a time, dosages to be 4 to 6 hours apart. The evidence I heard was that at no time prior to her death did she have the maximum permitted dose.
My concern relates to how it is that a person who is prescribed morphine and who has less than the amount prescribed for them, can nevertheless suffer an overdose. I write to enquire whether attention needs to be given to the maximum dose that can be recommended and whether it is, or should be, subject to factors such as body weight, any co morbidities and any other factors and whether attention should be directed towards the possible buildup of morphine in the body for those involved in long-term therapy .
” Open source report
1 May 2014 Elizabeth Jayne Cooper · Prevention of Future Deaths report Cumbria (South & East)
View report summary
Concerns raised 4 Unavailability of an information leaflet for patients on the fatal consequences of not seeking medical assistance View source Unclear advice on precautions for persons with the genetic condition during air and long-distance travel View source Unavailability of an information leaflet for family members on Factor V Leiden Mutation risks and available options View source Lack of a clear pathway for passing condition information to family members View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Elizabeth Jayne Cooper · 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
Elizabeth Jayne Cooper had Factor V Leiden mutation and died after a holiday involving air travel; the inquest recorded pulmonary thromboembolism and deep vein thrombosis, with a conclusion of natural causes. The principal concerns were conflicting or unclear advice about precautions for air and long-distance travel, the lack of a clear pathway for informing family members, and the absence of information leaflets about the risks and consequences of untreated DVT and Factor V Leiden mutation.
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 Unavailability of an information leaflet for patients on the fatal consequences of not seeking medical assistance
Wider context from the report “(3) No information leaflet
(a) was available to Elizabeth concerning the fatal consequences of not seeking medical assistance;
(b) was available to be given to members of Elizabeth’s family to inform them of the risks involved in Factor V Leiden Mutation and the options open to them.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 advice on precautions for persons with the genetic condition during air and long-distance travel
Wider context from the report “(1) Advice on precautions to be taken for those persons with the genetic condition is unclear especially concerning air and long distance travel.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 information leaflet for family members on Factor V Leiden Mutation risks and available options
Wider context from the report “(3) No information leaflet
(a) was available to Elizabeth concerning the fatal consequences of not seeking medical assistance;
(b) was available to be given to members of Elizabeth’s family to inform them of the risks involved in Factor V Leiden Mutation and the options open to them.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 pathway for passing condition information to family members
Wider context from the report “(2) There seems no clear pathway for information concerning the condition to be passed to members of the family of the patient for them to assess their own position.
” Open source report
Concerns raised 1 Failure to undertake rectal biopsy for diagnosis of Hirschsprung’s disease View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Nathan Douthwaite · 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
Nathan Douthwaite had a long history of severe constipation requiring repeated hospital admissions and died after emergency admission in December 2010. Autopsy found massive megacolon with abdominal compartment syndrome and a perforated caecum, with Hirschsprung’s disease recorded as an underlying cause. The report raised concerns that a rectal biopsy might have diagnosed Hirschsprung’s disease and identified a need to review relevant guidelines and clinical practices.
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 rectal biopsy for diagnosis of Hirschsprung’s disease
Wider context from the report “It is likely that if Nathan had undergone a rectal biopsy, Hirschsprung’s disease would have been diagnosed with the opportunity then being available for the appropriate treatment and thus I consider
(1) That NICE undertake a review of its guidelines in this regard
(2) That Count Durham and Darlington NHS Trust does review its own practices and procedures in avoidance of a NICE review and
(3) The Department of Health be aware of the circumstances of this case so that it can consider whether guidance should be issued in this regard pending the NICE review.
” Open source report
25 Feb 2014 Arthur Brockett-Deakins · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 8 Inadequate governance and oversight of private midwifery-led services across the mixed health economy View source Insufficient CTG interpretation training and competence View source Inconsistent thresholds for review and intervention between private and NHS maternity care View source Maternal pulse being displayed as fetal heart rate on CTG machines View source Unsafe staffing and shift arrangements for private midwifery services View source Failure to document and risk-assess private midwifery-led service arrangements View source Failure to escalate abnormal CTG findings appropriately in slow second-stage labour View source Insufficient specialist and interdisciplinary support for private midwifery-led services View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Arthur Brockett-Deakins · 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
Arthur Brockett-Deakins was born in poor condition on 16 December 2007 after complications during labour and suffered severe disabilities resulting from acute profound perinatal hypoxic-ischaemic encephalopathy. He died at home on 18 October 2011 from respiratory problems. The report identified concerns about failure to escalate an abnormal CTG, administration and monitoring of Syntocinon, CTG interpretation and display of the maternal heart rate, and the organisation and support of a private midwifery-led 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 Inadequate governance and oversight of private midwifery-led services across the mixed health economy
Wider context from the report “4. Models of private midwifery led services for low risk pregnancy: The private midwifery caseload for low risk pregnancies was managed by a pair of midwives who set up the service to provide continuity of care. The midwife service that was operating when ████████ was pregnant was not adequately documented. No job description was seen by the court and the referral and operational arrangements were discussed, but no documentation was brought to the court. There was no evidence of risk assessment. Although NHS employees were required to be self sufficient in terms of annual leave and sickness cover, on call arrangements and use of NHS personnel except in emergencies. They did not at the outset have a link obstetrician. This led to fear of burn out, a sense of isolation and lack of support and collegiality.
When they transferred babies to the Hospital Birthing Centre, they were expected to refer to a duty obstetric consultant, access to whom was described as variable. The midwife in charge of the NHS unit agreed that she provided a different threshold of care to private and NHS mothers and was reluctant to intervene or review the care plan for augmentation of labour, which she would have done in an NHS patient. The midwives expected her to be involved but did not ask her. In the event no peer senior midwife or obstetrician saw ████████ which was necessary. The reasons for non referral were complex and were not because the midwives thought they could not refer. Misjudgements were made which in part were caused by a 15 hour shift with only a 40 minute break. This would not occur in contexts where there was normal NHS management of staff, but this arrangement continued apparently unknown to the NHS Trust management. The service is no longer operational, the Trust reporting that it was discontinued for economic reasons.
Expert advice considered that the model of service created a risk of deaths, although it was not found to have directly done so in this case. Dr ████████ reported that there were similar units operating elsewhere in the country and that the lessons from the difficulties in operating this one should be disseminated to other such units. The expert midwife, Ms ████████ was particularly concerned about adequate support and Dr. ████████ was particularly concerned about the isolation and professional culture and lack of interdisciplinary peer discussion, in the context of increasingly risks in obstetric and midwifery practice.
The Trust head midwife reported that she expected that the matter would now be dealt with robustly by the statutory supervision system. No evidence was heard about whether this was now effective in this regard , nor how influence and information could be brought to bear on those setting up or managing such midwife led services. It was further reported that not all midwives are members of the College that runs that supervision and that midwives are not necessarily practising within the NHS. Thus is it was not clear how the risks are best identified and managed across a complex mixed health economy , which is why the Secretary of State is an addressee of my report.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 CTG interpretation training and competence
Wider context from the report “2. Training of one midwife in CTG interpretation: Both midwives underwent voluntary further training and supervision, including an expert workshop on CTG interpretation. Both accepted that a number of errors had been made by them and applied the learning to their current practice. However even in retrospect, one of the midwives could not accept that the early CTG trace was pathological , as held by both expert obstetrician and midwife. Although she would refer now, there is doubt about the urgency . She said in court it would be within half an hour but also that 40 minutes was needed to see if it was abnormal. The expert midwife said that she needed further training on CTG interpretation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 thresholds for review and intervention between private and NHS maternity care
Wider context from the report “4. Models of private midwifery led services for low risk pregnancy: The private midwifery caseload for low risk pregnancies was managed by a pair of midwives who set up the service to provide continuity of care. The midwife service that was operating when ████████ was pregnant was not adequately documented. No job description was seen by the court and the referral and operational arrangements were discussed, but no documentation was brought to the court. There was no evidence of risk assessment. Although NHS employees were required to be self sufficient in terms of annual leave and sickness cover, on call arrangements and use of NHS personnel except in emergencies. They did not at the outset have a link obstetrician. This led to fear of burn out, a sense of isolation and lack of support and collegiality.
When they transferred babies to the Hospital Birthing Centre, they were expected to refer to a duty obstetric consultant, access to whom was described as variable. The midwife in charge of the NHS unit agreed that she provided a different threshold of care to private and NHS mothers and was reluctant to intervene or review the care plan for augmentation of labour , which she would have done in an NHS patient. The midwives expected her to be involved but did not ask her. In the event no peer senior midwife or obstetrician saw ████████ which was necessary . The reasons for non referral were complex and were not because the midwives thought they could not refer. Misjudgements were made which in part were caused by a 15 hour shift with only a 40 minute break. This would not occur in contexts where there was normal NHS management of staff, but this arrangement continued apparently unknown to the NHS Trust management. The service is no longer operational, the Trust reporting that it was discontinued for economic reasons.
Expert advice considered that the model of service created a risk of deaths, although it was not found to have directly done so in this case. Dr ████████ reported that there were similar units operating elsewhere in the country and that the lessons from the difficulties in operating this one should be disseminated to other such units. The expert midwife, Ms ████████ was particularly concerned about adequate support and Dr. ████████ was particularly concerned about the isolation and professional culture and lack of interdisciplinary peer discussion, in the context of increasingly risks in obstetric and midwifery practice.
The Trust head midwife reported that she expected that the matter would now be dealt with robustly by the statutory supervision system. No evidence was heard about whether this was now effective in this regard, nor how influence and information could be brought to bear on those setting up or managing such midwife led services. It was further reported that not all midwives are members of the College that runs that supervision and that midwives are not necessarily practising within the NHS. Thus is it was not clear how the risks are best identified and managed across a complex mixed health economy, which is why the Secretary of State is an addressee of my report.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Maternal pulse being displayed as fetal heart rate on CTG machines
Wider context from the report “3. Display of MHR as FHR on CTGs: Ms ████████ explained that if the foetus moves out of the range of the ultrasound field or the baby has sadly died, the ultrasound transducer may then pick up the maternal pulse from the aorta, iliac or uterine artery and it is displayed as the FHR and can show reactivity and variability due to MHR changes and muscle contractions can be difficult to distinguish from the FHR. It is known that the rate can be doubled or halved .
The only explanation that both expert midwife and expert obstetrician could reach for the unusual CTG trace after 1pm, in the context of the state of the baby at birth, was that the maternal pulse rate was masquerading as the FHR but it had been multiplied by 1.5 . The CTG machine was not the type that is known rarely to multiply by 2 and the phenomenon of a multiplication by a factor other than 2, being unknown to both experts in their distinguished careers. Evidence was not heard from the manufacturer or the product's regulatory authority. The inquest heard that new CTG machines incorporate maternal ECG or pulse oximetry, which alerts staff to investigate when MHR and FHR appear the same. But it also heard that it will take some time before all old machines are replaced . It needs to be established if multiplying by 1.5 is a possible functional feature of some machines and if so whether either it can be designed away or whether dissemination or guidance or an action by the regulatory authority is needed to prevent it leading to a fatality or child disability.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Unsafe staffing and shift arrangements for private midwifery services
Wider context from the report “4. Models of private midwifery led services for low risk pregnancy: The private midwifery caseload for low risk pregnancies was managed by a pair of midwives who set up the service to provide continuity of care. The midwife service that was operating when ████████ was pregnant was not adequately documented. No job description was seen by the court and the referral and operational arrangements were discussed, but no documentation was brought to the court. There was no evidence of risk assessment. Although NHS employees were required to be self sufficient in terms of annual leave and sickness cover, on call arrangements and use of NHS personnel except in emergencies. They did not at the outset have a link obstetrician. This led to fear of burn out, a sense of isolation and lack of support and collegiality.
When they transferred babies to the Hospital Birthing Centre, they were expected to refer to a duty obstetric consultant, access to whom was described as variable. The midwife in charge of the NHS unit agreed that she provided a different threshold of care to private and NHS mothers and was reluctant to intervene or review the care plan for augmentation of labour, which she would have done in an NHS patient. The midwives expected her to be involved but did not ask her. In the event no peer senior midwife or obstetrician saw ████████ which was necessary. The reasons for non referral were complex and were not because the midwives thought they could not refer. Misjudgements were made which in part were caused by a 15 hour shift with only a 40 minute break . This would not occur in contexts where there was normal NHS management of staff, but this arrangement continued apparently unknown to the NHS Trust management. The service is no longer operational, the Trust reporting that it was discontinued for economic reasons.
Expert advice considered that the model of service created a risk of deaths, although it was not found to have directly done so in this case. Dr ████████ reported that there were similar units operating elsewhere in the country and that the lessons from the difficulties in operating this one should be disseminated to other such units. The expert midwife, Ms ████████ was particularly concerned about adequate support and Dr. ████████ was particularly concerned about the isolation and professional culture and lack of interdisciplinary peer discussion, in the context of increasingly risks in obstetric and midwifery practice.
The Trust head midwife reported that she expected that the matter would now be dealt with robustly by the statutory supervision system. No evidence was heard about whether this was now effective in this regard, nor how influence and information could be brought to bear on those setting up or managing such midwife led services. It was further reported that not all midwives are members of the College that runs that supervision and that midwives are not necessarily practising within the NHS. Thus is it was not clear how the risks are best identified and managed across a complex mixed health economy, which is why the Secretary of State is an addressee of my report.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 and risk-assess private midwifery-led service arrangements
Wider context from the report “4. Models of private midwifery led services for low risk pregnancy: The private midwifery caseload for low risk pregnancies was managed by a pair of midwives who set up the service to provide continuity of care. The midwife service that was operating when ████████ was pregnant was not adequately documented . No job description was seen by the court and the referral and operational arrangements were discussed, but no documentation was brought to the court . There was no evidence of risk assessment . Although NHS employees were required to be self sufficient in terms of annual leave and sickness cover, on call arrangements and use of NHS personnel except in emergencies. They did not at the outset have a link obstetrician. This led to fear of burn out, a sense of isolation and lack of support and collegiality.
When they transferred babies to the Hospital Birthing Centre, they were expected to refer to a duty obstetric consultant, access to whom was described as variable. The midwife in charge of the NHS unit agreed that she provided a different threshold of care to private and NHS mothers and was reluctant to intervene or review the care plan for augmentation of labour, which she would have done in an NHS patient. The midwives expected her to be involved but did not ask her. In the event no peer senior midwife or obstetrician saw ████████ which was necessary. The reasons for non referral were complex and were not because the midwives thought they could not refer. Misjudgements were made which in part were caused by a 15 hour shift with only a 40 minute break. This would not occur in contexts where there was normal NHS management of staff, but this arrangement continued apparently unknown to the NHS Trust management. The service is no longer operational, the Trust reporting that it was discontinued for economic reasons.
Expert advice considered that the model of service created a risk of deaths, although it was not found to have directly done so in this case. Dr ████████ reported that there were similar units operating elsewhere in the country and that the lessons from the difficulties in operating this one should be disseminated to other such units. The expert midwife, Ms ████████ was particularly concerned about adequate support and Dr. ████████ was particularly concerned about the isolation and professional culture and lack of interdisciplinary peer discussion, in the context of increasingly risks in obstetric and midwifery practice.
The Trust head midwife reported that she expected that the matter would now be dealt with robustly by the statutory supervision system. No evidence was heard about whether this was now effective in this regard, nor how influence and information could be brought to bear on those setting up or managing such midwife led services. It was further reported that not all midwives are members of the College that runs that supervision and that midwives are not necessarily practising within the NHS. Thus is it was not clear how the risks are best identified and managed across a complex mixed health economy, which is why the Secretary of State is an addressee of my report.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 escalate abnormal CTG findings appropriately in slow second-stage labour
Wider context from the report “1. When to escalate concerns about a CTG: With regard to not escalating an abnormal CTG that ran for about half an hour after augmentation of labour, reliance was placed by midwives on a clause of NICE Clinical Guidelines, Intrapartum Care, 2007, which advises that a 40 minutes trace should be studied before concluding if it is abnormal. Expert evidence from Dr ████████ and Ms ████████ suggested that this guidance was appropriate in the first stage of labour, but not in the context in this case, namely a slow second stage .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Insufficient specialist and interdisciplinary support for private midwifery-led services
Wider context from the report “4. Models of private midwifery led services for low risk pregnancy: The private midwifery caseload for low risk pregnancies was managed by a pair of midwives who set up the service to provide continuity of care. The midwife service that was operating when ████████ was pregnant was not adequately documented. No job description was seen by the court and the referral and operational arrangements were discussed, but no documentation was brought to the court. There was no evidence of risk assessment. Although NHS employees were required to be self sufficient in terms of annual leave and sickness cover, on call arrangements and use of NHS personnel except in emergencies. They did not at the outset have a link obstetrician . This led to fear of burn out, a sense of isolation and lack of support and collegiality.
When they transferred babies to the Hospital Birthing Centre, they were expected to refer to a duty obstetric consultant, access to whom was described as variable . The midwife in charge of the NHS unit agreed that she provided a different threshold of care to private and NHS mothers and was reluctant to intervene or review the care plan for augmentation of labour, which she would have done in an NHS patient. The midwives expected her to be involved but did not ask her. In the event no peer senior midwife or obstetrician saw ████████ which was necessary. The reasons for non referral were complex and were not because the midwives thought they could not refer. Misjudgements were made which in part were caused by a 15 hour shift with only a 40 minute break. This would not occur in contexts where there was normal NHS management of staff, but this arrangement continued apparently unknown to the NHS Trust management. The service is no longer operational, the Trust reporting that it was discontinued for economic reasons.
Expert advice considered that the model of service created a risk of deaths, although it was not found to have directly done so in this case. Dr ████████ reported that there were similar units operating elsewhere in the country and that the lessons from the difficulties in operating this one should be disseminated to other such units. The expert midwife, Ms ████████ was particularly concerned about adequate support and Dr. ████████ was particularly concerned about the isolation and professional culture and lack of interdisciplinary peer discussion , in the context of increasingly risks in obstetric and midwifery practice.
The Trust head midwife reported that she expected that the matter would now be dealt with robustly by the statutory supervision system. No evidence was heard about whether this was now effective in this regard, nor how influence and information could be brought to bear on those setting up or managing such midwife led services. It was further reported that not all midwives are members of the College that runs that supervision and that midwives are not necessarily practising within the NHS. Thus is it was not clear how the risks are best identified and managed across a complex mixed health economy, which is why the Secretary of State is an addressee of my report.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Intrapartum Care clinical guideline, including fetal assessment and monitoring recommendations.
Verbatim wording from the response “We review all of our guidance at regular intervals and also consider feedback and requests for updates where this is appropriate. Our clinical guideline on Intrapartum Care (CG55) is currently being updated. The progress of the update can be monitored via our website (http://guidance.nice.org.uk/CGWaveR/109).” Source location 2014-0077-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 Consult stakeholders on the draft Intrapartum Care guideline recommendations between 13 May and 24 June 2014.
Verbatim wording from the response “We will consult on the draft recommendations with stakeholders between 13th May – 24th June 2014 and the final guideline will be published in October 2014.” Source location 2014-0077-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 Publish the final updated Intrapartum Care clinical guideline in October 2014.
Verbatim wording from the response “We will consult on the draft recommendations with stakeholders between 13th May – 24th June 2014 and the final guideline will be published in October 2014.” Source location 2014-0077-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 evidence does not support a significant change to recommendations on fetal assessment and monitoring, although recommendations may be strengthened.
Verbatim wording from the response “The team working on updating this guideline have re-examined the evidence on fetal assessment and monitoring during labour. This specifically includes cardiotocography on admission to the labour ward and during labour and the definition and interpretation of the features of fetal heart rate trace. Whilst I am not able to anticipate the outcome of the final guideline, I can report that we have found no evidence to support a significant change in the recommendations but they have been further strengthened where appropriate.” Source location 2014-0077-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 retain responsibility for treatment decisions and may depart from NICE guidelines for appropriate, documented clinical reasons.
Verbatim wording from the response “We have confidence that our guidance, correctly implemented, will provide the best outcomes for patients but clinicians retain the responsibility for their decisions. NICE Clinical Guidelines are not mandated and clinical staff can depart from them if there are appropriate and documented clinical reasons for doing so.” Source location 2014-0077-Response-by-N.I.C.E
Open published response
17 Jan 2014 Selina Isabella Broadhurst · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Failure of head CT guidance to support imaging for frail elderly patients without obvious neurological signs 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
Selina Isabella Broadhurst · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Selina Isabella Broadhurst fell at the E.P.H. where she lived and suffered a head injury. She was not given a CT scan until a second hospital admission several hours later, when a major brain bleed was identified. The concern was that reliance on NICE guidelines may have contributed to missed or delayed diagnoses of severe brain injuries, particularly in very frail elderly patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Excellence; that does not assign responsibility.
PFD Monitor interpretation Failure of head CT guidance to support imaging for frail elderly patients without obvious neurological signs
Wider context from the report “The Emergency Department doctors indicated that they could not get a CT of the head because “the NICE Guidelines do not indicate as being appropriate where there are no obvious neurological signs” .
I have noted in this inquest and indeed in a number of inquests previously that the doctors are following these guidelines and in fact many severe brain injury cases are being missed or there is a delay in diagnosis . Is it not now time that this guideline was re-examined and the advice amended, especially when dealing with the very frail elderly patient ?
” Open source report
15 Oct 2013 Lucy KILVERT · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 2 NICE Guidelines insufficiently emphasising blood-thinning medication in elderly people who have a fall when determining the need for a head CT View source Delays in performing a CT scan of the head after hospital presentation 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
Lucy KILVERT · 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
Lucy KILVERT was taken to hospital on 14 June 2013 after falling at home on 10 June and subsequently deteriorating; she had hit her head and was taking blood-thinning medication. The principal concern was that she did not initially receive a head CT scan, which was performed about eight hours after hospital presentation and revealed an intracranial bleed; the report also noted possible shortcomings in how the significance of blood-thinning medication was emphasised in the relevant guidelines.
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 NICE Guidelines insufficiently emphasising blood-thinning medication in elderly people who have a fall when determining the need for a head CT
Wider context from the report “namely that Mrs Kilvert was not initially at the hospital given a CT scan of the head. It was not performed until about 8 hours after presentation at hospital and revealed an intracranial bleed. The medical cause of death was :-
1a) Intracranial bleed,
II Chronic Kidney Failure
Hypertension
Heart Valve Replacement.
As it turned out neurological intervention would not have been appropriate even if a brain bleed had been discovered immediately. I was told by the consultant in emergency medicine who gave evidence, that although the NICE Guidelines were considered, the clinical judgment of the senior house officer who saw her initially was that there was no reason to suspect a bleed, although the consultant said that his judgment may have been different. The consultant felt that the Guidelines possibly insufficiently emphasised the significance of blood thinning medication in elderly people who had a fall when considering whether a CT scan of the head was necessary , albeit that eventually the matter was a question of clinical judgment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the 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 performing a CT scan of the head after hospital presentation
Wider context from the report “namely that Mrs Kilvert was not initially at the hospital given a CT scan of the head . It was not performed until about 8 hours after presentation at hospital and revealed an intracranial bleed. The medical cause of death was :-
1a) Intracranial bleed,
II Chronic Kidney Failure
Hypertension
Heart Valve Replacement.
As it turned out neurological intervention would not have been appropriate even if a brain bleed had been discovered immediately. I was told by the consultant in emergency medicine who gave evidence, that although the NICE Guidelines were considered, the clinical judgment of the senior house officer who saw her initially was that there was no reason to suspect a bleed, although the consultant said that his judgment may have been different. The consultant felt that the Guidelines possibly insufficiently emphasised the significance of blood thinning medication in elderly people who had a fall when considering whether a CT scan of the head was necessary, albeit that eventually the matter was a question of clinical judgment.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations