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First report 8 Oct 2024•Latest report 8 Oct 2024

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from National Institute for Health and Care Research linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Devon, Plymouth and Torbay

    AI-generated summary

    Maeve Boothby O’Neill · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Maeve Boothby O’Neill, who had severe ME and was bedbound, died at home on 3 October 2021 after three hospital admissions during 2021. The report identified concerns about the lack of specialist care provision for severe ME, limited research funding and medical training, and insufficient guidance on managing severe ME in the home or community, including nutritional support.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Research; that does not assign responsibility.

    PFD Monitor interpretation

    Extremely limited doctor training on ME/CFS treatment, especially severe ME

    Wider context from the report

    “(3) During the course of the inquest it became clear that there was extremely limited training for Doctors on ME/ CFS and how to treat it – especially in relation to severe ME. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Research; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of specialist healthcare provision for patients with severe ME

    Wider context from the report

    “(1) During the course of the evidence it became clear that there were no specialist hospitals or hospices, beds, wards or other health care provision in England for patients with severe Myalgic encephalopathies (ME). This meant that the Royal Devon and Exeter Hospital had no commissioned service to treat Maeve and patients like her. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Research; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of NICE guidance to provide detailed guidance on managing severe ME at home or in the community

    Wider context from the report

    “(4 ) During the course of the inquest it became clear that the 2021 NICE guidelines on ME did not provide any detailed guidance at all on how severe ME should be managed at home or in the community and in particular whether or not there is any necessary adaptation needed to the 2017 guidance on Nutrition support for adults : oral nutrition support , enteral tube feeding and parenteral nutrition . ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Institute for Health and Care Research; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of current funding for ME/CFS treatment research and understanding of causes

    Wider context from the report

    “(2) During the course of the inquest it became clear that there was no current available funding for the research and development of treatment and further learning for understanding the causes of ME / Chronic Fatigue Syndrome (CFS). ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026