Concerns raised 22 Failure of child death review to identify learning across relevant environmental and service factors View source Uncertainty about learning identified through paediatric mortality review View source Lack of funding mechanisms enabling cardiac screening for competitive boxers View source Failure to obtain echocardiography for critically unwell patients in shock View source Failure to target intravenous fluid management against patient response View source Failure to retain emergency department monitor data for retrospective analysis View source Failure to undertake deep-dive safety audits examining patterns and trends View source Delays in obtaining the first blood gas View source Deficiencies in ECG interpretation View source Failure to formulate a differential diagnosis View source Lack of parental awareness of sudden cardiac death red-flag symptoms View source Insufficient radiologist capacity for expanding imaging demand View source Failure of communication within and between clinical teams View source Insufficient clinical knowledge of medication effects and pharmacologic consequences View source Lack of funding and implementation of defined cardiogenic shock escalation and care pathways View source Failure to embed HSSIB critically unwell patient guidance in staff training View source Lack of recorded assessment of radiological images View source Lack of recorded evidence on key aspects of patient care View source Insufficient critical care training View source Insufficient critical care resources View source Insufficient audit of sepsis pathway use View source Insufficient sepsis pathway training View source See 19 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
Christian James Gabriel Hobbs · 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
Christian James Gabriel Hobbs, a 17-year-old, suffered an acute deterioration at home and was taken to hospital on 26 December 2017, where he developed cardiac arrest and died after treatment was stopped. The inquest recorded multi-organ failure, cardiogenic shock and arrhythmogenic cardiomyopathy. Concerns included the absence of an echocardiogram before his arrest, non-targeted fluid management, delays in obtaining blood gases, team communication, radiology documentation, differential diagnosis, ECG interpretation, record keeping and emergency-department alarm data retention.
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 NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of child death review to identify learning across relevant environmental and service factors
Wider context from the report “POINT R – CHILD DEATH OVERVIEW PANEL REVIEW
Whilst the death occurred in Cambridgeshire, it is understood that the Northamptonshire CDOP reviewed this matter. However, it appears that a copy of the Analysis Proforma is not available but taking information from a collation of reviews, there was no identification of any learning in terms of factors intrinsic to the social environment, physical environment or service provision .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about learning identified through paediatric mortality review
Wider context from the report “POINT S – NWAFT PAEDIATRIC MORTALITY REVIEW
It is unclear whether any NWAFT paediatric review found any issues from a learning perspective given the matters analysed at length within the coronial investigation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of funding mechanisms enabling cardiac screening for competitive boxers
Wider context from the report “POINT Q – TESTING IN COMPETITIVE SPORTS FOR CARDIAC CONDITIONS
I have a concern about funding mechanisms being available to say England Boxing that would enable appropriate screening for competitive boxers where there is already a mandatory need for a medical examination under the ‘fit or not fit to box’ protocol. This would aid further research on this important topic.
Additionally, there may be a lack of general awareness for parents of sports participants on the issue of sudden cardiac death and so there may be a gap in knowledge/understanding of possible emergence of red flag symptoms.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain echocardiography for critically unwell patients in shock
Wider context from the report “POINT B - RE: ECHOCARDIOGRAPHY
Christian had not had an echocardiogram prior to his arrest . This was a concerning feature of his care in the ED given he was critically unwell and in a shocked state .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to target intravenous fluid management against patient response
Wider context from the report “POINT C - FLUID MANAGEMENT
Intravenous fluids were commenced but these were not targeted against response . Christian remained hypotensive and tachycardic despite the fluid administration. This is an area of concern also.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to retain emergency department monitor data for retrospective analysis
Wider context from the report “POINT N - DATA FROM EMERGENCY DEPARTMENT ALARMS
The monitor evidence was not available for analysis of heart rhythms etc because there was no retention of the data at the time . This hampered consideration of data in the death that required detailed review and this is a concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake deep-dive safety audits examining patterns and trends
Wider context from the report “POINT P - PATIENT SAFETY IN SOME TRUST AREAS
This is a concern and it is unclear as to whether there has been a deep dive audit/review to look at patterns/trends rather than simply looking at raw overall mortality data .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining the first blood gas
Wider context from the report “POINT G – BLOOD GASES/ ELEVATED LACTATE
There was a delay in getting the first blood gas . A cannula was in situ by circa 19:00, when intravenous fluids and antibiotics were given. A venous blood gas should have been taken from this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in ECG interpretation
Wider context from the report “POINT L – ECG ANALYSIS
Some Issues emerged in evidence on the interpretation of the ECG at 18:10.
This again raises concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to formulate a differential diagnosis
Wider context from the report “POINT I - DIFFERENTIAL DIAGNOSIS
A recurring theme is lack of a differential diagnosis which raises concerns about training.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of parental awareness of sudden cardiac death red-flag symptoms
Wider context from the report “POINT Q – TESTING IN COMPETITIVE SPORTS FOR CARDIAC CONDITIONS
I have a concern about funding mechanisms being available to say England Boxing that would enable appropriate screening for competitive boxers where there is already a mandatory need for a medical examination under the ‘fit or not fit to box’ protocol. This would aid further research on this important topic.
Additionally, there may be a lack of general awareness for parents of sports participants on the issue of sudden cardiac death and so there may be a gap in knowledge/understanding of possible emergence of red flag symptoms .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient radiologist capacity for expanding imaging demand
Wider context from the report “POINT F - RADIOLOGY NATIONALLY
I have a concern over whether there are sufficient numbers of radiologists to cover the ever-increasing expansion of imaging as a key diagnostic tool.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of communication within and between clinical teams
Wider context from the report “POINT D - TEAM INTERACTIONS
A concern arises over communications within a team itself and also interactions with other teams – e.g. when a referral is made to the medical team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient clinical knowledge of medication effects and pharmacologic consequences
Wider context from the report “POINT K- ANTIEMETIC MEDICATION
I have a concern on clinical knowledge of such effects of this drug and pharmacologic consequences of other drugs also .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of funding and implementation of defined cardiogenic shock escalation and care pathways
Wider context from the report “POINT A - RE: CARDIOGENIC SHOCK CS)
I have a concern over funding availability and implementation of the key recommendations set out below.
The Intensive Care Society and British Cardiovascular Society issued a comprehensive report in October 2022 with the title - Shock to Survival: a framework to improve the care and outcomes of people with cardiogenic shock in the UK.
The Executive Summary reported that patients with cardiogenic shock need defined pathways of escalation and care to improve survival .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to embed HSSIB critically unwell patient guidance in staff training
Wider context from the report “POINT O – LEARNING FROM HSSIB REPORTS
I have a concern on whether the HSSIB report – RECOGNISING AND RESPONDING TO CRITICALLY UNWELL PATIENTS is firmly embedded in staff training .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of recorded assessment of radiological images
Wider context from the report “POINT E – RADIOLOGY WITHIN NWAFT
Another recurring theme is radiology within the trust. In the case of Christian, nothing is recorded in the notes on assessment of the X-Rays undertaken .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of recorded evidence on key aspects of patient care
Wider context from the report “POINT M -RECORD KEEPING
There was a lack of recorded evidence on key aspects of Christians care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient critical care training
Wider context from the report “POINT H - CRITICAL CARE
There are concerns about resources and training within the trust for this specialty .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient critical care resources
Wider context from the report “POINT H - CRITICAL CARE
There are concerns about resources and training within the trust for this specialty .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient audit of sepsis pathway use
Wider context from the report “POINT J - SEPSIS PATHWAY
This is again another theme and accordingly raises a concern about training and auditing .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient sepsis pathway training
Wider context from the report “POINT J - SEPSIS PATHWAY
This is again another theme and accordingly raises a concern about training and auditing .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain monthly Clinical Review Quality Meetings and Technical Information Finance Meetings with providers.
Verbatim wording from the response “• CPICB recognises that while the recommendations within the Shock to Survival document have not been nationally mandated, they represent best practice and are integral to delivering high-quality care within acute NHS hospital settings. The ICB have implemented an improved contractual process where all providers have a Clinical Review Quality Meeting each month, alongside a Technical Information Finance Meeting. The ICB will seek assurance of compliance with the Shock to Survival recommendations through Clinical Quality Review Meetings with North West Anglia NHS Foundation Trust and other providers in the Cambridgeshire and Peterborough Integrated Care System that care for similar patient groups.” Source location Response from Cambridgeshire and Peterborough ICB
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 Work with providers to gain assurance that critically ill patients have 24/7 access to transthoracic or focused echocardiography.
Verbatim wording from the response “• CPICB will work with North West Anglia NHS Foundation Trust and other providers caring for similar patient groups to gain assurance that mechanisms are in place to ensure critically ill patients have 24/7 access to either transthoracic echocardiography or focused echocardiography. This process will be undertaken through Clinical Quality Review Meetings and is expected to be completed by 30 June 2025.” Source location Response from Cambridgeshire and Peterborough ICB
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 Work with the Trust to gain assurance that progress is being made on PSIRF quality improvement initiatives.
Verbatim wording from the response “• North West Anglia NHS Foundation Trust’s Quality Assurance Committee holds a monthly meeting, alternating between surveillance and deep dives on identified themes. This is attended by representatives from CPICB. The Trust’s Patient Safety Incident Response Framework (PSIRF) plan outlines detailed quality improvement initiatives, and we are working with the Trust to gain assurance that progress is being made in the areas defined.” Source location Response from Cambridgeshire and Peterborough ICB
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 Seek provider assurance that Shock to Survival recommendations are being complied with through Clinical Quality Review Meetings.
Verbatim wording from the response “• CPICB recognises that while the recommendations within the Shock to Survival document have not been nationally mandated, they represent best practice and are integral to delivering high-quality care within acute NHS hospital settings. The ICB have implemented an improved contractual process where all providers have a Clinical Review Quality Meeting each month, alongside a Technical Information Finance Meeting. The ICB will seek assurance of compliance with the Shock to Survival recommendations through Clinical Quality Review Meetings with North West Anglia NHS Foundation Trust and other providers in the Cambridgeshire and Peterborough Integrated Care System that care for similar patient groups.” Source location Response from Cambridgeshire and Peterborough ICB
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing data show fluid management is not recurrent, while ward accreditation and matron audits provide ongoing monitoring and quality improvement.
Verbatim wording from the response “• From analysis of patient safety data since 2017, fluid management has not emerged as a recurrent theme within North West Anglia NHS Foundation Trust (NWAF T). Furthermore, fluid balance monitoring forms part of the Trust’s ward accreditation programme, which reviews wards against a range of national care standards. It is also embedded within the Trust’s core matron audit programme, ensuring ongoing oversight and quality improvement. The Trust continues to hold the responsibility to ensure that it will share any emerging themes or risks to the ICB in the monthly Integrated Quality Report.” Source location Response from Cambridgeshire and Peterborough ICB
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Current sepsis data and provider reports do not identify a concern, and the Trust’s sepsis-management approach is assessed as adequate.
Verbatim wording from the response “• North West Anglia NHS Foundation Trust includes sepsis data as part of its monthly Integrated Quality Report to CPICB. This data is reviewed regularly and does not currently flag as an outlier when compared to regional or national benchmarks. Within this report, providers also highlight any emerging risks and issues. To date, sepsis has not been raised to CPICB as a concern. Based on current data and provider reports, CPICB assesses the Trust’s approach to sepsis management as adequate. We will continue to monitor for any changes in performance or risk indicators.” Source location Response from Cambridgeshire and Peterborough ICB
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 Trust remains responsible for sharing emerging fluid-management themes or risks with the ICB through the monthly Integrated Quality Report.
Verbatim wording from the response “• From analysis of patient safety data since 2017, fluid management has not emerged as a recurrent theme within North West Anglia NHS Foundation Trust (NWAF T). Furthermore, fluid balance monitoring forms part of the Trust’s ward accreditation programme, which reviews wards against a range of national care standards. It is also embedded within the Trust’s core matron audit programme, ensuring ongoing oversight and quality improvement. The Trust continues to hold the responsibility to ensure that it will share any emerging themes or risks to the ICB in the monthly Integrated Quality Report.” Source location Response from Cambridgeshire and Peterborough ICB
Open published response
Concerns raised 2 Lack of available suitable placements for people with complex needs View source Inadequacy of the Section 136 Suite 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
DECLAN GORDON GERARD MORRISON · 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
Declan Morrison, who had complex care needs and required 24-hour residential care, was detained under the Mental Health Act after no suitable alternative placement could be found. He was found unresponsive after suffering catastrophic brain injuries and died in hospital on 2 April 2022. The principal concerns were the shortage of suitable community and NHS placements and the use of a Section 136 Suite considered inappropriate for his longer-term detention and complex needs.
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 NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of available suitable placements for people with complex needs
Wider context from the report “(1) The evidence revealed that there is currently a widespread shortage of available placements for someone with Declan’s complex needs both in the community and within the NHS .
(2) Once it was clear that Declan’s community placement had broken down in late 2021 no suitable alternative could be found . This resulted in a decline in Declan’s mental health and behaviour which ultimately necessitated his detention under the Mental Health Act. There was then nowhere suitable to detain him under Section 2 of the Mental Health Act .
(3) The Section 136 Suite was completely inappropriate. Declan’s mental health and behaviour declined further and ultimately this resulted in his death.
(4) Declan was in crisis for several months – the facilities were simply not available in the community and once detained , in order to prevent his 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 NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of the Section 136 Suite
Wider context from the report “(1) The evidence revealed that there is currently a widespread shortage of available placements for someone with Declan’s complex needs both in the community and within the NHS.
(2) Once it was clear that Declan’s community placement had broken down in late 2021 no suitable alternative could be found. This resulted in a decline in Declan’s mental health and behaviour which ultimately necessitated his detention under the Mental Health Act. There was then nowhere suitable to detain him under Section 2 of the Mental Health Act.
(3) The Section 136 Suite was completely inappropriate . Declan’s mental health and behaviour declined further and ultimately this resulted in his death.
(4) Declan was in crisis for several months – the facilities were simply not available in the community and once detained, in order to prevent his death.
” Open source report
Concerns raised 1 Failure to provide clear information and direction on obtaining emergency mental health assessment and care 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
Kelvin Igweani · 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
Kelvin Igweani died from gunshot wounds after police forced entry into a flat where he had barricaded himself with a two-year-old boy during a severe mental health episode. The report identifies a concern that, despite repeated attempts by his mother to obtain help, unclear information and direction about accessing emergency mental health assessment and care meant Kelvin did not receive that 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 NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear information and direction on obtaining emergency mental health assessment and care
Wider context from the report “Through Kelvin's period of deteriorating mental health, which was obvious to those who knew him, his mother made repeated attempts to secure mental health assessment and care for him.
She was not directed clearly by the professionals she did have contact with, to take him to the Emergency Department for assistance. There was a gap which Kelvin fell through and he did not receive either mental health assessment or care. It was not possible to say that the failure to receive assessment or care resulted in Kelvin attempting to take the lives of others and succeeding in taking the life of his male neighbour.
It was clear that the lack of clear information and direction in regard to how to obtain that mental health assessment or care contributed to Kelvin not presenting for assessment which may possibly have averted the tragic events which unfolded on the 26th June 2021. This in turn raises the prospect that others, in similar predicaments may also be unable to obtain the care required.
” Open source report
Concerns raised 7 Failure to correct and monitor prescribing clinicians' failure to sign off IV fluid prescriptions View source Lack of effective, reliable recording of intravenous fluids administered in the emergency department View source Failure to accurately transcribe communications received at emergency department triage View source Failure to bring issues of concern to the attention of hospital authorities View source Failure of attending doctors to review source communications themselves View source Failure of incident investigations to provide detailed, evidence-challenging analysis View source Failure of treating doctors to make accurate clinical notes of major presenting symptoms View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Alexander Shone BLEWITT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alexander Shone Blewitt died at Milton Keynes University Hospital on 11 July 2022 after returning to the emergency department with faecal incontinence and abdominal pain, following an earlier visit where he had been referred from an urgent care centre. A possible acute abdomen was confirmed by CT, and he suffered a cardiac arrest before surgery. Concerns included inaccurate communication of important symptoms and treatment information, inadequate clinical recording, and the absence of reliable records of intravenous fluids administered in the emergency department.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to correct and monitor prescribing clinicians' failure to sign off IV fluid prescriptions
Wider context from the report “[5] The Incident Investigation Report which is in part designed to assist with learning from adverse events was of a generally poor standard. There was a failure to consider issues in detail; there was a failure to challenge the statements of clinicians where there were obvious contradictions between statements made and the medical record; there was a failure to put in place measures to correct and monitor prescribing clinicians failure to sign off on IV fluid prescriptions so that the contemporaneous record would be available for clinicians coming after them and they could see whether a patient had satisfactory or unsatisfactory fluid management . The only record in the case was a typed note by a junior doctor to the effect that it was thought Mr Blewitt had received 2 litres of fluid since arrival.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of effective, reliable recording of intravenous fluids administered in the emergency department
Wider context from the report “[1] At the time of Mr Blewitt's death there was no effective, reliable recording of intravenous fluids administered to patients in the emergency department . That in my view has potential to represent a threat to the safety and lives of patients suffering with a wide variety of different conditions. The author of the SI report who attended to give evidence did not, at the time of request 8 months later, was unable to demonstrate that the Trust had remedied that.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately transcribe communications received at emergency department triage
Wider context from the report “[3] On arrival at the ED a triage nurse summarised the communication from the urgent care centre. The triage nurse missed important points during the transcription . The attending doctor did not concern himself to look at the communication himself.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to bring issues of concern to the attention of hospital authorities
Wider context from the report “[2] Despite the 8 month interval between Mr Blewitt's death and the Inquest the issues of concern had not been brought to the attention of hospital authorities .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of attending doctors to review source communications themselves
Wider context from the report “[3] On arrival at the ED a triage nurse summarised the communication from the urgent care centre. The triage nurse missed important points during the transcription. The attending doctor did not concern himself to look at the communication himself .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of incident investigations to provide detailed, evidence-challenging analysis
Wider context from the report “[5] The Incident Investigation Report which is in part designed to assist with learning from adverse events was of a generally poor standard . There was a failure to consider issues in detail ; there was a failure to challenge the statements of clinicians where there were obvious contradictions between statements made and the medical record ; there was a failure to put in place measures to correct and monitor prescribing clinicians failure to sign off on IV fluid prescriptions so that the contemporaneous record would be available for clinicians coming after them and they could see whether a patient had satisfactory or unsatisfactory fluid management. The only record in the case was a typed note by a junior doctor to the effect that it was thought Mr Blewitt had received 2 litres of fluid since arrival.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of treating doctors to make accurate clinical notes of major presenting symptoms
Wider context from the report “[4] I was concerned that the treating doctor made aaneous note on the 9th July 2022 at Mr Blewitt's first presentation which failed to record the major presenting symptom, diarrhoea with faecal incontinence , which Mr Blewitt had communicated to the urgent care doctor who in turn had included that in her notes and letter to the ED. The treating doctor did record a flatly contradictory note to the effect there was no change in bowel habit .
” Open source report
Concerns raised 2 Failure to actively identify patients taking high-risk medication combinations and rationalize or reduce their medications View source Severe risk of cumulative and synergistic central nervous system depression from gabapentinoid and opioid polypharmacy 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
Jacqueline Sharman CAMPBELL · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jacqueline Sharman CAMPBELL was found collapsed at home after living with chronic back pain for more than 20 years and taking multiple prescribed medicines. The inquest concluded that she likely inadvertently overdosed on tramadol, which in combination with other medicines had a synergistic effect causing respiratory depression and death. The principal concern was the safety risk of polypharmacy involving gabapentinoids and opioids, particularly their cumulative and synergistic effects on the central nervous system.
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 NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to actively identify patients taking high-risk medication combinations and rationalize or reduce their medications
Wider context from the report “Her GP, ████████, gave clear and candid evidence. I accept the management of patients who describe intractable debilitating pain is challenging and difficult and that requests for other or increasing doses of medication can be difficult to resist. ████████ agreed that the prescribing of the various drugs identified had potential to be dangerous. He told me that after a certain point the benefits of increasing or adding doses or medications in terms of pain relief were minimal. This scenario seems to be an on individuals one for GP’s and patients alike.
████████ told me that subsequent to Ms Campbell’s death the practice had convened and discussed the circumstances and agreed on regular reviews for patients taking these sorts of medication. There were no plans identified to actively look for these patients and to work to rationalize and / or reduce their medications.
I am of the view that polypharmacy including gabapentinoids and opiates represents a severe safety risk in patients with a iatrogenic drug dependency. I consider that the risk in individuals like Ms Campbell of an inadvertent overdose of medications which have a cumulative and synergistic effect to depress the central nervous system can easily become extreme and lead to death. There have been a number of deaths in the Milton Keynes, Bedfordshire and Luton areas related to concomitant use of high dose and combination gabapentinoids and opioids.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Severe risk of cumulative and synergistic central nervous system depression from gabapentinoid and opioid polypharmacy
Wider context from the report “Her GP, ████████, gave clear and candid evidence. I accept the management of patients who describe intractable debilitating pain is challenging and difficult and that requests for other or increasing doses of medication can be difficult to resist. ████████ agreed that the prescribing of the various drugs identified had potential to be dangerous . He told me that after a certain point the benefits of increasing or adding doses or medications in terms of pain relief were minimal . This scenario seems to be an on individuals one for GP’s and patients alike.
████████ told me that subsequent to Ms Campbell’s death the practice had convened and discussed the circumstances and agreed on regular reviews for patients taking these sorts of medication. There were no plans identified to actively look for these patients and to work to rationalize and / or reduce their medications.
I am of the view that polypharmacy including gabapentinoids and opiates represents a severe safety risk in patients with a iatrogenic drug dependency . I consider that the risk in individuals like Ms Campbell of an inadvertent overdose of medications which have a cumulative and synergistic effect to depress the central nervous system can easily become extreme and lead to death . There have been a number of deaths in the Milton Keynes, Bedfordshire and Luton areas related to concomitant use of high dose and combination gabapentinoids and opioids.
” Open source report
Concerns raised 1 Lack of clarity over responsibility for monitoring GP antibiotic prescribing requested by a hospital 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
Ethel Ann Beaumont · 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
Ethel Ann Beaumont died on 11 May 2020 after developing nitrofurantoin-induced liver injury and liver failure while being treated before planned surgery. The report found that a significantly raised ALT result should have been followed up promptly and raised concerns about unclear responsibility between hospital and primary care for monitoring antibiotics prescribed at the hospital’s request.
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 NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity over responsibility for monitoring GP antibiotic prescribing requested by a hospital
Wider context from the report “that there is a lack of clarity between hospital and primary care as to which of them should be responsible for monitoring where a GP is prescribing an antibiotic on the request of the hospital that a patient is attending regularly for review. I am concerned that these pathways should be clarified and that there remains a risk of future death at present.
” Open source report
Concerns raised 3 Failure of school healthcare provision to share confidential health information with GP surgeries View source Lack of lower-level assistance for young people with life issues who do not meet CAMHS access criteria View source Failure to share relevant information between health agencies for fully informed healthcare decisions 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
Sam Michael Carl Grant · 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
Sam Michael Carl Grant, aged 16, died at home on 09/11/2018 after being found hanging by his sister. The report raised concerns about limited access to lower-level mental health support, incomplete information-sharing between services, and reduced confidential health-information sharing between the school and GP surgery.
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 NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of school healthcare provision to share confidential health information with GP surgeries
Wider context from the report “1) Sam’s GP referred Sam to CAMHS when he presented to the GP with irritability, anger and a report that he was close to being excluded from school. CAMHS rejected the referral because Sam did not meet their threshold of moderate to severe mental health issues. CAMHS did not suggest any alternative assistance. The GP did follow up with Sam to sign post him to two independent organisations who Sam would have to approach independently for help. The GP made it clear in his evidence that there is a lack of lower level assistance for young people who present with ‘life issues’ such as low mood, irritability and anger issues, but who nonetheless need help and assistance but do not meet the criteria for access to CAMHS services.
2) Sam had been referred to, and was receiving the services of COMPASS having been referred by his School. The GP was not made aware of this engagement and was unable to take this into account at the time when Sam did present himself to the GP. The evidence from COMPASS is that they maintain the confidentiality of patients even minors using their services unless they have express consent to disclose that information from the patient themselves. Without all relevant information neither the GP nor CAMHS was in a position to make a fully informed decision about the Sam’s needs. Sharing of information between relevant health agencies to ensure fully informed decisions are made as regards the healthcare needs of an individual should be a priority.
3) Evidence at the inquest from the GP also indicated that a reduction in healthcare provision at Sam’s school and in particular the removal of a medically qualified person(s) has meant that confidential health information is no longer shared between the school and the GP surgery. The school now only engages First Aiders, who are not medically qualified, and who do not therefore exchange information which in the past has proved essential in flagging concerns between the GP and the School. This is another route which has been closed and which would have allowed a potential flag to have been raised in respect of concerns around Sam and his wellbeing to be shared confidentially between GP and school.
2) Sam had been referred to, and was receiving the services of COMPASS having been referred by his School. The GP was not made aware of this engagement and was unable to take this into account at the time when Sam did present himself to the GP. The evidence from COMPASS is that they maintain the confidentiality of patients even minors using their services unless they have express consent to disclose that information from the patient themselves. Without all relevant information neither the GP nor CAMHS was in a position to make a fully informed decision about the Sam’s needs. Sharing of information between relevant health agencies to ensure fully informed decisions are made as regards the healthcare needs of an individual should be a priority.
3) Evidence at the inquest from the GP also indicated that a reduction in healthcare provision at Sam’s school and in particular the removal of a medically qualified person(s) has meant that confidential health information is no longer shared between the school and the GP surgery. The school now only engages First Aiders, who are not medically qualified, and who do not therefore exchange information which in the past has proved essential in flagging concerns between the GP and the School. This is another route which has been closed and which would have allowed a potential flag to have been raised in respect of concerns around Sam and his wellbeing to be shared confidentially between GP and school.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of lower-level assistance for young people with life issues who do not meet CAMHS access criteria
Wider context from the report “1) Sam’s GP referred Sam to CAMHS when he presented to the GP with irritability, anger and a report that he was close to being excluded from school. CAMHS rejected the referral because Sam did not meet their threshold of moderate to severe mental health issues. CAMHS did not suggest any alternative assistance. The GP did follow up with Sam to sign post him to two independent organisations who Sam would have to approach independently for help. The GP made it clear in his evidence that there is a lack of lower level assistance for young people who present with ‘life issues’ such as low mood, irritability and anger issues, but who nonetheless need help and assistance but do not meet the criteria for access to CAMHS services .
2) Sam had been referred to, and was receiving the services of COMPASS having been referred by his School. The GP was not made aware of this engagement and was unable to take this into account at the time when Sam did present himself to the GP. The evidence from COMPASS is that they maintain the confidentiality of patients even minors using their services unless they have express consent to disclose that information from the patient themselves. Without all relevant information neither the GP nor CAMHS was in a position to make a fully informed decision about the Sam’s needs. Sharing of information between relevant health agencies to ensure fully informed decisions are made as regards the healthcare needs of an individual should be a priority.
3) Evidence at the inquest from the GP also indicated that a reduction in healthcare provision at Sam’s school and in particular the removal of a medically qualified person(s) has meant that confidential health information is no longer shared between the school and the GP surgery. The school now only engages First Aiders, who are not medically qualified, and who do not therefore exchange information which in the past has proved essential in flagging concerns between the GP and the School. This is another route which has been closed and which would have allowed a potential flag to have been raised in respect of concerns around Sam and his wellbeing to be shared confidentially between GP and school.
2) Sam had been referred to, and was receiving the services of COMPASS having been referred by his School. The GP was not made aware of this engagement and was unable to take this into account at the time when Sam did present himself to the GP. The evidence from COMPASS is that they maintain the confidentiality of patients even minors using their services unless they have express consent to disclose that information from the patient themselves. Without all relevant information neither the GP nor CAMHS was in a position to make a fully informed decision about the Sam’s needs. Sharing of information between relevant health agencies to ensure fully informed decisions are made as regards the healthcare needs of an individual should be a priority.
3) Evidence at the inquest from the GP also indicated that a reduction in healthcare provision at Sam’s school and in particular the removal of a medically qualified person(s) has meant that confidential health information is no longer shared between the school and the GP surgery. The school now only engages First Aiders, who are not medically qualified, and who do not therefore exchange information which in the past has proved essential in flagging concerns between the GP and the School. This is another route which has been closed and which would have allowed a potential flag to have been raised in respect of concerns around Sam and his wellbeing to be shared confidentially between GP and school.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant information between health agencies for fully informed healthcare decisions
Wider context from the report “1) Sam’s GP referred Sam to CAMHS when he presented to the GP with irritability, anger and a report that he was close to being excluded from school. CAMHS rejected the referral because Sam did not meet their threshold of moderate to severe mental health issues. CAMHS did not suggest any alternative assistance. The GP did follow up with Sam to sign post him to two independent organisations who Sam would have to approach independently for help. The GP made it clear in his evidence that there is a lack of lower level assistance for young people who present with ‘life issues’ such as low mood, irritability and anger issues, but who nonetheless need help and assistance but do not meet the criteria for access to CAMHS services.
2) Sam had been referred to, and was receiving the services of COMPASS having been referred by his School. The GP was not made aware of this engagement and was unable to take this into account at the time when Sam did present himself to the GP. The evidence from COMPASS is that they maintain the confidentiality of patients even minors using their services unless they have express consent to disclose that information from the patient themselves. Without all relevant information neither the GP nor CAMHS was in a position to make a fully informed decision about the Sam’s needs. Sharing of information between relevant health agencies to ensure fully informed decisions are made as regards the healthcare needs of an individual should be a priority.
3) Evidence at the inquest from the GP also indicated that a reduction in healthcare provision at Sam’s school and in particular the removal of a medically qualified person(s) has meant that confidential health information is no longer shared between the school and the GP surgery. The school now only engages First Aiders, who are not medically qualified, and who do not therefore exchange information which in the past has proved essential in flagging concerns between the GP and the School. This is another route which has been closed and which would have allowed a potential flag to have been raised in respect of concerns around Sam and his wellbeing to be shared confidentially between GP and school.
2) Sam had been referred to, and was receiving the services of COMPASS having been referred by his School. The GP was not made aware of this engagement and was unable to take this into account at the time when Sam did present himself to the GP. The evidence from COMPASS is that they maintain the confidentiality of patients even minors using their services unless they have express consent to disclose that information from the patient themselves. Without all relevant information neither the GP nor CAMHS was in a position to make a fully informed decision about the Sam’s needs. Sharing of information between relevant health agencies to ensure fully informed decisions are made as regards the healthcare needs of an individual should be a priority.
3) Evidence at the inquest from the GP also indicated that a reduction in healthcare provision at Sam’s school and in particular the removal of a medically qualified person(s) has meant that confidential health information is no longer shared between the school and the GP surgery. The school now only engages First Aiders, who are not medically qualified, and who do not therefore exchange information which in the past has proved essential in flagging concerns between the GP and the School. This is another route which has been closed and which would have allowed a potential flag to have been raised in respect of concerns around Sam and his wellbeing to be shared confidentially between GP and school.
” Open source report
Concerns raised 1 Unavailability of a home-based falls response service View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Douglas Albert Walter MINNS · 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
Douglas Albert Walter MINNS, aged 93, fell at home on 21 August 2018 and made an emergency call. He was attended by ambulance after approximately four hours, taken to hospital with subarachnoid and subdural bleeding, and died there on 22 August 2018. The principal concern was the withdrawal of a falls service and the resulting delay in responding to people who had fallen, particularly amid strains on the ambulance 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 NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a home-based falls response service
Wider context from the report “During the course of the evidence it was explained to me that the provision of a falls service was withdrawn some years ago , the service would provide for someone to attend the home of the person who had fallen, get them on their feet, assess their wellbeing, serve a cup of tea and get them back into bed if required. If they required more urgent treatment, they would report to the ambulance service. The withdrawal of the service puts patient's lives at risk and, in view of the strains on the ambulance service, consideration should be given to re-introducing it. It is unacceptable for a 93 year old man to be left lying on the floor for four hours before someone responds.
” 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 Operate a 24/7 Home 1st Rapids service providing rapid triage, home attendance, assessment and escalation for acute falls.
Verbatim wording from the response “• A Home 1st Rapids service provided by our community provider, CNWL, comprising of experienced nurse practitioners and prescribers, who respond to a call from a GP, ambulance services or other allied health professional.” Source location 2019-0052-Response-by-Milton-Keynes-CCG
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing commissioned services sufficiently replace the discontinued falls service, covering acute, preventative and non-urgent community fall needs.
Verbatim wording from the response “I hope the above description of commissioned services provides suitable assurance that although the original falls services was discontinued, it has been replaced by a 24/7 Home 1st Rapids service to deal with acute episodes of falling in the community; supported by two in office hours services which focus on prevention and non-urgent needs. The Home 1st Rapids service reflects the objectives of the original falls service in that they attend the home, carry out an assessment, make the individual comfortable and call an ambulance if required.” Source location 2019-0052-Response-by-Milton-Keynes-CCG
Open published response
Concerns raised 1 Failure to provide counselling to very vulnerable people View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Neil Stephen David SWAISLAND · 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
Neil Stephen David SWAISLAND died after jumping from the top floor of a multi-storey car park in Milton Keynes on 14 July 2018. Evidence was heard that funding for MIND counselling services had been withdrawn by the Council and the CCG, raising concern that vulnerable people would be at increased risk of self-harm and suicide and that this could result in further suicide deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide counselling to very vulnerable people
Wider context from the report “During the course of the evidence I heard from a senior GP from Milton Keynes and from a senior clinician from mental health services that the funding for counselling services operated by MIND had been withdrawn by both the Council and the CCG . They expressed the view that as a result of this decision it is inevitable that further lives will be put at risk from self-harm and suicide. My concern is that the decision not to provide counselling to some of the very vulnerable people within our society will result in further deaths from suicide.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain statutory grant funding for subsidised counselling services through March 2019.
Verbatim wording from the response “Milton Keynes Council (MKC) has a historic contract for counselling services in Milton Keynes. MKCCG contributed towards the cost of this provision. MKC have been working with MIND for a number of years to ensure that this contract can operate with resource from grant funding and other opportunities available to third sector partners.” Source location 2018-0385-Response-by-Milton-Keynes-CCG
Open published response
Concerns raised 1 Failure to provide single-room accommodation for in-patient mental health patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Billie Jonathan LORD · 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
Billie Jonathan LORD died from suicide on 11 July 2017 after suffering from psychosis, autism and a psychotic illness associated with non-prescription drug use. He had been admitted voluntarily to the Campbell Centre and was being monitored by intermittent 15-minute observations before absconding and entering the path of a high-speed train. The concern raised was that three-bed dormitory accommodation at the Campbell Centre was inappropriate and may have added to the stress experienced by the patient; a review of the accommodation was suggested.
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 NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide single-room accommodation for in-patient mental health patients
Wider context from the report “During the course of the evidence I was informed by an independent expert that it is recognised that patients admitted to an in-patient mental health facility, such as the Campbell Centre, should be cared for in single rooms and that three bedded dormitory accommodation is inappropriate since in this particular case it added to the level of stress suffered by the patient. Consideration should be given to a review of the accommodation provided at the Campbell Centre, and whether alterations can be carried out to bring the accommodation up to modern standards as recommended by the Royal College of Psychiatrists.
” Open source report
Concerns raised 3 Unavailability of a facility in Milton Keynes for effectively managing patients in mental health crisis and bringing them to hospital for assessment and treatment View source Failure to complete a full Mental Health Act assessment by a psychiatrist before discharge View source Lack of a clear and agreed inter-agency protocol for discharge of patients brought in for assessment 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
Colette Denise Vivienne Jean DUNN · 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
Colette Denise Vivienne Jean Dunn was taken to hospital by ambulance with police officers after threatening to kill herself, but was discharged without a formal Mental Health Act assessment. Later that day, she doused herself with petrol and set fire to herself, sustaining severe burns, and died the following morning. Concerns included the absence of a full mental health assessment before discharge, lack of a clear discharge protocol between relevant agencies, and inadequate facilities in Milton Keynes for people experiencing a mental health crisis.
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 NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a facility in Milton Keynes for effectively managing patients in mental health crisis and bringing them to hospital for assessment and treatment
Wider context from the report “3. There does not appear to be any facility within Milton Keynes for dealing effectively with patients suffering a mental health crisis to ensure they are brought to the hospital for assessment and treatment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to complete a full Mental Health Act assessment by a psychiatrist before discharge
Wider context from the report “1. During the course of the evidence it was clear that prior to discharge from the hospital a full Mental Health Act assessment by a psychiatrist should have been carried out before the decision was taken to discharge Ms Dunn , particularly as the police officers were expressing their concerns to the staff that Ms Dunn had indicated that once she had left the hospital it was her intention to kill herself and indicated that she would tell the staff what they wanted to hear in order to secure her discharge.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear and agreed inter-agency protocol for discharge of patients brought in for assessment
Wider context from the report “2. That there needs to be a clear and agreed protocol between the police, the hospital and the CNWL NHS trust as to how the discharge of patients brought in for assessment is going to be dealt with .
” Open source report
Concerns raised 6 Lack of clear responsibility for care pending further mental health appointments View source Failure to provide medication risks and further-assistance contact information View source Failure of GPs to recognise their responsibility for prescribing and medication advice View source Failure to ensure patients know how to request discussion with a consultant psychiatrist View source Non-prescriber mental health staff advising GPs on medication View source Failure to ensure GPs know how to contact the duty psychiatrist 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
Edward Angus Mallen · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Edward Angus Mallen, who was suffering from depression and had disclosed suicidal thoughts, died after lying across a railway line and being struck by a train on 9 February 2015. The concerns included unclear responsibility for his care, advice from a non-prescriber about medication, lack of information about possible worsening symptoms and increased suicidal feelings, and inadequate awareness of routes to further psychiatric advice.
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 NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of clear responsibility for care pending further mental health appointments
Wider context from the report “3. Edward received no advice about the contraindications of the medication and critically that he may well feel worse before he felt better and may feel more suicidal. In either event he should have been told who to call to get further assistance.
4. The fact that Edward did not receive this information could be due to there being no clear sense of who would be responsible for his care pending further mental health team appointments .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide medication risks and further-assistance contact information
Wider context from the report “3. Edward received no advice about the contraindications of the medication and critically that he may well feel worse before he felt better and may feel more suicidal . In either event he should have been told who to call to get further assistance .
4. The fact that Edward did not receive this information could be due to there being no clear sense of who would be responsible for his care pending further mental health team appointments.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of GPs to recognise their responsibility for prescribing and medication advice
Wider context from the report “1. The GP, ████████ understood that he had been instructed by a member of the Assessment and Referral Team to prescribe citalopram. The member of staff with whom he spoke was a nurse with no prescriber status. The GP felt bound to follow the advice given seemingly without appreciating that prescribing was his responsibility and with it the obligation to advise the patient about the medication.
2. The trust acknowledges that it would be inappropriate for non psychiatrist members of staff to be advising GPs on medication and that this must be communicated to all staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure patients know how to request discussion with a consultant psychiatrist
Wider context from the report “5. ████████ did not appear to appreciate that he could ask to speak with a consultant psychiatrist if he had any concerns and wanted to discuss any aspect of care or treatment .
6. Apparently all GPs should have been made aware by the CCG that there is a duty psychiatrist with whom they can speak but according to the trust many GPs remain unaware of this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Non-prescriber mental health staff advising GPs on medication
Wider context from the report “1. The GP, ████████ understood that he had been instructed by a member of the Assessment and Referral Team to prescribe citalopram. The member of staff with whom he spoke was a nurse with no prescriber status . The GP felt bound to follow the advice given seemingly without appreciating that prescribing was his responsibility and with it the obligation to advise the patient about the medication.
2. The trust acknowledges that it would be inappropriate for non psychiatrist members of staff to be advising GPs on medication and that this must be communicated to all staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure GPs know how to contact the duty psychiatrist
Wider context from the report “5. ████████ did not appear to appreciate that he could ask to speak with a consultant psychiatrist if he had any concerns and wanted to discuss any aspect of care or treatment.
6. Apparently all GPs should have been made aware by the CCG that there is a duty psychiatrist with whom they can speak but according to the trust many GPs remain unaware of this .
” Open source report
Concerns raised 2 Lack of medication-detail checks with the previous GP practice when prescribing responsibility changes View source Failure of the General Practitioner to confirm the correct medication rather than relying on nursing-home staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James Duncan STEWART · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Duncan STEWART, a resident of Manton Heights Nursing Home, was admitted to hospital with decreased mobility and responsiveness after his Parkinson’s medication had apparently not been provided. He was discharged to Airedale Nursing Home for end-of-life care and died on 21 April 2014. The principal concerns were the absence of a system to check medication details with a previous GP practice and uncertainty about responsibility for confirming the correct medication prescription.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of medication-detail checks with the previous GP practice when prescribing responsibility changes
Wider context from the report “(1) There did not appear to be any system whereby when a new GP Practice is requested to prescribe medication from a patient’s Nursing Home the details are not checked with the previous Practice . Such a system would have highlighted the fact that Mr. Stewart’s Co-Careldopa medication had not been included.
(2) It was felt by those giving evidence from the GP Practice, and from the two Nursing Homes, that the correct medication to be prescribed should be a matter for the General Practitioner to confirm rather than relying upon qualified staff from the Home. They also felt that the Clinical Commissioning Group were the obvious body to ensure that a robust and consistent system is put in place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of the General Practitioner to confirm the correct medication rather than relying on nursing-home staff
Wider context from the report “(1) There did not appear to be any system whereby when a new GP Practice is requested to prescribe medication from a patient’s Nursing Home the details are not checked with the previous Practice. Such a system would have highlighted the fact that Mr. Stewart’s Co-Careldopa medication had not been included.
(2) It was felt by those giving evidence from the GP Practice, and from the two Nursing Homes, that the correct medication to be prescribed should be a matter for the General Practitioner to confirm rather than relying upon qualified staff from the Home . They also felt that the Clinical Commissioning Group were the obvious body to ensure that a robust and consistent system is put in place.
” 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 Develop and consult stakeholders on a medication-reconciliation protocol for transfers into care homes and registration with a new GP.
Verbatim wording from the response “In the meantime, in liaison with GP colleagues, Bedfordshire Clinical Commissioning Group have developed a protocol for reconciliation of medications when people are transferred into care homes and are registered with a new GP. The protocol is under consultation with stakeholders in primary and social care. This will also be shared with the commissioners of General Practitioners, NHS England Area Team, for them to consider whether contractual actions can be taken to strengthen compliance with the protocol. An action plan has been written to drive this work forward and progress will be monitored by our Patient Safety and Quality Committee.” Source location 2014-0526-Response-by-Bedfordshire-Clinical-Commissioning-Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the medication-reconciliation protocol with GP commissioners and NHS England’s Area Team for consideration of contractual compliance measures.
Verbatim wording from the response “In the meantime, in liaison with GP colleagues, Bedfordshire Clinical Commissioning Group have developed a protocol for reconciliation of medications when people are transferred into care homes and are registered with a new GP. The protocol is under consultation with stakeholders in primary and social care. This will also be shared with the commissioners of General Practitioners, NHS England Area Team, for them to consider whether contractual actions can be taken to strengthen compliance with the protocol. An action plan has been written to drive this work forward and progress will be monitored by our Patient Safety and Quality Committee.” Source location 2014-0526-Response-by-Bedfordshire-Clinical-Commissioning-Group
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 Write an action plan to drive the medication-reconciliation work forward and monitor its progress through the Patient Safety and Quality Committee.
Verbatim wording from the response “In the meantime, in liaison with GP colleagues, Bedfordshire Clinical Commissioning Group have developed a protocol for reconciliation of medications when people are transferred into care homes and are registered with a new GP. The protocol is under consultation with stakeholders in primary and social care. This will also be shared with the commissioners of General Practitioners, NHS England Area Team, for them to consider whether contractual actions can be taken to strengthen compliance with the protocol. An action plan has been written to drive this work forward and progress will be monitored by our Patient Safety and Quality Committee.” Source location 2014-0526-Response-by-Bedfordshire-Clinical-Commissioning-Group
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue local efforts to improve information-technology systems and communication between care providers.
Verbatim wording from the response “Use of Information Technology (IT) solutions is key to standardising practice and improving patient safety particularly in relation to medicines management. Initiatives relating to electronic prescribing in acute and primary care which are in discussion stages but are currently underdeveloped across Health and Social Care and remain a barrier to efficient communication processes. We will continue to endeavour to improve IT systems as far as possible locally to improve communication between care providers.” Source location 2014-0526-Response-by-Bedfordshire-Clinical-Commissioning-Group
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National and incompatible IT systems prevent fully standardising electronic medicines information transfer between care providers.
Verbatim wording from the response “(1) There is currently no standardised system for when a GP practice is requested to prescribe medication for a new patient at a nursing home to include checks with the previous practice. Practices have developed local processes to facilitate accurate prescribing, however these remain subject to inconsistencies and interpretation. The main current IT software (called System One) in primary care does not have a process to share an accurate list of prescribed medicines and there is a delay in transfer of records to the new registered GP. This remains a national IT issue further complicated when GP practices are utilising IT systems which are not compatible.” Source location 2014-0526-Response-by-Bedfordshire-Clinical-Commissioning-Group
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prescribing GPs are responsible for ensuring medication meets patients’ clinical needs, rather than relying on non-clinical care-home staff to identify errors.
Verbatim wording from the response “(2) It is agreed by our GP members that it is the responsibility of the prescribing GP that the correct medication is prescribed to meet the clinical needs of the person and it should not be dependent upon non-clinical staff in Care Homes to challenge the accuracy of this process.” Source location 2014-0526-Response-by-Bedfordshire-Clinical-Commissioning-Group
Open published response
Concerns raised 1 Failure to provide psychiatric illness and ADHD treatment at the same hospital View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Aaron Michael VRANAS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Aaron Michael VRANAS died after falling from a tenth-floor window at Bury Court, Church Lane, Bedford, on 13 April 2014, sustaining fatal multiple injuries. A concern was raised that treatment for psychiatric illness and ADHD was provided at two different hospitals many miles apart, making the patient difficult to manage.
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 NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide psychiatric illness and ADHD treatment at the same hospital
Wider context from the report “1. ████████ told me that it would be in the best interests of the patients if the treatment of the psychiatric illness and the patient’s ADHD (Attention Deficit Hyperactivity Disorder) were dealt with at the same Hospital as it is difficult to manage a patient when their treatment is carried out in two entirely different hospitals many miles apart . He went on to say in evidence that he had argued for that change many times in the past, but to no avail .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider supporting people with ADHD through local services as part of the mental health services procurement.
Verbatim wording from the response “This is being considered currently, as part of the procurement of mental health services in Bedfordshire, which is due to be completed by April 2015. In the interim period, Bedfordshire Clinical Commissioning Group will work with South Essex Partnership Trust on the development of a pathway that clearly outlines the responsibilities for safe and effective care of people that have a diagnosis of ADHD and a psychiatric illness and are in receipt of services from local and specialist services. This will be completed by end of October 2014.” Source location 2014-0376-Response-by-Bedfordshire-Clinical-Commissioning-Group
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a pathway with South Essex Partnership Trust defining safe-care responsibilities for people with ADHD and psychiatric illness using local and specialist services.
Verbatim wording from the response “This is being considered currently, as part of the procurement of mental health services in Bedfordshire, which is due to be completed by April 2015. In the interim period, Bedfordshire Clinical Commissioning Group will work with South Essex Partnership Trust on the development of a pathway that clearly outlines the responsibilities for safe and effective care of people that have a diagnosis of ADHD and a psychiatric illness and are in receipt of services from local and specialist services. This will be completed by end of October 2014.” Source location 2014-0376-Response-by-Bedfordshire-Clinical-Commissioning-Group
Open published response
Concerns raised 2 Lack of full triage before streaming View source Failure to refer suspected head injuries to the A&E team 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
Gianni Khan · 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
Gianni Khan suffered a catastrophic head injury at a birthday party on 21 December 2013 and died at Addenbrooke’s Hospital on 28 December 2013 after his condition deteriorated and he underwent neurosurgery. The principal concern was that, after reporting a head injury at the hospital, he was streamed to an urgent GP clinic rather than being assessed by a doctor in the Emergency Department, with a failure to recognise the seriousness of the injury and lost opportunities for further medical attention.
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 NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of full triage before streaming
Wider context from the report “That when Gianni was taken to the A&E Department at the Hospital and reported that he had suffered a head injury he was “streamed” to be seen in the GP Clinic rather than see a Doctor in the Emergency Department. The Consultant from the Department told me, during the course of his evidence, that it would be ‘good practice’ for all suspected head injuries to be referred to the A&E Team. I was also told that the Hospital have always requested a full triage before streaming and the Clinical Commissioning Group refused to allow for such a triage .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Central East Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to refer suspected head injuries to the A&E team
Wider context from the report “That when Gianni was taken to the A&E Department at the Hospital and reported that he had suffered a head injury he was “streamed” to be seen in the GP Clinic rather than see a Doctor in the Emergency Department . The Consultant from the Department told me, during the course of his evidence, that it would be ‘good practice’ for all suspected head injuries to be referred to the A&E Team . I was also told that the Hospital have always requested a full triage before streaming and the Clinical Commissioning Group refused to allow for such a triage.
” 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