Concerns raised 1 Lack of out-of-hours consultant radiologist cover for hospitals in Exeter, Plymouth and Torbay 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
John Thomas Cleave · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Thomas Cleave sustained a cervical spine fracture and probable haemothorax in an unwitnessed fall at his allotment on 28 December 2023. He died at Torbay Hospital on 29 December 2023 after vomiting, aspirating and suffering cardiac arrest. Concerns included the CT scan report failing to identify a high suspicion of haemothorax, the lack of out-of-hours consultant radiologist cover, and his care not being transferred promptly to a major trauma centre.
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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of out-of-hours consultant radiologist cover for hospitals in Exeter, Plymouth and Torbay
Wider context from the report “During the course of the inquest, evidence was given to me that a level of complexity due to the Deceased’s medical history, his injuries and an apparent artifact in the CT-Scan caused by metalwork in the Deceased’s spine from previous surgery required the expertise of a consultant radiologist. I was informed that there was (and is still) no out of hours consultant radiologist cover for hospitals in Exeter, Plymouth and Torbay .
I am concerned that there will be from time to time a need for scans and x-rays to be considered and interpreted at consultant radiologist level to facilitate urgent treatment and there is at present a gap in such cover which puts patients at risk .
” 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 Seek governance assurance that out-of-hours escalation pathways, learning from investigations, and access to senior radiological expertise remain appropriate for complex cases.
Verbatim wording from the response “The Integrated Care Boards will seek assurance through existing quality governance arrangements that:” Source location Response from DHSE NHS England
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 Ask provider organisations to review out-of-hours imaging escalation pathways and assurance processes for major trauma and complex radiological findings.
Verbatim wording from the response “The Integrated Care Boards therefore understand that consultant radiologist expertise is available on a 24-hour basis either on site or through established on-call systems. Notwithstanding this, we recognise the concern raised by the circumstances of this case regarding the timely availability and utilisation of senior radiological expertise in complex trauma cases. We will therefore ask provider organisations to review current escalation pathways and assurance processes relating to out-of-hours imaging interpretation, particularly in cases involving major trauma and complex radiological findings.” Source location Response from DHSE NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Integrated Care Boards did not identify an absence of consultant radiologist cover across Devon hospitals, while acknowledging complex-case escalation concerns.
Verbatim wording from the response “The information provided confirms that consultant radiologist cover is available 24 hours a day. In Torbay and South Devon NHS Foundation Trust consultant radiologists are working on site 0800-2200 and through formal on-call arrangements overnight. Whilst consultant radiologists are not routinely resident within radiology departments overnight, consultant radiologists remain available outside normal working hours and can be contacted for advice, review and support when clinically required.” Source location Response from DHSE NHS England
Open published response
Concerns raised 1 Insufficient capacity for timely admission and treatment of stroke patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Geoffrey Gudgeon · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Geoffrey Gudgeon suffered a spontaneous ischaemic stroke on 11 June 2024 and was admitted to West Cornwall Hospital the following morning. After difficulties securing appropriate stroke and rehabilitation beds, he was transferred between care settings before moving to Poldhu Nursing Home, where he died on 1 December 2024. The principal concern was a capacity issue in Cornwall affecting the timely admission and treatment of stroke patients.
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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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient capacity for timely admission and treatment of stroke patients
Wider context from the report “1) The inquest heard evidence from ████████ stroke consultant, that, at the time of these events, only 35% of patients were admitted to a stroke unit from an ED within 4.5 hours , while only 55% of patients were spending over 90% of their time on a stroke unit . Further, that there were approximately 80 admissions of stroke patients/month or about 900/year. The obvious concern was that there was a capacity issue in Cornwall concerning the timely admission and treatment of stroke patients .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update demand and capacity modelling for beds, workforce, therapy provision and patient flow.
Verbatim wording from the response “The ICB is leading a system-wide programme of review and improvement in relation to stroke capacity and pathway provision. This includes development of a unified integrated stroke pathway, strengthened cross-organisational governance, and updated demand and capacity modelling covering bed capacity, workforce, therapy provision, and patient flow.” Source location 2026-0095 - Response from Cornwall & Isles of Scilly Integrated Care Board
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 business case covering capacity, workforce, governance, service options, finances, risks and mitigations.
Verbatim wording from the response “This work reflects the system’s recognition that the issue is not limited to acute stroke bed capacity alone, but relates to wider pathway resilience, including rehabilitation provision, workforce capacity, and patient flow across organisational boundaries. A cross-organisational working group has been established, with a three-month timeframe agreed for development of a business case incorporating demand and capacity modelling, workforce requirements, governance arrangements, service options, financial implications, and key risks and mitigations.” Source location 2026-0095 - Response from Cornwall & Isles of Scilly Integrated Care Board
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 unified integrated stroke pathway across organisations.
Verbatim wording from the response “The ICB is leading a system-wide programme of review and improvement in relation to stroke capacity and pathway provision. This includes development of a unified integrated stroke pathway, strengthened cross-organisational governance, and updated demand and capacity modelling covering bed capacity, workforce, therapy provision, and patient flow.” Source location 2026-0095 - Response from Cornwall & Isles of Scilly Integrated Care Board
Open published response
Concerns raised 3 Failure to provide an interpreter during ante- and post-natal visits for a woman who did not speak English View source Failure to establish the contents of an infant’s bottle feed View source Lack of culturally informed professional curiosity in infant feeding 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.
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AI-generated summary
Izzah Fatima Ali · 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
Izzah Fatima Ali, a nine-month-old infant, died after developing profound iron-deficiency anaemia associated with consumption of cow’s milk. The report identified concerns about healthcare professionals failing to establish what was in her bottles, insufficient consideration of cultural practices, and the repeated absence of an interpreter during ante- and post-natal visits.
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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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an interpreter during ante- and post-natal visits for a woman who did not speak English
Wider context from the report “1) A theme that emerged during the evidence was the repeated reference to Izzah being ‘bottle-fed’ without further inquiry. In this country, bottle-fed infers ‘formula-fed’ but it is a presumption and in this case it was a wrongly assumed presumption. As one witness observed: ‘bottle-fed’ does not explain what was in the bottle. It could be a formula preparation, equally, it could be expressed breast milk. In this case, it was cow’s milk but until Izzah’s last admission into hospital no healthcare professional established that crucial fact.
That reflects a failure to recognise that ‘bottle-fed’ is an incomplete description and requires an additional question of what is in the bottle.
It also reflects a lack of appreciation around different cultural practices: while it may be assumed that cow’s milk would not be given to an infant under one in this country, it does not automatically follow that the same is true in other countries, for example, Pakistan. There was, in my judgment, an element of assumption made here which could alternatively be described as a lack of professional curiosity.
- A second concern that emerged was that during both ante- and post-natal visits to a woman who did not speak English, no interpreter was involved , contrary to guidance .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to establish the contents of an infant’s bottle feed
Wider context from the report “1) A theme that emerged during the evidence was the repeated reference to Izzah being ‘bottle-fed’ without further inquiry . In this country, bottle-fed infers ‘formula-fed’ but it is a presumption and in this case it was a wrongly assumed presumption. As one witness observed: ‘bottle-fed’ does not explain what was in the bottle . It could be a formula preparation, equally, it could be expressed breast milk. In this case, it was cow’s milk but until Izzah’s last admission into hospital no healthcare professional established that crucial fact .
That reflects a failure to recognise that ‘bottle-fed’ is an incomplete description and requires an additional question of what is in the bottle .
It also reflects a lack of appreciation around different cultural practices: while it may be assumed that cow’s milk would not be given to an infant under one in this country, it does not automatically follow that the same is true in other countries, for example, Pakistan. There was, in my judgment, an element of assumption made here which could alternatively be described as a lack of professional curiosity.
- A second concern that emerged was that during both ante- and post-natal visits to a woman who did not speak English, no interpreter was involved, contrary to guidance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of culturally informed professional curiosity in infant feeding assessment
Wider context from the report “1) A theme that emerged during the evidence was the repeated reference to Izzah being ‘bottle-fed’ without further inquiry. In this country, bottle-fed infers ‘formula-fed’ but it is a presumption and in this case it was a wrongly assumed presumption. As one witness observed: ‘bottle-fed’ does not explain what was in the bottle. It could be a formula preparation, equally, it could be expressed breast milk. In this case, it was cow’s milk but until Izzah’s last admission into hospital no healthcare professional established that crucial fact.
That reflects a failure to recognise that ‘bottle-fed’ is an incomplete description and requires an additional question of what is in the bottle.
It also reflects a lack of appreciation around different cultural practices : while it may be assumed that cow’s milk would not be given to an infant under one in this country, it does not automatically follow that the same is true in other countries , for example, Pakistan. There was, in my judgment, an element of assumption made here which could alternatively be described as a lack of professional curiosity .
- A second concern that emerged was that during both ante- and post-natal visits to a woman who did not speak English, no interpreter was involved, contrary to guidance.
” Open source report
Concerns raised 3 Failure to explore or test a capacitated patient's refusal to disclose information to a potentially protective relative View source Failure to record the rationale for mental health assessment decisions View source Failure to complete Nearest Relative details on the MH 1 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
Callum James Hargreaves · 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
Callum James Hargreaves, who had a history of substance misuse and housing instability, was found dead in the sea on 20 January 2024 after being removed from a cliff edge and assessed under the Mental Health Act the previous day. The principal concerns were that the rationale for not pursuing a short-term admission was not recorded, and that clinicians did not further explore or test Callum’s refusal to allow his mother to be informed of his discharge. The report also noted that the Nearest Relative’s details appeared not to have been completed on the MH 1.
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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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to explore or test a capacitated patient's refusal to disclose information to a potentially protective relative
Wider context from the report “I accepted independent expert evidence that the mental health act assessment had been thorough and appropriately concluded there were no grounds in law for detaining Callum. Additionally, I accepted evidence given by the clinicians that while NICE guidance did allow for short-term admissions to manage a period of crisis in a patient presenting with complex PTSD/EUPD, that was not indicated here. It was identified that the rationale for reaching that decision was not recorded in the notes. This is a matter I have taken up separately with those responsible for the AMHP.
1) It was accepted in evidence that, owing to the decisions made by Callum, there were only limited options available to the clinicians. Of note, an offer to have personal follow-up by one of the clinicians involved in the assessment through the HTT was rejected. Additionally, the possibility of prescribing additional Diazepam was correctly discounted once it became evident Callum was already sourcing illicitly more than could be prescribed safely.
2) Callum refused permission for his mother (described as his rock) to be informed of his imminent discharge. On her evidence, she had been (wrongly) advised by police that her son would be detained and was safe. There was no evidence that this decision by Callum was explored or tested by the clinicians – instead it simply appeared to have been accepted by the clinicians without further enquiry . The independent expert was of the view that in a situation like this, where the assessing team had very few ‘levers’ available to it, Callum’s mother was potentially one that could and should have been explored further .
It was noted that GMC guidance allows for further enquiry, specifically that 58. If an adult patient who has capacity to make the decision refuses to consent to information being disclosed that you consider necessary for their protection, you should explore their reasons for this. It may be appropriate to encourage the patient to consent to the disclosure and to warn them of the risks of refusing to consent.
It was noted that the Nearest Relative’s details appeared not to have been completed on the MH 1. Again, this is a matter that has been brought to the attention of those responsible for the AMHP.
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to record the rationale for mental health assessment decisions
Wider context from the report “I accepted independent expert evidence that the mental health act assessment had been thorough and appropriately concluded there were no grounds in law for detaining Callum. Additionally, I accepted evidence given by the clinicians that while NICE guidance did allow for short-term admissions to manage a period of crisis in a patient presenting with complex PTSD/EUPD, that was not indicated here. It was identified that the rationale for reaching that decision was not recorded in the notes . This is a matter I have taken up separately with those responsible for the AMHP.
1) It was accepted in evidence that, owing to the decisions made by Callum, there were only limited options available to the clinicians. Of note, an offer to have personal follow-up by one of the clinicians involved in the assessment through the HTT was rejected. Additionally, the possibility of prescribing additional Diazepam was correctly discounted once it became evident Callum was already sourcing illicitly more than could be prescribed safely.
2) Callum refused permission for his mother (described as his rock) to be informed of his imminent discharge. On her evidence, she had been (wrongly) advised by police that her son would be detained and was safe. There was no evidence that this decision by Callum was explored or tested by the clinicians – instead it simply appeared to have been accepted by the clinicians without further enquiry. The independent expert was of the view that in a situation like this, where the assessing team had very few ‘levers’ available to it, Callum’s mother was potentially one that could and should have been explored further.
It was noted that GMC guidance allows for further enquiry, specifically that 58. If an adult patient who has capacity to make the decision refuses to consent to information being disclosed that you consider necessary for their protection, you should explore their reasons for this. It may be appropriate to encourage the patient to consent to the disclosure and to warn them of the risks of refusing to consent.
It was noted that the Nearest Relative’s details appeared not to have been completed on the MH 1. Again, this is a matter that has been brought to the attention of those responsible for the AMHP.
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to complete Nearest Relative details on the MH 1
Wider context from the report “I accepted independent expert evidence that the mental health act assessment had been thorough and appropriately concluded there were no grounds in law for detaining Callum. Additionally, I accepted evidence given by the clinicians that while NICE guidance did allow for short-term admissions to manage a period of crisis in a patient presenting with complex PTSD/EUPD, that was not indicated here. It was identified that the rationale for reaching that decision was not recorded in the notes. This is a matter I have taken up separately with those responsible for the AMHP.
1) It was accepted in evidence that, owing to the decisions made by Callum, there were only limited options available to the clinicians. Of note, an offer to have personal follow-up by one of the clinicians involved in the assessment through the HTT was rejected. Additionally, the possibility of prescribing additional Diazepam was correctly discounted once it became evident Callum was already sourcing illicitly more than could be prescribed safely.
2) Callum refused permission for his mother (described as his rock) to be informed of his imminent discharge. On her evidence, she had been (wrongly) advised by police that her son would be detained and was safe. There was no evidence that this decision by Callum was explored or tested by the clinicians – instead it simply appeared to have been accepted by the clinicians without further enquiry. The independent expert was of the view that in a situation like this, where the assessing team had very few ‘levers’ available to it, Callum’s mother was potentially one that could and should have been explored further.
It was noted that GMC guidance allows for further enquiry, specifically that 58. If an adult patient who has capacity to make the decision refuses to consent to information being disclosed that you consider necessary for their protection, you should explore their reasons for this. It may be appropriate to encourage the patient to consent to the disclosure and to warn them of the risks of refusing to consent.
It was noted that the Nearest Relative’s details appeared not to have been completed on the MH 1 . Again, this is a matter that has been brought to the attention of those responsible for the AMHP.
” Open source report
Concerns raised 3 Unavailability of therapeutic crisis alternatives to secure hospital admission View source Shortage of staff View source Insufficient capacity for autism assessments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Brandon William Turner · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Brandon William Turner, who had diagnoses of PTSD and autism, died from suicide on 21 June 2023 at age 21; the recorded cause of death was asphyxia from fatal pressure on the neck. He had been referred to a community mental health therapy pathway, but treatment had not commenced before his death. Concerns included staffing shortages, the absence in Cornwall of a therapeutic alternative to hospital detention for people with complex PTSD/EUPD in crisis, and a lengthy autism assessment waiting list.
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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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of therapeutic crisis alternatives to secure hospital admission
Wider context from the report “(2) As noted above, the inquest was informed that where patients with complex PTSD/EUPD present in crisis, national and local practice is not to detain in a secure hospital. The inquest also heard that in other areas of the country there is a therapeutic alternative of admission to a day hospital (ie not detained, but somewhere to permit de-escalation) or to a crisis unit/house/café. That option is not currently available in Cornwall.
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Shortage of staff
Wider context from the report “(1) Shortage of staff. This has been a longstanding concern in Cornwall. I am aware there have been initiatives undertaken nationally and internationally and yet the problem remains. It seems this is not an issue that can be resolved by the local ICB and so this concern is directed to the Secretary of State for her attention and formal response.
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient capacity for autism assessments
Wider context from the report “(3) The inquest heard that CPFT is commissioned to assess 140 patients annually for autism. The current waiting list for assessment is in the region of two years. In other words, the demand for the service greatly exceeds the current supply.
” 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 Develop the Crisis Resolution Home Treatment Team by expanding 24/7 service delivery.
Verbatim wording from the response “ICB commissioning intentions include an upscaling of the current project above to include sanctuary support for autistic people and day reablement support on site. The commissioning intentions also include a commitment to developing our Crisis Resolution Home Treatment Team (HTT) further by expanding the 24/7 delivery of the service.” Source location Response from Cornwall NHS (Update - December 2024)
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 Make a community reablement service available, including admission avoidance and crisis sanctuary options.
Verbatim wording from the response “This issue has been recognised by our health and care system and a 24/7 crisis care pathway is in development in a phased and scaled manner. Initially, we have opened a reablement bedded unit with a block purchase of 4 beds. In addition to this, a community reablement service has been made available where an inpatient bed is not appropriate or warranted. The service includes the option for admission avoidance and crisis sanctuary, to drive improvement and prevent mental ill health crises in a resilient, recovery and trauma informed way.” Source location Response from Cornwall NHS (Update - December 2024)
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 Continue developing the service and confirm a sustainable funding source for the scheme.
Verbatim wording from the response “It is important that the delivery of this care is well planned if we are to ensure it meets the requirements we have set out. Work continues to develop this, at pace, and confirm a sustainable funding source for the scheme, but mental health investment remains a core priority for the NHS, so we would expect this to be prioritised from future investments made in line with the national Mental Health Investment Standard requirements. Whilst we may not be able to give you full assurance of the action and timescales immediately, we would like to keep you informed as the work progresses.” Source location Response from Cornwall NHS (Update - December 2024)
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 Open a reablement bedded unit with four purchased beds.
Verbatim wording from the response “This issue has been recognised by our health and care system and a 24/7 crisis care pathway is in development in a phased and scaled manner. Initially, we have opened a reablement bedded unit with a block purchase of 4 beds. In addition to this, a community reablement service has been made available where an inpatient bed is not appropriate or warranted. The service includes the option for admission avoidance and crisis sanctuary, to drive improvement and prevent mental ill health crises in a resilient, recovery and trauma informed way.” Source location Response from Cornwall NHS (Update - December 2024)
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 Upscale the current project to include sanctuary support for autistic people and on-site day reablement support.
Verbatim wording from the response “ICB commissioning intentions include an upscaling of the current project above to include sanctuary support for autistic people and day reablement support on site. The commissioning intentions also include a commitment to developing our Crisis Resolution Home Treatment Team (HTT) further by expanding the 24/7 delivery of the service.” Source location Response from Cornwall NHS (Update - December 2024)
Open published response
Concerns raised 11 Absence of a planned route back to mental health assessment View source Failure to distinguish GP requests for advice from referrals View source Lack of professional curiosity about drug-taking and its clinical contribution View source Lack of continuity in primary care after patient relocation View source Delays in responding to GP requests for mental health advice due to staffing shortages View source Discharging referrals without clinical triage of non-response View source Failure to adapt patient contact methods to known communication needs View source Failure to share relevant presentation information with family View source Delays in recording family-provided clinical timelines View source Failure to advise Nearest Relatives of statutory rights to request MHA assessment View source Inaccurate or incomplete discharge summaries failing to record diagnostic uncertainty View source See 8 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
Sally Poynton · 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
Sally Poynton, aged 44, was fatally stabbed by her son on 22 June 2021. The report raised concerns about failures in mental-health assessment and follow-up, including inadequate discharge information, difficulties obtaining reassessment, referral handling, communication with family, and discharge without clinical consideration despite signs of deteriorating mental health.
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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Absence of a planned route back to mental health assessment
Wider context from the report “a) In-patient care at Longreach Hospital
Approximately one year before Sally’s homicide, ████████ had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. ████████ was selectively mute, fasting and drinking only distilled water.
He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care.
At inquest, ████████████ accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, ████████████, referred to a ‘quandary’ in identifying how much of ████████ presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described ████████ as a ‘model patient.’
One of the most striking features of the evidence was the difficulty Sally then encountered in having ████████ re-assessed. Indeed, in the year that followed, despite multiple attempts, ████████ was not seen again by a doctor from the mental health team. It is noteworthy that ████████ did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care.
I felt there were a number of points of learning:
i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest;
ii) A failure to discuss with Sally or the maternal side of ████████ family how he presented, notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult.
It may be of note that there was a difficult family dynamic with an acrimonious separation of ████████ parents. ████████ father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s.
iii) The absence of a plan detailing the route back for ████████ to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices;
iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request ████████ assessment under the MHA. This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard.
v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while ████████ was an in-patient. ████████ accepted that had he seen it at the time, he would have had further questions for Jacob.
vi) A lack of understanding or professional curiosity about ████████ drug-taking and the extent to which, if at all, this contributed to ████████ presentation. It was accepted by ████████ that he had been misled by ████████ who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics.
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to distinguish GP requests for advice from referrals
Wider context from the report “2) Community Mental Health Team
i) There was a delay of one month in responding to a letter requesting advice from a GP. This was said to be due to staff shortages. At inquest it was noted that, 3.5 years later, staff shortages remain.
I am aware the ICB has made concerted efforts to recruit. This is a concern that appears to require attention from central government and so this point needs addressing by the Secretary of State. I note this is not the first occasion I have written to the Minister to make her aware of the persisting difficulties in recruiting mental health staff in Cornwall and the Isles of Scilly.
ii) A letter requesting advice was treated as a referral (twice.) It was accepted in evidence that there appeared to be confusion on the part of CMHT staff about how to treat a letter from a GP notwithstanding it set out clearly it was a request for advice.
iii) Once the letter from the GP was taken as a request for a referral, attempting to contact the patient by telephone. It was known Jacob was selectively mute and so it should have been readily apparent he was not going to respond. Policy appears to have been followed without consideration of the clinical circumstances.
iv) Discharging a patient’s referral without any clinical judgment. ████████ referral was discharged after he did not answer his phone twice (as he wouldn’t, being mute) or respond to an opt-in letter (that was sent to the wrong address.) The evidence was clear that ████████ lacked insight into his condition and steadfastly refused all offers of support. He was not going to ‘opt-in’ voluntarily. What appeared from the evidence to be a blanket policy of discharging patients who fail to respond (because they are unwell and lack insight) will result in those patients most in need of care being wrongly discharged. In my view, there needs to be some form of triage or clinical attention given to why a patient has not responded and whether it is appropriate to discharge.
I recognise that this consideration, in addition to informing Nearest Relatives of their right to request a MHA, will result in additional burdens for what is an already over-stretched workforce. This may be a matter for the Minister to reflect upon in considering the staffing issue highlighted above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of professional curiosity about drug-taking and its clinical contribution
Wider context from the report “a) In-patient care at Longreach Hospital
Approximately one year before Sally’s homicide, ████████ had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. ████████ was selectively mute, fasting and drinking only distilled water.
He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care.
At inquest, ████████████ accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, ████████████, referred to a ‘quandary’ in identifying how much of ████████ presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described ████████ as a ‘model patient.’
One of the most striking features of the evidence was the difficulty Sally then encountered in having ████████ re-assessed. Indeed, in the year that followed, despite multiple attempts, ████████ was not seen again by a doctor from the mental health team. It is noteworthy that ████████ did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care.
I felt there were a number of points of learning:
i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest;
ii) A failure to discuss with Sally or the maternal side of ████████ family how he presented, notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult.
It may be of note that there was a difficult family dynamic with an acrimonious separation of ████████ parents. ████████ father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s.
iii) The absence of a plan detailing the route back for ████████ to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices;
iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request ████████ assessment under the MHA. This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard.
v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while ████████ was an in-patient. ████████ accepted that had he seen it at the time, he would have had further questions for Jacob.
vi) A lack of understanding or professional curiosity about ████████ drug-taking and the extent to which, if at all, this contributed to ████████ presentation. It was accepted by ████████ that he had been misled by ████████ who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics.
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of continuity in primary care after patient relocation
Wider context from the report “Primary Care
There was an accepted lack in continuity in ████████ primary care after he moved from Sally’s address (and a GP in Marazion) to his father’s house in Ponsanooth (and a GP in Penryn.)
The inquest was told that there are now regular Multi Agency Safeguarding Hubs (MASH) where patients who may be known to both the mental health service and adult safeguarding are discussed.
It struck me that there may be value in someone from the ICB attending MASH meetings on behalf of GPs in Cornwall. That individual could then feed back information to the surgery where a patient was registered. In this instance, that would have provided ████████ with the ‘backstory’ she did not have, now being in receipt of ████████ records or the discharge summary from Longreach when she saw him and given the difficulties associated with taking a history from Jacob when he was mute.
I wonder if you feel an initiative in this regard would be sensible?
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in responding to GP requests for mental health advice due to staffing shortages
Wider context from the report “2) Community Mental Health Team
i) There was a delay of one month in responding to a letter requesting advice from a GP . This was said to be due to staff shortages. At inquest it was noted that, 3.5 years later, staff shortages remain .
I am aware the ICB has made concerted efforts to recruit. This is a concern that appears to require attention from central government and so this point needs addressing by the Secretary of State. I note this is not the first occasion I have written to the Minister to make her aware of the persisting difficulties in recruiting mental health staff in Cornwall and the Isles of Scilly.
ii) A letter requesting advice was treated as a referral (twice.) It was accepted in evidence that there appeared to be confusion on the part of CMHT staff about how to treat a letter from a GP notwithstanding it set out clearly it was a request for advice.
iii) Once the letter from the GP was taken as a request for a referral, attempting to contact the patient by telephone. It was known Jacob was selectively mute and so it should have been readily apparent he was not going to respond. Policy appears to have been followed without consideration of the clinical circumstances.
iv) Discharging a patient’s referral without any clinical judgment. ████████ referral was discharged after he did not answer his phone twice (as he wouldn’t, being mute) or respond to an opt-in letter (that was sent to the wrong address.) The evidence was clear that ████████ lacked insight into his condition and steadfastly refused all offers of support. He was not going to ‘opt-in’ voluntarily. What appeared from the evidence to be a blanket policy of discharging patients who fail to respond (because they are unwell and lack insight) will result in those patients most in need of care being wrongly discharged. In my view, there needs to be some form of triage or clinical attention given to why a patient has not responded and whether it is appropriate to discharge.
I recognise that this consideration, in addition to informing Nearest Relatives of their right to request a MHA, will result in additional burdens for what is an already over-stretched workforce. This may be a matter for the Minister to reflect upon in considering the staffing issue highlighted above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Discharging referrals without clinical triage of non-response
Wider context from the report “2) Community Mental Health Team
i) There was a delay of one month in responding to a letter requesting advice from a GP. This was said to be due to staff shortages. At inquest it was noted that, 3.5 years later, staff shortages remain.
I am aware the ICB has made concerted efforts to recruit. This is a concern that appears to require attention from central government and so this point needs addressing by the Secretary of State. I note this is not the first occasion I have written to the Minister to make her aware of the persisting difficulties in recruiting mental health staff in Cornwall and the Isles of Scilly.
ii) A letter requesting advice was treated as a referral (twice.) It was accepted in evidence that there appeared to be confusion on the part of CMHT staff about how to treat a letter from a GP notwithstanding it set out clearly it was a request for advice.
iii) Once the letter from the GP was taken as a request for a referral, attempting to contact the patient by telephone. It was known Jacob was selectively mute and so it should have been readily apparent he was not going to respond. Policy appears to have been followed without consideration of the clinical circumstances.
iv) Discharging a patient’s referral without any clinical judgment . ████████ referral was discharged after he did not answer his phone twice (as he wouldn’t, being mute) or respond to an opt-in letter (that was sent to the wrong address.) The evidence was clear that ████████ lacked insight into his condition and steadfastly refused all offers of support. He was not going to ‘opt-in’ voluntarily. What appeared from the evidence to be a blanket policy of discharging patients who fail to respond (because they are unwell and lack insight) will result in those patients most in need of care being wrongly discharged. In my view, there needs to be some form of triage or clinical attention given to why a patient has not responded and whether it is appropriate to discharge .
I recognise that this consideration, in addition to informing Nearest Relatives of their right to request a MHA, will result in additional burdens for what is an already over-stretched workforce. This may be a matter for the Minister to reflect upon in considering the staffing issue highlighted above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to adapt patient contact methods to known communication needs
Wider context from the report “2) Community Mental Health Team
i) There was a delay of one month in responding to a letter requesting advice from a GP. This was said to be due to staff shortages. At inquest it was noted that, 3.5 years later, staff shortages remain.
I am aware the ICB has made concerted efforts to recruit. This is a concern that appears to require attention from central government and so this point needs addressing by the Secretary of State. I note this is not the first occasion I have written to the Minister to make her aware of the persisting difficulties in recruiting mental health staff in Cornwall and the Isles of Scilly.
ii) A letter requesting advice was treated as a referral (twice.) It was accepted in evidence that there appeared to be confusion on the part of CMHT staff about how to treat a letter from a GP notwithstanding it set out clearly it was a request for advice.
iii) Once the letter from the GP was taken as a request for a referral, attempting to contact the patient by telephone . It was known Jacob was selectively mute and so it should have been readily apparent he was not going to respond . Policy appears to have been followed without consideration of the clinical circumstances .
iv) Discharging a patient’s referral without any clinical judgment. ████████ referral was discharged after he did not answer his phone twice (as he wouldn’t, being mute) or respond to an opt-in letter (that was sent to the wrong address.) The evidence was clear that ████████ lacked insight into his condition and steadfastly refused all offers of support. He was not going to ‘opt-in’ voluntarily. What appeared from the evidence to be a blanket policy of discharging patients who fail to respond (because they are unwell and lack insight) will result in those patients most in need of care being wrongly discharged. In my view, there needs to be some form of triage or clinical attention given to why a patient has not responded and whether it is appropriate to discharge.
I recognise that this consideration, in addition to informing Nearest Relatives of their right to request a MHA, will result in additional burdens for what is an already over-stretched workforce. This may be a matter for the Minister to reflect upon in considering the staffing issue highlighted above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant presentation information with family
Wider context from the report “a) In-patient care at Longreach Hospital
Approximately one year before Sally’s homicide, ████████ had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. ████████ was selectively mute, fasting and drinking only distilled water.
He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care.
At inquest, ████████████ accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, ████████████, referred to a ‘quandary’ in identifying how much of ████████ presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described ████████ as a ‘model patient.’
One of the most striking features of the evidence was the difficulty Sally then encountered in having ████████ re-assessed. Indeed, in the year that followed, despite multiple attempts, ████████ was not seen again by a doctor from the mental health team. It is noteworthy that ████████ did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care.
I felt there were a number of points of learning:
i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest;
ii) A failure to discuss with Sally or the maternal side of ████████ family how he presented , notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult.
It may be of note that there was a difficult family dynamic with an acrimonious separation of ████████ parents. ████████ father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s.
iii) The absence of a plan detailing the route back for ████████ to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices;
iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request ████████ assessment under the MHA. This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard.
v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while ████████ was an in-patient. ████████ accepted that had he seen it at the time, he would have had further questions for Jacob.
vi) A lack of understanding or professional curiosity about ████████ drug-taking and the extent to which, if at all, this contributed to ████████ presentation. It was accepted by ████████ that he had been misled by ████████ who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics.
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in recording family-provided clinical timelines
Wider context from the report “a) In-patient care at Longreach Hospital
Approximately one year before Sally’s homicide, ████████ had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. ████████ was selectively mute, fasting and drinking only distilled water.
He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care.
At inquest, ████████████ accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, ████████████, referred to a ‘quandary’ in identifying how much of ████████ presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described ████████ as a ‘model patient.’
One of the most striking features of the evidence was the difficulty Sally then encountered in having ████████ re-assessed. Indeed, in the year that followed, despite multiple attempts, ████████ was not seen again by a doctor from the mental health team. It is noteworthy that ████████ did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care.
I felt there were a number of points of learning:
i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest;
ii) A failure to discuss with Sally or the maternal side of ████████ family how he presented, notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult.
It may be of note that there was a difficult family dynamic with an acrimonious separation of ████████ parents. ████████ father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s.
iii) The absence of a plan detailing the route back for ████████ to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices;
iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request ████████ assessment under the MHA. This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard.
v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while ████████ was an in-patient. ████████ accepted that had he seen it at the time, he would have had further questions for Jacob.
vi) A lack of understanding or professional curiosity about ████████ drug-taking and the extent to which, if at all, this contributed to ████████ presentation. It was accepted by ████████ that he had been misled by ████████ who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics.
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to advise Nearest Relatives of statutory rights to request MHA assessment
Wider context from the report “a) In-patient care at Longreach Hospital
Approximately one year before Sally’s homicide, ████████ had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. ████████ was selectively mute, fasting and drinking only distilled water.
He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care.
At inquest, ████████████ accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, ████████████, referred to a ‘quandary’ in identifying how much of ████████ presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described ████████ as a ‘model patient.’
One of the most striking features of the evidence was the difficulty Sally then encountered in having ████████ re-assessed. Indeed, in the year that followed, despite multiple attempts, ████████ was not seen again by a doctor from the mental health team. It is noteworthy that ████████ did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care.
I felt there were a number of points of learning:
i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest;
ii) A failure to discuss with Sally or the maternal side of ████████ family how he presented, notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult.
It may be of note that there was a difficult family dynamic with an acrimonious separation of ████████ parents. ████████ father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s.
iii) The absence of a plan detailing the route back for ████████ to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices;
iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request ████████ assessment under the MHA . This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard.
v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while ████████ was an in-patient. ████████ accepted that had he seen it at the time, he would have had further questions for Jacob.
vi) A lack of understanding or professional curiosity about ████████ drug-taking and the extent to which, if at all, this contributed to ████████ presentation. It was accepted by ████████ that he had been misled by ████████ who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics.
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inaccurate or incomplete discharge summaries failing to record diagnostic uncertainty
Wider context from the report “a) In-patient care at Longreach Hospital
Approximately one year before Sally’s homicide, ████████ had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. ████████ was selectively mute, fasting and drinking only distilled water.
He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care.
At inquest, ████████████ accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, ████████████, referred to a ‘quandary’ in identifying how much of ████████ presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described ████████ as a ‘model patient.’
One of the most striking features of the evidence was the difficulty Sally then encountered in having ████████ re-assessed. Indeed, in the year that followed, despite multiple attempts, ████████ was not seen again by a doctor from the mental health team. It is noteworthy that ████████ did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care.
I felt there were a number of points of learning:
i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest;
ii) A failure to discuss with Sally or the maternal side of ████████ family how he presented, notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult.
It may be of note that there was a difficult family dynamic with an acrimonious separation of ████████ parents. ████████ father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s.
iii) The absence of a plan detailing the route back for ████████ to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices;
iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request ████████ assessment under the MHA. This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard.
v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while ████████ was an in-patient. ████████ accepted that had he seen it at the time, he would have had further questions for Jacob.
vi) A lack of understanding or professional curiosity about ████████ drug-taking and the extent to which, if at all, this contributed to ████████ presentation. It was accepted by ████████ that he had been misled by ████████ who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics.
” Open source report
Concerns raised 4 Inadequate cross-organisational access to clinical records and information View source Failure to use an assertive approach to engage clients referred to mental health services View source Failure to provide an adequate service to people presenting with a dual diagnosis View source Failure to consider suitable alternative agency support for patients outside severe and enduring mental illness criteria View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Emma Burbury · 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
Emma Burbury collapsed after an altercation with her partner and died in hospital on 19 September 2018; the forensic pathologist considered it possible that injuries from the altercation caused or contributed to her death, but the evidence was insufficient to establish this as probable or certain. The report identified a missed opportunity to provide treatment after her July 2017 assessment and concerns about services for people with dual diagnoses, including care coordination, communication between organisations, engagement, and discharge arrangements.
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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate cross-organisational access to clinical records and information
Wider context from the report “a] I heard that CMHT staff have read-only access to WAWY notes and records, but this fact is not widely known amongst Trust staff . It was recognised that a reciprocal arrangement allowing WAWY clinicians to have read-only access to the Trust’s RiO records would be of benefit . I understand a formal request in this regard has been made and is receiving due consideration. One of the most common concerns I hear at inquest is the difficulty with communication between separate organisations and this may also be an initiative you feel able to support in delivering a more integrated service.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to use an assertive approach to engage clients referred to mental health services
Wider context from the report “b] There was concern raised on the part of We Are With You that clients referred to the Trust were too easily discharged , for example, where they failed to attend for two appointments . It was felt a more assertive approach towards engagement would be beneficial . You may feel it would be desirable to try and minimise the amount of wasted and limited CMHT/WAWY resource through non-attendance at appointments or otherwise. You may consider reflection on how this can best be achieved through a more joined up approach would be sensible.
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an adequate service to people presenting with a dual diagnosis
Wider context from the report “It was accepted in evidence that it was “very regrettable” Emma was not taken on to caseload after her assessment in July 2017. There was clearly a missed opportunity to work with her while she was open to treatment. It was accepted that there was no guarantee this would have avoided the eventual outcome, but it was recognised a better service needed to be provided to those presenting with a dual diagnosis, like Emma .
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to consider suitable alternative agency support for patients outside severe and enduring mental illness criteria
Wider context from the report “c] It was felt patients referred to the Trust who did not fall within the strict parameters of a severe and enduring mental illness were discharged without sufficient thought being given by the Trust’s clinicians to whether another agency such as Valued Lives may be able to offer assistance . You may feel it would be a worthwhile exercise to consider how to join up the wider services available within the Trust, the voluntary sector or elsewhere.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update and jointly implement the dual-diagnosis strategy with multiagency partners to improve integrated mental-health support.
Verbatim wording from the response “As previously reported to your office, the Dual Diagnosis (DD) strategy for Cornwall and the Isles of Scilly was re-launched in 2018/19 after a period of review. This work was led by NHS Kernow CCG and Cornwall Council and culminated in a co-produced and jointly owned document supported by a range of multiagency partners and stakeholders including people with lived experience, carers and professionals from across statutory as well as the voluntary and third sectors. In 2021 the strategy was updated to incorporate emergent best practice guidance and executive level signatures from representative organisational leads, including CPFT and WAWY, demonstrate a clear commitment to continue to deliver the journey of change and improvement.” Source location 2021-0382-Response-from-Kernow-CCG_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a revised data protection impact assessment to govern reciprocal information access and strengthen information-sharing arrangements.
Verbatim wording from the response “In respect of your first concern, it is acknowledged that messaging and training is of vital importance in ensuring continuity and equity of approach. We can report that a task and finish group, which includes WAWY and all NHS and Local Authority Commissioned mental health providers, are developing a revised Data Protection Impact Assessment (DPIA), to provide additional governance and ensure continuity of approach and adherence to system operational and strategic intention. The DPIA makes clear the justification and rationale for access to, and/or the process of, personal information to enhance existing information sharing agreements between organisations. It will help to address the request for reciprocal access to data and specifically RIO clinical records systems operated by CFT.” Source location 2021-0382-Response-from-Kernow-CCG_Published
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 Jointly fund a dedicated role providing oversight and scrutiny of dual-diagnosis strategy implementation and delivery.
Verbatim wording from the response “In 2021 a dedicated role was jointly funded by both the NHS and local authority, to specifically provide additional oversight and scrutiny of the implementation and delivery of the dual diagnosis strategy. This work is ongoing and regular reporting serves robust governance” Source location 2021-0382-Response-from-Kernow-CCG_Published
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 We Are With You to establish regular meetings and embed reciprocal data access into business-as-usual processes.
Verbatim wording from the response “CFT will work with WAWY to include them in relevant regular meetings and to embed this access to data as business as usual.” Source location 2021-0382-Response-from-Kernow-CCG_Published
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 Maintain ongoing governance of the dual-diagnosis strategy through formal oversight, risk management and reporting.
Verbatim wording from the response “In 2021 a dedicated role was jointly funded by both the NHS and local authority, to specifically provide additional oversight and scrutiny of the implementation and delivery of the dual diagnosis strategy. This work is ongoing and regular reporting serves robust governance” Source location 2021-0382-Response-from-Kernow-CCG_Published
Open published response
Concerns raised 4 Failure of Addaction to communicate and provide feedback to GPs View source Failure to consider consent for disclosure to GPs at Recovery Plan reviews View source Lack of consideration of underlying mental health issues in patients with alcohol or drug problems View source Failure of mental health services to accept responsibility for providing professional care View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Benjamin Colin Williamson · 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
Benjamin Colin Williamson had a long history of alcohol-related issues and was receiving treatment, with regular GP contact. He died on 4 April 2018, and the inquest recorded a conclusion of suicide, with asphyxia by hanging and alcohol intoxication. Concerns included fragmented mental health services for people with both mental health and alcohol problems, and inadequate liaison and feedback between Addaction and the GP.
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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of Addaction to communicate and provide feedback to GPs
Wider context from the report “CMHT Commissioners
At inquest, I heard from ████████, a partner at Mullion and Constantine Group Practice and the Locality Lead for Commissioning. Mr Williamson was his patient. ███ told me that Mr Williamson had been referred twice to CMHT. On both occasions, ████████ described this as having a significant impact upon his patient who was left feeling he was not ill enough to be worthy of support. ████████ expressed his view that the system is not set up to serve the population. He said it was his experience that patients like Benjamin are bounced between the various mental health services seemingly with ████████ one willing or able to accept responsibility for providing professional care, and he felt it had failed to meet the needs of his patient.
████████ identified that the problem was particularly acute for patients who have a mental health issue plus an alcohol (or drug) problem. He felt that while referring Benjamin to Addaction had addressed his alcohol-related concerns, there had been a total lack of consideration of any underlying mental health issue. This is not the first occasion on which observations of this nature have been made before me although in ████████ I have rarely had a more articulate or well-placed witness.
Addaction
████████ told me that after referring Benjamin to Addaction he had no communications or feedback from the service . I heard from ████████ in this regard. It was accepted that there should have been more liaison with the GP and that, in particular, a letter from the doctor in January 2018 was not answered and should have been.
Upon further exploration, it emerged that Benjamin had not given full consent for disclosure to his GP. I was told that his Recovery Plan had been reviewed on 25/5/17, 16/8/17, 27/10/17 and 12/2/18. I was advised that the issue of consent should have been considered at these reviews but that did not appear to have happened. Both Benjamin’s mother and ████████ were of the view that if this matter had been dealt with fully, consent for disclosure to the GP would have been provided. ████████ felt that the lack of feedback compromised his ability to provide care to his patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to consider consent for disclosure to GPs at Recovery Plan reviews
Wider context from the report “CMHT Commissioners
At inquest, I heard from ████████, a partner at Mullion and Constantine Group Practice and the Locality Lead for Commissioning. Mr Williamson was his patient. ███ told me that Mr Williamson had been referred twice to CMHT. On both occasions, ████████ described this as having a significant impact upon his patient who was left feeling he was not ill enough to be worthy of support. ████████ expressed his view that the system is not set up to serve the population. He said it was his experience that patients like Benjamin are bounced between the various mental health services seemingly with ████████ one willing or able to accept responsibility for providing professional care, and he felt it had failed to meet the needs of his patient.
████████ identified that the problem was particularly acute for patients who have a mental health issue plus an alcohol (or drug) problem. He felt that while referring Benjamin to Addaction had addressed his alcohol-related concerns, there had been a total lack of consideration of any underlying mental health issue. This is not the first occasion on which observations of this nature have been made before me although in ████████ I have rarely had a more articulate or well-placed witness.
Addaction
████████ told me that after referring Benjamin to Addaction he had no communications or feedback from the service. I heard from ████████ in this regard. It was accepted that there should have been more liaison with the GP and that, in particular, a letter from the doctor in January 2018 was not answered and should have been.
Upon further exploration, it emerged that Benjamin had not given full consent for disclosure to his GP. I was told that his Recovery Plan had been reviewed on 25/5/17, 16/8/17, 27/10/17 and 12/2/18. I was advised that the issue of consent should have been considered at these reviews but that did not appear to have happened . Both Benjamin’s mother and ████████ were of the view that if this matter had been dealt with fully, consent for disclosure to the GP would have been provided. ████████ felt that the lack of feedback compromised his ability to provide care to his patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of consideration of underlying mental health issues in patients with alcohol or drug problems
Wider context from the report “CMHT Commissioners
At inquest, I heard from ████████, a partner at Mullion and Constantine Group Practice and the Locality Lead for Commissioning. Mr Williamson was his patient. ███ told me that Mr Williamson had been referred twice to CMHT. On both occasions, ████████ described this as having a significant impact upon his patient who was left feeling he was not ill enough to be worthy of support. ████████ expressed his view that the system is not set up to serve the population. He said it was his experience that patients like Benjamin are bounced between the various mental health services seemingly with ████████ one willing or able to accept responsibility for providing professional care, and he felt it had failed to meet the needs of his patient.
████████ identified that the problem was particularly acute for patients who have a mental health issue plus an alcohol (or drug) problem. He felt that while referring Benjamin to Addaction had addressed his alcohol-related concerns, there had been a total lack of consideration of any underlying mental health issue . This is not the first occasion on which observations of this nature have been made before me although in ████████ I have rarely had a more articulate or well-placed witness.
Addaction
████████ told me that after referring Benjamin to Addaction he had no communications or feedback from the service. I heard from ████████ in this regard. It was accepted that there should have been more liaison with the GP and that, in particular, a letter from the doctor in January 2018 was not answered and should have been.
Upon further exploration, it emerged that Benjamin had not given full consent for disclosure to his GP. I was told that his Recovery Plan had been reviewed on 25/5/17, 16/8/17, 27/10/17 and 12/2/18. I was advised that the issue of consent should have been considered at these reviews but that did not appear to have happened. Both Benjamin’s mother and ████████ were of the view that if this matter had been dealt with fully, consent for disclosure to the GP would have been provided. ████████ felt that the lack of feedback compromised his ability to provide care to his patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of mental health services to accept responsibility for providing professional care
Wider context from the report “CMHT Commissioners
At inquest, I heard from ████████, a partner at Mullion and Constantine Group Practice and the Locality Lead for Commissioning. Mr Williamson was his patient. ███ told me that Mr Williamson had been referred twice to CMHT. On both occasions, ████████ described this as having a significant impact upon his patient who was left feeling he was not ill enough to be worthy of support. ████████ expressed his view that the system is not set up to serve the population. He said it was his experience that patients like Benjamin are bounced between the various mental health services seemingly with ████████ one willing or able to accept responsibility for providing professional care , and he felt it had failed to meet the needs of his patient.
████████ identified that the problem was particularly acute for patients who have a mental health issue plus an alcohol (or drug) problem. He felt that while referring Benjamin to Addaction had addressed his alcohol-related concerns, there had been a total lack of consideration of any underlying mental health issue. This is not the first occasion on which observations of this nature have been made before me although in ████████ I have rarely had a more articulate or well-placed witness.
Addaction
████████ told me that after referring Benjamin to Addaction he had no communications or feedback from the service. I heard from ████████ in this regard. It was accepted that there should have been more liaison with the GP and that, in particular, a letter from the doctor in January 2018 was not answered and should have been.
Upon further exploration, it emerged that Benjamin had not given full consent for disclosure to his GP. I was told that his Recovery Plan had been reviewed on 25/5/17, 16/8/17, 27/10/17 and 12/2/18. I was advised that the issue of consent should have been considered at these reviews but that did not appear to have happened. Both Benjamin’s mother and ████████ were of the view that if this matter had been dealt with fully, consent for disclosure to the GP would have been provided. ████████ felt that the lack of feedback compromised his ability to provide care to his patient.
” 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 a robust multi-agency implementation plan for the Dual Diagnosis Strategy.
Verbatim wording from the response “An exceptional Crisis Care Concordat meeting was held on the 22 January 2019. The meeting was well-attended by the relevant statutory organisations and providers. The purpose of this meeting was for providers to agree a way forward and specific actions have been identified to review the Dual Diagnosis Strategy and implement a robust multi-agency implementation plan. A draft implementation strategy completed by NHS Kernow provided the focus of the meeting. The providers of services will chair a monthly Implementation Steering Group in order to develop the draft implementation plan. The chair will rotate quarterly between the various providers ensuring a sharing of responsibilities and commitment to improving integrated working.” Source location 2018-0384-Response-by-Kernow-CCG-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review contract requirements for providers supporting people with dual diagnosis under the new contract commencing April 2019.
Verbatim wording from the response “NHS Kernow is reviewing the contract requirements for new contract commencing April 2019, in relation to providers supporting individuals with a dual diagnosis. Whilst current contracts and the multi-agency strategy already specify how providers should meet the needs of people” Source location 2018-0384-Response-by-Kernow-CCG-NHS-Trust
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 Operate a monthly Multiagency Implementation Steering Group with rotating provider leadership to develop the implementation plan.
Verbatim wording from the response “An exceptional Crisis Care Concordat meeting was held on the 22 January 2019. The meeting was well-attended by the relevant statutory organisations and providers. The purpose of this meeting was for providers to agree a way forward and specific actions have been identified to review the Dual Diagnosis Strategy and implement a robust multi-agency implementation plan. A draft implementation strategy completed by NHS Kernow provided the focus of the meeting. The providers of services will chair a monthly Implementation Steering Group in order to develop the draft implementation plan. The chair will rotate quarterly between the various providers ensuring a sharing of responsibilities and commitment to improving integrated working.” Source location 2018-0384-Response-by-Kernow-CCG-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a dynamic risk register to identify and collaboratively review people at risk with dual diagnosis.
Verbatim wording from the response “It is expected that the review of the strategy and comprehensive development of the implementation plan will be completed in six months. Whilst this is being undertaken priority will be given to actions that can be undertaken immediately and will support individuals with a dual diagnosis. For example, the development of a dynamic risk register so that people at risk can be identified and reviewed collaboratively. A similar register has been implemented for another group of people who have specific needs and has provided positive outcomes.” Source location 2018-0384-Response-by-Kernow-CCG-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Cornwall and Isles of Scilly Dual Diagnosis Strategy for Adults.
Verbatim wording from the response “An exceptional Crisis Care Concordat meeting was held on the 22 January 2019. The meeting was well-attended by the relevant statutory organisations and providers. The purpose of this meeting was for providers to agree a way forward and specific actions have been identified to review the Dual Diagnosis Strategy and implement a robust multi-agency implementation plan. A draft implementation strategy completed by NHS Kernow provided the focus of the meeting. The providers of services will chair a monthly Implementation Steering Group in order to develop the draft implementation plan. The chair will rotate quarterly between the various providers ensuring a sharing of responsibilities and commitment to improving integrated working.” Source location 2018-0384-Response-by-Kernow-CCG-NHS-Trust
Open published response
Concerns raised 3 Lack of commissioned adult ADHD assessment, diagnosis and treatment by CPT View source Lack of access to a suitably skilled specialist psychiatrist for ADHD diagnosis and treatment View source Failure to provide a practicable out-of-county ADHD treatment pathway with ongoing medication oversight and review View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Morley Sargeant · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Morley Sargeant died on 16 June 2017 from the toxic effects of an intentional overdose of prescribed and controlled drugs, with suspension by a ligature around his neck also recorded. He had a history of chaotic illicit substance misuse and had been referred for assessment of possible ADHD, but specialist services in Cornwall or out of county were unable to diagnose and treat him. The principal concern was the lack of access to specialist ADHD assessment and treatment, including the absence of suitable ongoing medication oversight arrangements.
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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of commissioned adult ADHD assessment, diagnosis and treatment by CPT
Wider context from the report “In October 2016 Davy was referred by his GP to the community mental health team (CMHT), part of Cornwall Partnership NHS Foundation Trust (CPT) for assessment of possible ‘Attention deficit hyperactivity disorder’ (ADHD) which is a group of behavioural symptoms that include inattentiveness, hyperactivity and impulsiveness.
Davy was assessed in December 2016 by CMHT. However, Davy was discharged from CMHT without further diagnosis and treatment. This was because of the following reasons;-
1) CPT is not commissioned to assess, diagnose or treat adult ADHD.
2) Addaction Cornwall does not have access to a specialist psychiatrist with the skills to diagnose or treat ADHD.
3) Although the GP had the option to refer under Patient Choice for treatment out of county, the GPs previous experience indicated that this was impracticable because it would not be possible to successfully deliver the ongoing oversight and review of medication.
In summary, Davy could not be diagnosed and treated by specialist services either in Cornwall or out of county.
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of access to a suitably skilled specialist psychiatrist for ADHD diagnosis and treatment
Wider context from the report “In October 2016 Davy was referred by his GP to the community mental health team (CMHT), part of Cornwall Partnership NHS Foundation Trust (CPT) for assessment of possible ‘Attention deficit hyperactivity disorder’ (ADHD) which is a group of behavioural symptoms that include inattentiveness, hyperactivity and impulsiveness.
Davy was assessed in December 2016 by CMHT. However, Davy was discharged from CMHT without further diagnosis and treatment. This was because of the following reasons;-
1) CPT is not commissioned to assess, diagnose or treat adult ADHD.
2) Addaction Cornwall does not have access to a specialist psychiatrist with the skills to diagnose or treat ADHD.
3) Although the GP had the option to refer under Patient Choice for treatment out of county, the GPs previous experience indicated that this was impracticable because it would not be possible to successfully deliver the ongoing oversight and review of medication.
In summary, Davy could not be diagnosed and treated by specialist services either in Cornwall or out of county.
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a practicable out-of-county ADHD treatment pathway with ongoing medication oversight and review
Wider context from the report “In October 2016 Davy was referred by his GP to the community mental health team (CMHT), part of Cornwall Partnership NHS Foundation Trust (CPT) for assessment of possible ‘Attention deficit hyperactivity disorder’ (ADHD) which is a group of behavioural symptoms that include inattentiveness, hyperactivity and impulsiveness.
Davy was assessed in December 2016 by CMHT. However, Davy was discharged from CMHT without further diagnosis and treatment. This was because of the following reasons;-
1) CPT is not commissioned to assess, diagnose or treat adult ADHD.
2) Addaction Cornwall does not have access to a specialist psychiatrist with the skills to diagnose or treat ADHD.
3) Although the GP had the option to refer under Patient Choice for treatment out of county, the GPs previous experience indicated that this was impracticable because it would not be possible to successfully deliver the ongoing oversight and review of medication.
In summary, Davy could not be diagnosed and treated by specialist services either in Cornwall or out of county.
” 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 Establish and operate a specialist adult ADHD assessment, diagnosis and treatment pathway in Cornwall.
Verbatim wording from the response “1) CFT is not commissioned to assess, diagnose or treat ADHD:
NHS Kernow Clinical Commissioning Group (CCG) has not historically commissioned a specialist adult ADHD service. However, in April 2018 it was acknowledged that this constituted a gap in service provision, and therefore an intention was set to develop and operate a pathway for adults (18 years and older) with ADHD. NHS Kernow identified and committed to a recurrent investment for CFT to co-design, develop and deliver the required level of intervention in line with the National Institute for Health and Care Excellence (NICE) guidance. The new service, due to be established in early 2019, will deliver an adult ADHD assessment, diagnosis and treatment pathway.” Source location 2018-0312-Response-by-Kernow-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 Develop a shared-care agreement and prescribing guideline for pharmacological treatment of adult ADHD.
Verbatim wording from the response “A Shared Care Agreement and Guideline for the treatment of ADHD in adults will be developed by the NHS Kernow prescribing team to support the new commissioning model. This will support the prescribing of the evidence based pharmacological treatment, and is supported by an already identified budget within the prescribing team.” Source location 2018-0312-Response-by-Kernow-Clinical-Commissioning-Group
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 Cornwall Council, as lead commissioner of Addaction services, is responsible for addressing Addaction’s lack of specialist ADHD expertise.
Verbatim wording from the response “2) Addaction Cornwall does not have access to a specialist psychiatrist with skills to diagnose or treat ADHD:
Cornwall Council’s Drug and Alcohol Action Team (DAAT) are responsible for the commissioning of Addaction services which provide treatment for adults with substance misuse where ADHD is a co-occurring diagnosis. We would ask that you seek clarification regarding this point from Cornwall Council as the lead commissioner of Addaction.” Source location 2018-0312-Response-by-Kernow-Clinical-Commissioning-Group
Open published response
Concerns raised 4 Lack of compliant bids for the replacement non-emergency transfer service View source Failure to meet non-emergency patient transfer collection standards View source Lack of available high dependency transport provision View source Failure to resource emergency ambulance transport to minimum performance standards View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
William George Irvin Watson · 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
William George Irvin Watson was admitted with worsening angina, underwent triple coronary artery bypass surgery, and experienced post-operative complications including an infected sternal wound. He died after difficulties and delays in emergency, high-dependency and non-emergency patient transfers. The principal concerns were inadequate ambulance and patient-transport resources, performance gaps, and the potential risk of avoidable deaths or deterioration when transfers are delayed.
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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of compliant bids for the replacement non-emergency transfer service
Wider context from the report “I was told at inquest that this service, commissioned by NHS Kernow, was being provided by a company called Eezel. I was further advised that its performance requirements are to collect 95% of patients within 1 hour and for short notice bookings, 50% were to be collected with 1 hour and 95% within 2 hours. I was informed that these targets are not being met.
The inquest was advised that a new service provider will be taking on this business from April 2019 . Of great concern to me was the revelation made at inquest that there are currently no compliant bids .
It seems obvious that a patient who would ordinarily require a non-emergency transfer but who is kept waiting beyond acceptable performance standards may deteriorate and potentially have their life put at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to meet non-emergency patient transfer collection standards
Wider context from the report “I was told at inquest that this service, commissioned by NHS Kernow, was being provided by a company called Eezel. I was further advised that its performance requirements are to collect 95% of patients within 1 hour and for short notice bookings, 50% were to be collected with 1 hour and 95% within 2 hours . I was informed that these targets are not being met .
The inquest was advised that a new service provider will be taking on this business from April 2019. Of great concern to me was the revelation made at inquest that there are currently no compliant bids.
It seems obvious that a patient who would ordinarily require a non-emergency transfer but who is kept waiting beyond acceptable performance standards may deteriorate and potentially have their life put at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of available high dependency transport provision
Wider context from the report “I heard that the only provider of this service in Cornwall is Lifestar. I was informed that on occasions when Lifestar has no available resource it is necessary to contact providers from out of country .
The evidence I heard from ████████ was that there was a definite gap in service provision . Given that this involves the transport of patients with a High Dependency there is again a real risk that fatalities may arise in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to resource emergency ambulance transport to minimum performance standards
Wider context from the report “It is equally clear that a significant performance gap remains indeed, as I understand the position, it is accepted that minimum performance standards cannot be met under the current financial position . The obvious implication is that where an adequate response cannot be made because of insufficient funding to resource the service appropriately , the consequent delays may result in lives being lost. These could be avoidable deaths.
” 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 Work with current providers to extend existing contracts and prevent disruption to the non-emergency transport service.
Verbatim wording from the response “The procurement process was not successful in securing the universal non-emergency patient transport service we were trying to achieve so in order to mitigate future risk NHS Kernow has been working with our current providers who have agreed, in principle, to an extension of their current contracts. This will ensure that the current service that people receive will not be disrupted.” Source location 2018-0237-Response-by-Kernow-Clinical-Commissioning-Group2
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 current and potential providers, stakeholders and the public to understand the failed procurement and identify service improvements.
Verbatim wording from the response “Over the coming months NHS Kernow will be working with current and potential providers, stakeholders and the public in order to understand why the procurement exercise was unsuccessful and how we can improve going forward.” Source location 2018-0237-Response-by-Kernow-Clinical-Commissioning-Group2
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 Finalise future commissioning arrangements for one universal non-emergency patient transport service.
Verbatim wording from the response “The re-procurement is viewed by NHS Kernow as a potential opportunity to improve service provision and we are committed to achieving this. During this extension the CCG will finalise their future commissioning arrangements for one universal non-emergency patient transport service with the continued aim of meeting the needs of the population of Cornwall and the Isles of Scilly.” Source location 2018-0237-Response-by-Kernow-Clinical-Commissioning-Group2
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 Continue working with the transport provider and health system to manage demand and capacity and achieve required collection standards.
Verbatim wording from the response “E-zec Medical Services has made significant improvements over the last 12 months and is currently on target to meet their trajectory of improvement in order to meet the required standards. NHS Kernow continues to work with the provider and the health system to ensure demand and capacity is manged in order to achieve these standards.” Source location 2018-0237-Response-by-Kernow-Clinical-Commissioning-Group2
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 Emergency ambulance transport concerns will be addressed by Dorset CCG in a separate response.
Verbatim wording from the response “The matters of concern relating to emergency ambulance transport will be addressed by Dorset CCG in a separate response.” Source location 2018-0237-Response-by-Kernow-Clinical-Commissioning-Group2
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 Deteriorating patients requiring escalation should be transferred by SWAST using an emergency ambulance.
Verbatim wording from the response “We would also not expect a person to be transferred from a specialist centre (Derriford) to another acute hospital unless the person was fit and safe to be transported, as this is a de-escalation of care. A delay in the high dependency transport arriving for the journey would not cause harm to the person as they would be in the most appropriate environment to meet their health care needs and able to access high quality care immediately if needed. If it was an escalation of care and the person’s condition was deteriorating then we would expect the person to be transferred in an emergency ambulance by the South West Ambulance Service Trust (SWAST).” Source location 2018-0237-Response-by-Kernow-Clinical-Commissioning-Group2
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 There is no gap in high-dependency transport provision because two providers and additional out-of-county capacity can meet demand.
Verbatim wording from the response “There is more than one provider of this service. The predominant providers of high dependency transport are Lifestar Medical and First Care Ambulances. Lifestar are based in Cornwall, First Care is based in Exeter and provides a service across the South West. They also provide services to Northern Eastern and Western Devon Clinical Commissioning Group. High dependency transport is non-emergency and therefore planned; if extra capacity is required above and beyond the capacity of the two providers mentioned above then provision may be purchased from another provider out of county in order to meet that need. NHS Kernow therefore is not aware of any gap in commissioned service.” Source location 2018-0237-Response-by-Kernow-Clinical-Commissioning-Group2
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 Delays in high-dependency transport would not cause harm because patients would remain in the most appropriate environment with immediate access to care.
Verbatim wording from the response “We would also not expect a person to be transferred from a specialist centre (Derriford) to another acute hospital unless the person was fit and safe to be transported, as this is a de-escalation of care. A delay in the high dependency transport arriving for the journey would not cause harm to the person as they would be in the most appropriate environment to meet their health care needs and able to access high quality care immediately if needed. If it was an escalation of care and the person’s condition was deteriorating then we would expect the person to be transferred in an emergency ambulance by the South West Ambulance Service Trust (SWAST).” Source location 2018-0237-Response-by-Kernow-Clinical-Commissioning-Group2
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 Extending current provider contracts will mitigate procurement risks and prevent disruption to the existing non-emergency transport service.
Verbatim wording from the response “The procurement process was not successful in securing the universal non-emergency patient transport service we were trying to achieve so in order to mitigate future risk NHS Kernow has been working with our current providers who have agreed, in principle, to an extension of their current contracts. This will ensure that the current service that people receive will not be disrupted.” Source location 2018-0237-Response-by-Kernow-Clinical-Commissioning-Group2
Open published response
Concerns raised 3 Requirement for substance misuse treatment before mental health treatment View source Lack of access to mental health support for people with drug dependency View source Discharge from CMHT after two missed appointments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Marcus HANCE · 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
Marcus Hance died on 13 October 2017 from the synergistic effect of a reckless overdose of illicit and therapeutic drugs, in the context of a history of drug abuse. Concerns included the separation of support for substance misuse from support for associated mental health issues, the approach that substance misuse should be addressed before mental health treatment, and his discharge from the Community Mental Health Team after two missed appointments.
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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Requirement for substance misuse treatment before mental health treatment
Wider context from the report “(2) The approach to cases of dual diagnosis, that substance misuse should be addressed before any mental health treatment could proceed .
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of access to mental health support for people with drug dependency
Wider context from the report “(1) Marcus was in a position where he was getting support with his drug dependency from the drug and alcohol team but was not able to access support for the mental health issues which were associated with the drug dependency .
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Discharge from CMHT after two missed appointments
Wider context from the report “(3) The discharge from CMHT on failing to attend two appointments .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review interdependencies between mental health and substance misuse services, refreshing referral, transition, risk management and information-sharing protocols.
Verbatim wording from the response “NHS Kernow are reviewing interdependencies between Outlook SW and Cornwall Partnership NHS Foundation Trust. This work includes a joint refresh of existing protocols in support of smooth referral pathways and transitions between services and different service lines, a review of risk management processes and information sharing arrangements. The intention is to conclude this work by December 2018.” Source location 2018-0173-Kernow-NHS-Trust
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 Commence a formal review of service specifications, including the approach to non-attendance at mental health appointments.
Verbatim wording from the response “NHS Kernow and Cornwall Partnership NHS Foundation Trust have agreed to commence a formalised process to review a number of service specifications which will prioritise those services currently subject to transformation. This will include the approach taken in cases of non-attendance at mental health appointments,” Source location 2018-0173-Kernow-NHS-Trust
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 Cornwall Council leads commissioning of drug and alcohol services, assigning responsibility for that provision to another body.
Verbatim wording from the response “NHS Kernow are partners in the implementation of the existing Dual Diagnosis Strategy, along with DAAT commissioners and Cornwall Partnership NHS Foundation Trust. The strategy requires that at an operational and clinical level, services work together to ensure safe and seamless care for individual’s most affected. The Crisis Care Concordat multi-agency group, Chaired by the GP Clinical Lead for Mental Health, includes representation from the Drug and Alcohol Action Team (DAAT), and is reviewing its local action plans with a view to setting out revised actions associated with Dual Diagnosis. Cornwall Council are lead commissioners of drug and alcohol services, and there is a joint commitment to establish meaningful, equitable and sustainable service change and promote joint working across agencies.” Source location 2018-0173-Kernow-NHS-Trust
Open published response
Concerns raised 2 Deficiencies in aftercare or transition arrangements for patients discharged home at moderate to high risk of self-harm or suicide View source Failure to put in place contact arrangements for patients discharged home at moderate to high risk of self-harm or suicide 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
Miriam Roach · 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
Miriam Roach, who had a history of depression, anxiety, alcohol dependency and self-harm, was discharged from hospital on 30 June 2017 after assessment following an overdose. She died by suicide on 1 July 2017 by hanging. The substantive concerns related to aftercare and the absence of arrangements to contact patients discharged home with moderate to high risks of self-harm or suicide.
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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in aftercare or transition arrangements for patients discharged home at moderate to high risk of self-harm or suicide
Wider context from the report “(1) Regarding the aftercare or transition arrangements for those discharged from hospital to home with a moderate to high risk of self-harm and/or suicide following incidents of self-harm or suicide .
(2) Specifically the obligations for putting in place contact arrangements for such patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to put in place contact arrangements for patients discharged home at moderate to high risk of self-harm or suicide
Wider context from the report “(1) Regarding the aftercare or transition arrangements for those discharged from hospital to home with a moderate to high risk of self-harm and/or suicide following incidents of self-harm or suicide.
(2) Specifically the obligations for putting in place contact arrangements for such patients .
” Open source report
Concerns raised 14 Inappropriate RCHT SI and SOM View source Failure to identify red flag signs of neonatal sepsis View source Unavailability and non-use of standard physiological observation equipment for mothers and babies View source Failure to undertake and record routine physiological observations of mothers and babies View source Core midwifery paperwork failing to prompt routine physiological assessments View source Failure of neonatal infection guidelines to be known and consistent with NICE guidance View source Failure to formally record Maternity Helpline calls and outcomes View source Use of a single birth-weight threshold in hypoglycaemic guidance View source Failure to complete NEWS on all babies View source Delays in full assessment of labour progress View source Insufficient systemic, rigorous and regular neonatal sepsis training View source Maternity Helpline triage by unregistered, inadequately trained and unqualified staff View source Unavailability of centile charts in handheld maternity records View source Failure to undertake and record capillary refill time in suspected neonatal sepsis View source See 11 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Charlie Mark Jermyn · 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
Charlie Jermyn was born at home on 9 May 2015 and developed sleepiness, feeding difficulty and possible respiratory distress. He stopped breathing during a routine visit the following day and died in hospital despite resuscitation attempts. The principal concerns were delayed recognition and referral for suspected sepsis, inadequate telephone triage and recording, insufficient observations, and wider shortcomings in midwifery guidance, equipment and training.
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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inappropriate RCHT SI and SOM
Wider context from the report “9. The Expert Midwife noted that RCHT SI and SOM were not appropriate and been identified in the most recent LSA report on the Trust.
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to identify red flag signs of neonatal sepsis
Wider context from the report “8. The red flag signs for sepsis (in this case sleepy, possible respiratory distress (grunting) and difficulty in feeding) were overlooked resulting in a fatal delay in referral to specialist hospital support/treatment. Identification of sepsis in new born babies is difficult and the staff and Trust should have had in place a systemic, rigorous and regular training in this area. The Trust's own clinical guidelines for the Prevention, Diagnosis and Treatment of Early Onset Neonatal Bacterial Infection, were not known to the midwives at the inquest. The Expert Midwife gave the opinion that the RCHT Trust guidelines were not consistent with the NICE guidance or best practice on this matter (page 14). In particular it was noted that capillary re-fill time should be undertaken and recorded in cases of suspected sepsis.
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability and non-use of standard physiological observation equipment for mothers and babies
Wider context from the report “4. All Community Midwives should be provided with standard equipment to include, ear thermometers, stethoscopes, blood sugar testing and SATS monitors and these should be used as routine practice to make routine observations on mother and baby .
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake and record routine physiological observations of mothers and babies
Wider context from the report “2. Routine physiological observations of mother and baby were not undertaken and recorded by the Community Midwives . This practice is not in line with national practice. The accurate temperature, heart rate and other appropriate observations/ recording should be routine and formally recorded with stethoscope and thermometer etc (not just visual and touch). NEWS should be completed on all babies.
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Core midwifery paperwork failing to prompt routine physiological assessments
Wider context from the report “3. The Royal Cornwall Hospital Trust core midwifery paperwork does not meet best practice or NICE guidelines and does not prompt midwives to undertake routine physiological assessments .
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of neonatal infection guidelines to be known and consistent with NICE guidance
Wider context from the report “8. The red flag signs for sepsis (in this case sleepy, possible respiratory distress (grunting) and difficulty in feeding) were overlooked resulting in a fatal delay in referral to specialist hospital support/treatment. Identification of sepsis in new born babies is difficult and the staff and Trust should have had in place a systemic, rigorous and regular training in this area. The Trust's own clinical guidelines for the Prevention, Diagnosis and Treatment of Early Onset Neonatal Bacterial Infection, were not known to the midwives at the inquest. The Expert Midwife gave the opinion that the RCHT Trust guidelines were not consistent with the NICE guidance or best practice on this matter (page 14). In particular it was noted that capillary re-fill time should be undertaken and recorded in cases of suspected sepsis.
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to formally record Maternity Helpline calls and outcomes
Wider context from the report “7. The telephone Maternity Helpline was inappropriately triaged by unregistered inappropriately trained and qualified staff, who were unable to identify obvious and significant sepsis markers indicating the seriousness of the deterioration in Charlie’s health. No structured note taking or recording of the call was made for future referral. Nor was the call/caller recorded. Helpline triage is a complex task and should only be undertaken after specialist training by an appropriately qualified person and the outcome of the conversations should be recorded formally in line with best practice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Use of a single birth-weight threshold in hypoglycaemic guidance
Wider context from the report “6. The Expert Midwife advised that the use of a single birth weight in the Trusts hypoglycaemic guidance (at risk at 2.5 kg) was not best practice and suggested the use of three weights: pre term, term, and late weight.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to complete NEWS on all babies
Wider context from the report “2. Routine physiological observations of mother and baby were not undertaken and recorded by the Community Midwives. This practice is not in line with national practice. The accurate temperature, heart rate and other appropriate observations/ recording should be routine and formally recorded with stethoscope and thermometer etc (not just visual and touch). NEWS should be completed on all babies .
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in full assessment of labour progress
Wider context from the report “1. The Delay of over 5 hours, in full assessment of ████████ labour progress in the Day Assessment Unit at Royal Cornwall Hospital on the 8th/9th May 2015 was unacceptable (systemic failing).
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient systemic, rigorous and regular neonatal sepsis training
Wider context from the report “8. The red flag signs for sepsis (in this case sleepy, possible respiratory distress (grunting) and difficulty in feeding) were overlooked resulting in a fatal delay in referral to specialist hospital support/treatment. Identification of sepsis in new born babies is difficult and the staff and Trust should have had in place a systemic, rigorous and regular training in this area . The Trust's own clinical guidelines for the Prevention, Diagnosis and Treatment of Early Onset Neonatal Bacterial Infection, were not known to the midwives at the inquest. The Expert Midwife gave the opinion that the RCHT Trust guidelines were not consistent with the NICE guidance or best practice on this matter (page 14). In particular it was noted that capillary re-fill time should be undertaken and recorded in cases of suspected sepsis.
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Maternity Helpline triage by unregistered, inadequately trained and unqualified staff
Wider context from the report “7. The telephone Maternity Helpline was inappropriately triaged by unregistered inappropriately trained and qualified staff , who were unable to identify obvious and significant sepsis markers indicating the seriousness of the deterioration in Charlie’s health. No structured note taking or recording of the call was made for future referral. Nor was the call/caller recorded. Helpline triage is a complex task and should only be undertaken after specialist training by an appropriately qualified person and the outcome of the conversations should be recorded formally in line with best practice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of centile charts in handheld maternity records
Wider context from the report “5. There was a recommendation by the Midwife Consultant that centile charts for each baby should be available in all hand held maternity records to assist midwives identify babies who are potentially at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake and record capillary refill time in suspected neonatal sepsis
Wider context from the report “8. The red flag signs for sepsis (in this case sleepy, possible respiratory distress (grunting) and difficulty in feeding) were overlooked resulting in a fatal delay in referral to specialist hospital support/treatment. Identification of sepsis in new born babies is difficult and the staff and Trust should have had in place a systemic, rigorous and regular training in this area. The Trust's own clinical guidelines for the Prevention, Diagnosis and Treatment of Early Onset Neonatal Bacterial Infection, were not known to the midwives at the inquest. The Expert Midwife gave the opinion that the RCHT Trust guidelines were not consistent with the NICE guidance or best practice on this matter (page 14). In particular it was noted that capillary re-fill time should be undertaken and recorded in cases of suspected sepsis .
” Open source report
Concerns raised 3 Failure to recognise and act on paediatric respiratory red flag markers View source Failure to routinely use oxygen blood monitoring in paediatric medicine View source Failure to routinely use respiratory rate benchmarks in paediatric respiratory medicine 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
Esmee Shayla Polmear · 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
Esmee Polmear fell ill during a school trip on 1 July 2015, later collapsed and went into cardiac arrest, and was pronounced dead in hospital despite resuscitation attempts. She had pulmonary veno-occlusive disease that was not diagnosed or recognised before her death; concerns included the use of respiratory-rate benchmarks and oxygen monitoring, and recognition and action on red-flag symptoms.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and act on paediatric respiratory red flag markers
Wider context from the report “At the inquest the Paediatric Expert, ████████ gave the opinion that
• The routine use of respiratory rate bench-markers in paediatric respiratory medicine
• The use of routine oxygen blood monitoring in paediatric medicine
• The recognition and action on red flag markers (which in this case were shortness of breath, chest pain and blue lips)
Would have assisted and improved the chances of diagnosis and treatment of Esmee and other children, with a view to preventing future deaths or providing appropriate treatment and palliative care in life limiting cases.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely use oxygen blood monitoring in paediatric medicine
Wider context from the report “At the inquest the Paediatric Expert, ████████ gave the opinion that
• The routine use of respiratory rate bench-markers in paediatric respiratory medicine
• The use of routine oxygen blood monitoring in paediatric medicine
• The recognition and action on red flag markers (which in this case were shortness of breath, chest pain and blue lips)
Would have assisted and improved the chances of diagnosis and treatment of Esmee and other children, with a view to preventing future deaths or providing appropriate treatment and palliative care in life limiting cases.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely use respiratory rate benchmarks in paediatric respiratory medicine
Wider context from the report “At the inquest the Paediatric Expert, ████████ gave the opinion that
• The routine use of respiratory rate bench-markers in paediatric respiratory medicine
• The use of routine oxygen blood monitoring in paediatric medicine
• The recognition and action on red flag markers (which in this case were shortness of breath, chest pain and blue lips)
Would have assisted and improved the chances of diagnosis and treatment of Esmee and other children, with a view to preventing future deaths or providing appropriate treatment and palliative care in life limiting cases.
” Open source report
Concerns raised 5 Failure to ensure availability of psychiatric beds in Cornwall View source Failure to ensure procedures prioritise high-risk patients on psychological therapy waiting lists View source Failure to ensure adequate resource allocation to the home treatment team View source Failure to manage waiting lists for individual psychological therapy safely View source Failure to ensure an appropriate threshold for offering home treatment support View source See 2 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
Simon Jonathon Klemberg · 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
Simon Jonathon Klemberg died in the early hours of 7 June 2015 following a reckless and impulsive overdose of prescription medication taken to address acute head pain, possibly related to his psychological condition. He had serious mental health problems, and individual psychological therapy recommended in February 2015 was delayed and never commenced. The report raised concerns about psychiatric bed availability, resources and thresholds for the home treatment team, and the prioritisation of high-risk patients awaiting psychological therapy.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure availability of psychiatric beds in Cornwall
Wider context from the report “(1) To review the availability of beds for psychiatric patients in Cornwall . Kernow Clinical Commissioning group (KCCG) to respond
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure procedures prioritise high-risk patients on psychological therapy waiting lists
Wider context from the report “(4) To review procedures for prioritizing high risk patients in waiting lists for psychological therapy . Cornwall Partnership NHS Foundation Trust (CFT) to respond.
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure adequate resource allocation to the home treatment team
Wider context from the report “(2) To review the allocation of resources to the home treatment team , with particular reference to the threshold for offering support. Both Kernow Clinical Commissioning group (KCCG) and Cornwall Partnership NHS Foundation Trust (CFT) to respond
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to manage waiting lists for individual psychological therapy safely
Wider context from the report “(3) To review the waiting lists for individual psychological therapy . Cornwall Partnership NHS Foundation Trust (CFT) to respond.
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure an appropriate threshold for offering home treatment support
Wider context from the report “(2) To review the allocation of resources to the home treatment team, with particular reference to the threshold for offering support . Both Kernow Clinical Commissioning group (KCCG) and Cornwall Partnership NHS Foundation Trust (CFT) to respond
” Open source report
Concerns raised 1 Lack of acute psychiatric beds View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
George Allan Taylor · 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
George Allan Taylor, who had a history of mental health issues and previous overdoses, was found hanged at home on 2 July 2013 after leaving a care home and returning home under daily supervision. The report identified concerns about inadequate provision of acute psychiatric beds in Cornwall, with 8 to 12 patients per month typically sent out of county, and noted that a future death could result from this lack of beds in changed circumstances.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of acute psychiatric beds
Wider context from the report “It was established in evidence that Mr Taylor’s death was not caused by the lack of an acute psychiatric bed.
Furthermore, it was established that no patient had died out of county because an in county acute psychiatric bed was not available. It was further established that no patient had died in Cornwall while waiting for an acute psychiatric bed to become available.
That said, it appears far from desirable that 8 to 12 patients are being sent out of county per month due to a lack of acute psychiatric beds .
It is easy to see that, with only a small change in circumstances, a future death could result as a consequence of a lack of acute psychiatric beds .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review out-of-county placements and current provision with providers to inform future commissioning and service delivery.
Verbatim wording from the response “NHS Kernow is actively working with Cornwall Partnership NHS Foundation Trust and providers to review current provision and the needs of individuals who due to complex need and demand issues, are placed out of county. This review will inform future commissioning and service delivery.” Source location 2015-0044-Response-by-Kernow-CCG
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 Assign alternative funding to support least-restrictive community care and interventions specified in individual care plans.
Verbatim wording from the response “As part of the health and social care community commitment to implementing the National Crisis Care concordat, NHS Kernow is working with Cornwall Partnership NHS Foundation Trust, Royal Cornwall Hospitals Trust, service users and other providers to develop alternatives to hospital admission and to ensure the individual receives assessment and intervention as early as possible. This includes a notional budget assigned to Cornwall Partnership NHS Foundation Trust to implement the least restrictive option by delivering care to the individual in the community and prevent admission to hospital. The ‘alternative funding’ will facilitate access to a range of interventions that meet the needs of the individual as evidenced in the individual’s written care plan. This work commenced in October 2014 and will be reviewed in 2015 to assess the impact for individuals and the whole system.” Source location 2015-0044-Response-by-Kernow-CCG
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 and service users to develop alternatives to hospital admission and enable earlier assessment and intervention.
Verbatim wording from the response “As part of the health and social care community commitment to implementing the National Crisis Care concordat, NHS Kernow is working with Cornwall Partnership NHS Foundation Trust, Royal Cornwall Hospitals Trust, service users and other providers to develop alternatives to hospital admission and to ensure the individual receives assessment and intervention as early as possible. This includes a notional budget assigned to Cornwall Partnership NHS Foundation Trust to implement the least restrictive option by delivering care to the individual in the community and prevent admission to hospital. The ‘alternative funding’ will facilitate access to a range of interventions that meet the needs of the individual as evidenced in the individual’s written care plan. This work commenced in October 2014 and will be reviewed in 2015 to assess the impact for individuals and the whole system.” Source location 2015-0044-Response-by-Kernow-CCG
Open published response
Concerns raised 3 Difficulties in transferring medical notes and records View source Delays in resolving disputes over which organisation should treat a patient View source Failure of OSW and CMHT treatment thresholds to provide continuous service coverage 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
Shannon Kimberley Gee · 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
Shannon Kimberley Gee, aged 16, died as the result of an Accident. The report raised concerns about gaps between mental health services, delays of weeks in resolving disputes over responsibility for treatment, and difficulties transferring medical notes and records.
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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Difficulties in transferring medical notes and records
Wider context from the report “The situation now is improved from when ████████ encountered the delay in treatment to her but, on the evidence should ████████ a delay of ‘weeks’ in resolving clinical disputes as to which organisation should treat a patient is still worrying. Ideally, there should be a seamless union between the two organisations.
The fact that there is not appears to be a consequence of the maximum threshold for treatment by OSW being lower than the minimum threshold for acceptance on to the CMHT workload. Put another way, it is entirely conceivable that both OSW and CMHT may be correct in applying their respective rules as to whether a patient needs to be taken on where that patient’s presenting complaints falls between the two organisations’ rules. That may require formal guidance to resolve hence directing this letter to the Secretary in addition to the Commissioners. The difficulties set out concerning the transfer of medical notes and records appear more difficult to justify.
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in resolving disputes over which organisation should treat a patient
Wider context from the report “The situation now is improved from when ████████ encountered the delay in treatment to her but, on the evidence should ████████ a delay of ‘weeks’ in resolving clinical disputes as to which organisation should treat a patient is still worrying . Ideally, there should be a seamless union between the two organisations.
The fact that there is not appears to be a consequence of the maximum threshold for treatment by OSW being lower than the minimum threshold for acceptance on to the CMHT workload. Put another way, it is entirely conceivable that both OSW and CMHT may be correct in applying their respective rules as to whether a patient needs to be taken on where that patient’s presenting complaints falls between the two organisations’ rules. That may require formal guidance to resolve hence directing this letter to the Secretary in addition to the Commissioners. The difficulties set out concerning the transfer of medical notes and records appear more difficult to justify.
” 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 Cornwall and the Isles of Scilly Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of OSW and CMHT treatment thresholds to provide continuous service coverage
Wider context from the report “The situation now is improved from when ████████ encountered the delay in treatment to her but, on the evidence should ████████ a delay of ‘weeks’ in resolving clinical disputes as to which organisation should treat a patient is still worrying. Ideally, there should be a seamless union between the two organisations.
The fact that there is not appears to be a consequence of the maximum threshold for treatment by OSW being lower than the minimum threshold for acceptance on to the CMHT workload . Put another way, it is entirely conceivable that both OSW and CMHT may be correct in applying their respective rules as to whether a patient needs to be taken on where that patient’s presenting complaints falls between the two organisations’ rules . That may require formal guidance to resolve hence directing this letter to the Secretary in addition to the Commissioners. The difficulties set out concerning the transfer of medical notes and records appear more difficult to justify.
” Open source report
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Addressed to NHS Kernow Clinical Commissioning Group, now represented here by NHS Cornwall and the Isles of Scilly Integrated Care Board.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations