Recipient

NHS Coventry and Warwickshire Integrated Care Board

First report 26 Jan 2018•Latest report 16 Sep 2025

Recipient record

Reports, concerns and published responses

Health and care · Integrated care board. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 3
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from NHS Coventry and Warwickshire Integrated Care Board linked to the concerns in each report. Select any concern, action or position to view the source wording.

16 Sep2025
Birmingham and Solihull
Concerns raised2
1. Lack of mandatory and comprehensive paramedic training in obstetric emergencies
2. Failure to adhere to clinical guidance for assessing and managing delayed breech birth
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

Mohammed Ismail KHAN · Prevention of Future Deaths report

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

Report summary

Mohammed Ismail Khan sustained a catastrophic brain injury during a breech delivery at 35 weeks and 2 days gestation on 6 September 2022, after his mother had been discharged from hospital earlier that day despite antenatal risk factors. He later died following a respiratory infection, with the medical cause of death recorded as respiratory failure due to parainfluenza virus infection, with hypoxic-ischaemic brain damage. The investigation identified delayed and suboptimal emergency care, failure to adhere to breech-delivery guidance, and the absence of mandatory paramedic training in obstetric emergencies as substantive concerns.

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 Coventry and Warwickshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Lack of mandatory and comprehensive paramedic training in obstetric emergencies
Wider context from the report
“2. The WMAS investigation concluded that the national, JRCALC guidelines for the clinical assessment and management of breech birth were not adhered by the paramedics and regional trauma desk as the clinicians did not appreciate that the delivery was delayed and that intervention to aid delivery should be attempted. 3. Whilst the JRCALC guidance has since been updated (October 2023) to be clearer and provide much better assistance ████████ explained that it is not mandatory for paramedics to receive specific training on obstetric emergencies, including breech delivery, either in their foundation training/education or as part of continuing professional development. 4. The clinicians who attended Mrs Khan said they would not have felt confident to attempt the techniques advised by JRCALC even if they had realised they were advised. 5. ████████ explained that maternity and obstetric care makes up 3 per cent of emergency ambulance responses. 6. Whilst WMAS have purchased specific training equipment and an online course for clinicians on the management of obstetric emergencies in response to the findings of the investigation, resourcing is such that it has not been possible for all paramedics to receive this additional training e.g. less than a third of paramedics with WMAS have completed the online course. 7. ████████ evidence was that in her opinion the absence of any mandatory training on obstetric emergencies was putting lives 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 Coventry and Warwickshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Failure to adhere to clinical guidance for assessing and managing delayed breech birth
Wider context from the report
“2. The WMAS investigation concluded that the national, JRCALC guidelines for the clinical assessment and management of breech birth were not adhered by the paramedics and regional trauma desk as the clinicians did not appreciate that the delivery was delayed and that intervention to aid delivery should be attempted. 3. Whilst the JRCALC guidance has since been updated (October 2023) to be clearer and provide much better assistance ████████ explained that it is not mandatory for paramedics to receive specific training on obstetric emergencies, including breech delivery, either in their foundation training/education or as part of continuing professional development. 4. The clinicians who attended Mrs Khan said they would not have felt confident to attempt the techniques advised by JRCALC even if they had realised they were advised. 5. ████████ explained that maternity and obstetric care makes up 3 per cent of emergency ambulance responses. 6. Whilst WMAS have purchased specific training equipment and an online course for clinicians on the management of obstetric emergencies in response to the findings of the investigation, resourcing is such that it has not been possible for all paramedics to receive this additional training e.g. less than a third of paramedics with WMAS have completed the online course. 7. ████████ evidence was that in her opinion the absence of any mandatory training on obstetric emergencies was putting lives at risk. ”
Open source report
25 Jun2018
Coventry
Concerns raised4
1. Failure to act on deterioration or requests for earlier prompt review raised through the flagging process
2. Failure to change the service to address identified clinical risks
3. Failure to transcribe information provided by patients or families for clinical teams
1. Destruction of handwritten patient or family registration forms instead of retaining them in the medical record
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

Vanessa Ferkova and Sylvia Daniel · 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

Vanessa Ferkova, aged 2, died after presenting to a walk-in centre with fever and vomiting, developing a rash, and later suffering cardiac arrest; the report states she died from meningococcus septicaemia. Sylvia Daniel, aged 73, presented with symptoms including neck pain, was diagnosed with an ear infection, and was found deceased the following morning; the report states she died from acute meningitis. Concerns included delays and deficiencies in initial assessment and registration, failure to transcribe or retain information provided by families, and an unsafe non-clinical triage and flagging process.

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 Coventry and Warwickshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Failure to act on deterioration or requests for earlier prompt review raised through the flagging process
Wider context from the report
“4. My final specific concern relates to the process whereby patients/families are asked to let the reception team know if the patient is deteriorating, or if they are concerned that earlier prompt review is required. I heard evidence that such concerns were raised but no action was taken. This seemingly runs counter to Virgin Care’s own ‘flagging’ system. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Coventry and Warwickshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Failure to change the service to address identified clinical risks
Wider context from the report
“1. I am concerned that this standard is being introduced to address clinical risks but Virgin Care do not intend to change their service to address this risk but are instead awaiting a change in their commissioning arrangements. I am concerned that future deaths could arise in this circumstance. ”
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 Coventry and Warwickshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Failure to transcribe information provided by patients or families for clinical teams
Wider context from the report
“2. I am concerned that some information provided by Mrs Daniel’s family was not transcribed by the reception team, meaning that it was not available in written form to the clinical team as part of the initial ‘paper’ triage process and at the later formal consultation. ”
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 Coventry and Warwickshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Destruction of handwritten patient or family registration forms instead of retaining them in the medical record
Wider context from the report
“3. Related to this, I am also concerned that an important part of the medical records (the handwritten form completed by patients/families on registration) is destroyed, rather than added to the notes. The fact that information provided directly by patients/families is not available to clinicians is one issue that arises, another is that review of incidents, such as Mrs Daniel’s death is hampered where ‘primary evidence’ is unavailable. ”
Open source report
26 Jan2018
Coventry
Concerns raised5
1. Difference in commissioned services between primary and secondary care settings for similar unscreened patient populations
2. Failure to include clinical observations in walk-in centre triage
3. Confusion among the public about the roles of walk-in centres, urgent care centres and GP services attached to Emergency Departments
1. Failure to maintain equivalent triage systems for unscreened patients across walk-in centres and emergency departments
2. Unavailability of timely clinical triage including assessment of clinical observations at walk-in centre services
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

Vanessa Ferkova · 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

Vanessa Ferkova, aged 2, attended a GP walk-in centre with fever and vomiting and later developed a rash. She was subsequently recognised as very unwell and likely suffering from meningococcal septicaemia, went into cardiac arrest in an ambulance, and died after unsuccessful resuscitation. The principal concern was that the walk-in centre did not provide clinical triage or a required timeframe for initial assessment, despite concerns that earlier observations could have identified and treated shock.

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 Coventry and Warwickshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Difference in commissioned services between primary and secondary care settings for similar unscreened patient populations
Wider context from the report
“I am concerned that there is a difference in the services commissioned between primary and secondary care settings, where the potential population of patients is similar; that being unscreened members of the public, including children. I heard evidence that there is a confusion amongst the general public as to the roles of walk-in centres, urgent care centres and GP services attached to Emergency Departments. In this case it was likely that, had Vanessa presented to a GP service attached to an Emergency Department, she would have had a clinical triage within 15 minutes of arriving (including an assessment of clinical observations) and that she would not have died from septicaemia. I am concerned that she did not receive this care because of the service from which her parents (understandably) sought treatment. The walk-in centre provider is currently investigating whether it should/could provide a triage service which includes an assessment of clinical observations. I am to be provided the outcome of this investigation at the end of February 2018. As such, I have not written a prevention of future deaths report to this provider but I am concerned that this is a nationwide issue which warrants consideration by NHS England as the commissioner of primary care services. ”
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 Coventry and Warwickshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Failure to include clinical observations in walk-in centre triage
Wider context from the report
“I heard evidence from the CQC that the walk-in centre had been inspected for the first time in the June following Vanessa’s death. It was judged to have ‘triage process whereby patients were assessed so they were seen according to clinical need...’ but also that ‘Patients arriving at the service were seen generally according to arrival time’. The report also states that ‘Screening, prioritising and navigation of patients was completed by an appropriate clinician’. These conclusions were based on the process of receptionists documenting the presence/absence of ‘red flags’ and clinicians reviewing the waiting list when considering which patient was next to be seen. I am concerned that the CQC judged the centre to have a triage process that was based on clinical need when that assessment does not include taking clinical observations which, in secondary care hospitals, was stated to be a vital patient safety tool. Given that walk-in centres and emergency departments both accept ‘unscreened’ patients, it is concerning that such differing triage systems should be in place; a situation which is seeming accepted by the regulator. I heard evidence that, should this circumstance repeat itself, then it is likely that the same outcome would occur. As such, my duty to raise these concerns is engaged. ”
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 Coventry and Warwickshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Confusion among the public about the roles of walk-in centres, urgent care centres and GP services attached to Emergency Departments
Wider context from the report
“I am concerned that there is a difference in the services commissioned between primary and secondary care settings, where the potential population of patients is similar; that being unscreened members of the public, including children. I heard evidence that there is a confusion amongst the general public as to the roles of walk-in centres, urgent care centres and GP services attached to Emergency Departments. In this case it was likely that, had Vanessa presented to a GP service attached to an Emergency Department, she would have had a clinical triage within 15 minutes of arriving (including an assessment of clinical observations) and that she would not have died from septicaemia. I am concerned that she did not receive this care because of the service from which her parents (understandably) sought treatment. The walk-in centre provider is currently investigating whether it should/could provide a triage service which includes an assessment of clinical observations. I am to be provided the outcome of this investigation at the end of February 2018. As such, I have not written a prevention of future deaths report to this provider but I am concerned that this is a nationwide issue which warrants consideration by NHS England as the commissioner of primary care services. ”
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 Coventry and Warwickshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain equivalent triage systems for unscreened patients across walk-in centres and emergency departments
Wider context from the report
“I heard evidence from the CQC that the walk-in centre had been inspected for the first time in the June following Vanessa’s death. It was judged to have ‘triage process whereby patients were assessed so they were seen according to clinical need...’ but also that ‘Patients arriving at the service were seen generally according to arrival time’. The report also states that ‘Screening, prioritising and navigation of patients was completed by an appropriate clinician’. These conclusions were based on the process of receptionists documenting the presence/absence of ‘red flags’ and clinicians reviewing the waiting list when considering which patient was next to be seen. I am concerned that the CQC judged the centre to have a triage process that was based on clinical need when that assessment does not include taking clinical observations which, in secondary care hospitals, was stated to be a vital patient safety tool. Given that walk-in centres and emergency departments both accept ‘unscreened’ patients, it is concerning that such differing triage systems should be in place; a situation which is seeming accepted by the regulator. I heard evidence that, should this circumstance repeat itself, then it is likely that the same outcome would occur. As such, my duty to raise these concerns is engaged. ”
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 Coventry and Warwickshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of timely clinical triage including assessment of clinical observations at walk-in centre services
Wider context from the report
“I am concerned that there is a difference in the services commissioned between primary and secondary care settings, where the potential population of patients is similar; that being unscreened members of the public, including children. I heard evidence that there is a confusion amongst the general public as to the roles of walk-in centres, urgent care centres and GP services attached to Emergency Departments. In this case it was likely that, had Vanessa presented to a GP service attached to an Emergency Department, she would have had a clinical triage within 15 minutes of arriving (including an assessment of clinical observations) and that she would not have died from septicaemia. I am concerned that she did not receive this care because of the service from which her parents (understandably) sought treatment. The walk-in centre provider is currently investigating whether it should/could provide a triage service which includes an assessment of clinical observations. I am to be provided the outcome of this investigation at the end of February 2018. As such, I have not written a prevention of future deaths report to this provider but I am concerned that this is a nationwide issue which warrants consideration by NHS England as the commissioner of primary care services. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised2

Lack of mandatory and comprehensive paramedic training in obstetric emergencies

Failure to adhere to clinical guidance for assessing and managing delayed breech birth

Concerns raised4

Failure to act on deterioration or requests for earlier prompt review raised through the flagging process

Failure to change the service to address identified clinical risks

Failure to transcribe information provided by patients or families for clinical teams

Destruction of handwritten patient or family registration forms instead of retaining them in the medical record

Concerns raised5

Difference in commissioned services between primary and secondary care settings for similar unscreened patient populations

Failure to include clinical observations in walk-in centre triage

Confusion among the public about the roles of walk-in centres, urgent care centres and GP services attached to Emergency Departments

Failure to maintain equivalent triage systems for unscreened patients across walk-in centres and emergency departments

Unavailability of timely clinical triage including assessment of clinical observations at walk-in centre services