3 Mar 2026 Wendy BODDINGTON · Prevention of Future Deaths report Derby and Derbyshire
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Concerns raised 2 Lack of support for reducing, stopping, or substituting long-term opiate and opioid medication for chronic pain View source Unavailability of specialist services for dependence on prescribed opiates and opioids View source
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AI-generated summary
Wendy BODDINGTON · 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
Wendy BODDINGTON was found deceased at home on 24 March 2025 after friends had been unable to contact her for several days. She had two fentanyl patches on her body instead of the single prescribed patch; toxicology found fentanyl at a fatal level, with prescribed codeine adding to the toxicity. The principal concern was that people receiving long-term, often high-dose opiate and opioid prescriptions for chronic pain may not receive adequate support to reduce, stop, or substitute these medications.
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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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of support for reducing, stopping, or substituting long-term opiate and opioid medication for chronic pain
Wider context from the report “The context for my concerns is the well-recognised situation of long-term prescription of opiate and opioid medications, often at high doses, for chronic pain. It is now recognised that such prescribing will usually cause other health problems, including dependence and tolerance, and over time becomes limited in controlling pain. Whilst current guidance is against such prescribing, there are many people who have been taking these medications for a long time for whom stopping or reducing the medications is very challenging. Use of those medications carries risk of accidental or deliberate overdose and death.
Wendy’s inquest heard that her GP practice has initiated a targeted programme to identify patients who have been receiving long-term prescription of opiate and opioid medications and engage them in focussed review to agree planned reduction, stoppage, or substitution of those medications. This programme involves 2 senior GPs and 2 pharmacists and so is a significant commitment. The practice is incrementally concentrating on those patients with high-dose prescriptions. Relatedly the practice has introduced a number of measures to try and avoid patients being inappropriately prescribed these medications for chronic pain in the first place.
In evidence the GP partner stated that he was unaware of other GP practices in the Derbyshire area undertaking similar programmes. The inquest also heard that there are no specialist services for patients who have developed dependence on opiates and opioids, and that substance misuse services will only work with people with non-prescribed drug issues.
The inquest did hear anecdotal evidence that NHS England may be pursuing some relevant initiatives but the details and extent of this was unclear.
My specific concern is that there appear to be a significant number of people who are being prescribed opiate and opioid medications for chronic pain, often at high doses and for long periods, but may not be receiving support to reduce, stop, or substitute those medications . It appears to me that the ICB is in a position to consider this problem and potential remedies on a regional basis, and feed into national strategies.
” 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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of specialist services for dependence on prescribed opiates and opioids
Wider context from the report “The context for my concerns is the well-recognised situation of long-term prescription of opiate and opioid medications, often at high doses, for chronic pain. It is now recognised that such prescribing will usually cause other health problems, including dependence and tolerance, and over time becomes limited in controlling pain. Whilst current guidance is against such prescribing, there are many people who have been taking these medications for a long time for whom stopping or reducing the medications is very challenging. Use of those medications carries risk of accidental or deliberate overdose and death.
Wendy’s inquest heard that her GP practice has initiated a targeted programme to identify patients who have been receiving long-term prescription of opiate and opioid medications and engage them in focussed review to agree planned reduction, stoppage, or substitution of those medications. This programme involves 2 senior GPs and 2 pharmacists and so is a significant commitment. The practice is incrementally concentrating on those patients with high-dose prescriptions. Relatedly the practice has introduced a number of measures to try and avoid patients being inappropriately prescribed these medications for chronic pain in the first place.
In evidence the GP partner stated that he was unaware of other GP practices in the Derbyshire area undertaking similar programmes. The inquest also heard that there are no specialist services for patients who have developed dependence on opiates and opioids , and that substance misuse services will only work with people with non-prescribed drug issues .
The inquest did hear anecdotal evidence that NHS England may be pursuing some relevant initiatives but the details and extent of this was unclear.
My specific concern is that there appear to be a significant number of people who are being prescribed opiate and opioid medications for chronic pain, often at high doses and for long periods, but may not be receiving support to reduce, stop, or substitute those medications. It appears to me that the ICB is in a position to consider this problem and potential remedies on a regional basis, and feed into national strategies.
” 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 Review and re-procure pain-management services.
Verbatim wording from the response “Considering the concerns raised by the coroner in this report, the ICB is undertaking the following further actions:” Source location Response from NHS Derby and Derbyshire Integrated Care Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out Ten Footsteps pain-support programmes and establish facilitated pain-management support groups.
Verbatim wording from the response “• Roll out of pain support programmes developed in Derby using the evidence based 10 footsteps approach, with 20 pain management support groups facilitated by social prescribing / health coaching teams set up.” Source location Response from NHS Derby and Derbyshire Integrated Care Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide targeted practice support and optional funded protected learning sessions for general practices undertaking prescribing improvement work.
Verbatim wording from the response “• Targeted Practice support for Quality Improvement projects” Source location Response from NHS Derby and Derbyshire Integrated Care Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require practices to identify high-dose opioid patients, review their treatment, document risk and reduction discussions, and add safeguards against dose escalation.
Verbatim wording from the response “GP Quality schedule” Source location Response from NHS Derby and Derbyshire Integrated Care Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the 2026/27 quality schedule to retain high-dose opioid reviews and align the threshold with updated Faculty of Pain Medicine recommendations.
Verbatim wording from the response “Considering the concerns raised by the coroner in this report, the ICB is undertaking the following further actions:” Source location Response from NHS Derby and Derbyshire Integrated Care Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Collaborate with Live Well with Pain to develop and evaluate digital tools supporting holistic pain-management reviews.
Verbatim wording from the response “• Collaboration with the national charity Live Well with Pain to develop and evaluate digital tools for primary care to support patients and clinicians to perform a holistic pain management review.” Source location Response from NHS Derby and Derbyshire Integrated Care Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver opioid and chronic-pain education through specialist webinars and practitioner training in the Ten Footsteps approach.
Verbatim wording from the response “Education –” Source location Response from NHS Derby and Derbyshire Integrated Care Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement recommendations from the GIRFT chronic-pain review in line with national and organisational objectives.
Verbatim wording from the response “In January 2026, the ICB participated in an NHS England GIRFT chronic pain virtual system review, working in collaboration with the Faculty of Pain Medicine and the British Pain Society. The review looked to identify variation and challenges across the whole chronic pain pathway to help address challenges in service delivery for pain management, in line with the strategic aims of the Department of Health and Social Care and NHS England. The aim is to develop a structured model to ensure patients receive personalised, holistic and evidence-based care at each stage, with seamless transitions between services– in turn, improving the patient experience. This is part of a programme of multiple ICS reviews, at the end of which a joint report will be published, highlighting priority areas for national improvement.” Source location Response from NHS Derby and Derbyshire Integrated Care Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop opioid prescribing resources, including a quality-improvement toolkit, repeat-prescribing standards and an opioid-tapering resource.
Verbatim wording from the response “Between January 2022 and March 2025, as part of the national MedSIP, Joined Up Care Derbyshire (JUCD) Integrated Care System took a systems approach to change opioid prescribing in chronic non-cancer pain, supported by Health Innovation East Midlands, who host the East Midlands PSC. The programme involved:” Source location Response from NHS Derby and Derbyshire Integrated Care Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver ICB-funded education sessions for local prescribing leads focused on opioid prescribing.
Verbatim wording from the response “Considering the concerns raised by the coroner in this report, the ICB is undertaking the following further actions:” Source location Response from NHS Derby and Derbyshire Integrated Care Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate in a system-wide GIRFT chronic-pain review to identify pathway variation and service-delivery challenges.
Verbatim wording from the response “Getting it Right First Time (GIRFT) chronic pain review” Source location Response from NHS Derby and Derbyshire Integrated Care Board
Open published response
9 Dec 2025 Hannah Louise Booth · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 4 Failure to record or cross-reference information relevant to both mother and baby in both records View source Lack of a single electronic patient record accessible to all services View source Lack of shared policies, guidance and understanding about information relevant for sharing between services View source Failure to escalate and share increasing contact with health visitors with perinatal mental health services View source See 1 more concern
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
Hannah Louise Booth · 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
Hannah Louise Booth, who had been diagnosed with post-natal depression after giving birth in July 2024, drowned in the Goyt River on 6 January 2025 after sending a message evidencing her intention to take her own life. The report identified concerns about information sharing between services, including different record systems, incomplete records, and relevant information about Hannah being recorded only in her baby’s records. Increasing contact about her baby’s development was not shared with perinatal mental health services or recognised as potentially indicating that Hannah was struggling.
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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to record or cross-reference information relevant to both mother and baby in both records
Wider context from the report “This inquest has exposed important issues with information sharing between services and also within services. Those issues are:
• Difficulties encountered because different IT systems were being used for record keeping in different services. Essentially a lack of a single patient record.
• A lack of a shared understanding of what is relevant information and needs to be made available to other services.
• Relevant notes being made in records of baby and not repeated in notes of the mum.
Further detail:
1. Sett Valley, the health visitors and perinatal mental health services all had information about Hannah that was potentially relevant to her mental health, but none had the whole picture. It was evident that had those within the perinatal mental health services known about Hannah’s increasing frequency of contact with services about her baby’s development, it would have prompted further contact by them with Hannah and prompted a review of risk and support offered. They did not know and there was no further contact.
2. There was no single electronic patient record accessible to all services. Whilst the perinatal mental health and health visitors used SystmOne, Sett Valley did not. The health visitor had not informed Sett Valley about the contact Hannah had had with them on 27th December so that the GP seeing Hannah on 31st did not know that Hannah was beginning to make increased contact with services about her concerns and did not share any information about that consultation with other services.
3. There was increasing contact with health visitors that was not escalated to or shared with perinatal mental health. The significance of the increased contact, to Hannah’s mental health, did not appear to have been understood. The concerns raised at each contact around her baby’s development were dealt with at face value with exploration and examination of her baby’s development and reassurances given to Hannah regarding the particular concerns raised. The evidence revealed that it was not the individual concerns raised that were relevant to Hannah’s mental health but the fact that she was making more frequent contact which suggested she was struggling. There are no policies, guidance or any shared understanding between services of what might be relevant information to be shared and when.
4. Within both Sett Valley and health visitor records there was potentially important information relevant to Hannah’s mental health recorded only within her baby’s records. At any future appointments concerning Hannah the relevant medical history available on her record would have been incomplete. It also meant that whilst the perinatal mental health services had access to the health visitor notes in relation to Hannah (because they both used SystmOne), even had they had cause to look at Hannah’s notes they would still not have had all relevant information. There are no policies or guidance regarding when information potentially relevant to both mother and baby should be placed in both records or cross referenced. This appears to be particularly important in the perinatal period.
” 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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a single electronic patient record accessible to all services
Wider context from the report “This inquest has exposed important issues with information sharing between services and also within services. Those issues are:
• Difficulties encountered because different IT systems were being used for record keeping in different services. Essentially a lack of a single patient record.
• A lack of a shared understanding of what is relevant information and needs to be made available to other services.
• Relevant notes being made in records of baby and not repeated in notes of the mum.
Further detail:
1. Sett Valley, the health visitors and perinatal mental health services all had information about Hannah that was potentially relevant to her mental health, but none had the whole picture. It was evident that had those within the perinatal mental health services known about Hannah’s increasing frequency of contact with services about her baby’s development, it would have prompted further contact by them with Hannah and prompted a review of risk and support offered. They did not know and there was no further contact.
2. There was no single electronic patient record accessible to all services. Whilst the perinatal mental health and health visitors used SystmOne, Sett Valley did not. The health visitor had not informed Sett Valley about the contact Hannah had had with them on 27th December so that the GP seeing Hannah on 31st did not know that Hannah was beginning to make increased contact with services about her concerns and did not share any information about that consultation with other services.
3. There was increasing contact with health visitors that was not escalated to or shared with perinatal mental health. The significance of the increased contact, to Hannah’s mental health, did not appear to have been understood. The concerns raised at each contact around her baby’s development were dealt with at face value with exploration and examination of her baby’s development and reassurances given to Hannah regarding the particular concerns raised. The evidence revealed that it was not the individual concerns raised that were relevant to Hannah’s mental health but the fact that she was making more frequent contact which suggested she was struggling. There are no policies, guidance or any shared understanding between services of what might be relevant information to be shared and when.
4. Within both Sett Valley and health visitor records there was potentially important information relevant to Hannah’s mental health recorded only within her baby’s records. At any future appointments concerning Hannah the relevant medical history available on her record would have been incomplete. It also meant that whilst the perinatal mental health services had access to the health visitor notes in relation to Hannah (because they both used SystmOne), even had they had cause to look at Hannah’s notes they would still not have had all relevant information. There are no policies or guidance regarding when information potentially relevant to both mother and baby should be placed in both records or cross referenced. This appears to be particularly important in the perinatal period.
” 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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of shared policies, guidance and understanding about information relevant for sharing between services
Wider context from the report “This inquest has exposed important issues with information sharing between services and also within services. Those issues are:
• Difficulties encountered because different IT systems were being used for record keeping in different services. Essentially a lack of a single patient record.
• A lack of a shared understanding of what is relevant information and needs to be made available to other services.
• Relevant notes being made in records of baby and not repeated in notes of the mum.
Further detail:
1. Sett Valley, the health visitors and perinatal mental health services all had information about Hannah that was potentially relevant to her mental health, but none had the whole picture. It was evident that had those within the perinatal mental health services known about Hannah’s increasing frequency of contact with services about her baby’s development, it would have prompted further contact by them with Hannah and prompted a review of risk and support offered. They did not know and there was no further contact.
2. There was no single electronic patient record accessible to all services. Whilst the perinatal mental health and health visitors used SystmOne, Sett Valley did not. The health visitor had not informed Sett Valley about the contact Hannah had had with them on 27th December so that the GP seeing Hannah on 31st did not know that Hannah was beginning to make increased contact with services about her concerns and did not share any information about that consultation with other services.
3. There was increasing contact with health visitors that was not escalated to or shared with perinatal mental health. The significance of the increased contact, to Hannah’s mental health, did not appear to have been understood. The concerns raised at each contact around her baby’s development were dealt with at face value with exploration and examination of her baby’s development and reassurances given to Hannah regarding the particular concerns raised. The evidence revealed that it was not the individual concerns raised that were relevant to Hannah’s mental health but the fact that she was making more frequent contact which suggested she was struggling. There are no policies, guidance or any shared understanding between services of what might be relevant information to be shared and when.
4. Within both Sett Valley and health visitor records there was potentially important information relevant to Hannah’s mental health recorded only within her baby’s records. At any future appointments concerning Hannah the relevant medical history available on her record would have been incomplete. It also meant that whilst the perinatal mental health services had access to the health visitor notes in relation to Hannah (because they both used SystmOne), even had they had cause to look at Hannah’s notes they would still not have had all relevant information. There are no policies or guidance regarding when information potentially relevant to both mother and baby should be placed in both records or cross referenced. This appears to be particularly important in the perinatal period.
” 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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate and share increasing contact with health visitors with perinatal mental health services
Wider context from the report “This inquest has exposed important issues with information sharing between services and also within services. Those issues are:
• Difficulties encountered because different IT systems were being used for record keeping in different services. Essentially a lack of a single patient record.
• A lack of a shared understanding of what is relevant information and needs to be made available to other services.
• Relevant notes being made in records of baby and not repeated in notes of the mum.
Further detail:
1. Sett Valley, the health visitors and perinatal mental health services all had information about Hannah that was potentially relevant to her mental health, but none had the whole picture. It was evident that had those within the perinatal mental health services known about Hannah’s increasing frequency of contact with services about her baby’s development, it would have prompted further contact by them with Hannah and prompted a review of risk and support offered. They did not know and there was no further contact.
2. There was no single electronic patient record accessible to all services. Whilst the perinatal mental health and health visitors used SystmOne, Sett Valley did not. The health visitor had not informed Sett Valley about the contact Hannah had had with them on 27th December so that the GP seeing Hannah on 31st did not know that Hannah was beginning to make increased contact with services about her concerns and did not share any information about that consultation with other services.
3. There was increasing contact with health visitors that was not escalated to or shared with perinatal mental health. The significance of the increased contact, to Hannah’s mental health, did not appear to have been understood. The concerns raised at each contact around her baby’s development were dealt with at face value with exploration and examination of her baby’s development and reassurances given to Hannah regarding the particular concerns raised. The evidence revealed that it was not the individual concerns raised that were relevant to Hannah’s mental health but the fact that she was making more frequent contact which suggested she was struggling. There are no policies, guidance or any shared understanding between services of what might be relevant information to be shared and when.
4. Within both Sett Valley and health visitor records there was potentially important information relevant to Hannah’s mental health recorded only within her baby’s records. At any future appointments concerning Hannah the relevant medical history available on her record would have been incomplete. It also meant that whilst the perinatal mental health services had access to the health visitor notes in relation to Hannah (because they both used SystmOne), even had they had cause to look at Hannah’s notes they would still not have had all relevant information. There are no policies or guidance regarding when information potentially relevant to both mother and baby should be placed in both records or cross referenced. This appears to be particularly important in the perinatal period.
” 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 Request discussion of recording information in both mother’s and baby’s notes at the next local maternity network meeting.
Verbatim wording from the response “The ICB will work with Derbyshire Community Health Services NHS Foundation Trust, and Derbyshire Healthcare NHS Foundation Trust, to ensure relevant guidance is provided in these areas by Quarter 1 of the 26/27 financial year. The coronial concerns have been raised with both organisations in quality assurance meetings in the last month and we have also requested that the issue of recording information in both mother’s and baby’s notes is discussed at the next local maternity network meeting for shared learning.” Source location Response from Nottingham and Nottinghamshire Integrated Care Board
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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 NHS England on cross-referencing information in mother and baby records.
Verbatim wording from the response “DDICB notes that some of the matters of concern extend substantially beyond the borders of our organisational influence. We are committed to work with NHS England on these areas; in particular, the matter of concern related to cross-referencing of information in records of mother and baby, which will have a national impact.” Source location Response from Nottingham and Nottinghamshire Integrated Care Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide providers with guidance on recording information relevant to mother and baby and sharing information about frequent service access.
Verbatim wording from the response “DDICB is committed to ensuring that providers understand their obligations to share information between providers, where that information relates to the delivery of patient care. We note the coronial concern around the lack of policy or guidance relating to the recording of information potentially relevant to both mother and baby; and guidance relating to information sharing between healthcare providers in the case of a pattern of more frequent access to services.” Source location Response from Nottingham and Nottinghamshire Integrated Care Board
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Some concerns, particularly cross-referencing mother and baby records, extend beyond the ICB’s organisational influence and require work with NHS England.
Verbatim wording from the response “DDICB notes that some of the matters of concern extend substantially beyond the borders of our organisational influence. We are committed to work with NHS England on these areas; in particular, the matter of concern related to cross-referencing of information in records of mother and baby, which will have a national impact.” Source location Response from Nottingham and Nottinghamshire Integrated Care Board
Open published response
30 Jun 2025 Aaron ATKINSON · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 2 Lack of clear and consistent guidance on ECGs during annual monitoring of long-term antipsychotic medication View source Failure to include ECGs in annual reviews for people prescribed antipsychotic medication long term View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Aaron ATKINSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Aaron Atkinson was found deceased at his home on 20 April 2023, and the death was unexpected. The inquest conclusion was unascertained, with medical evidence considering seizure and positional asphyxia, or cardiac arrhythmia associated with prescribed medication. The principal concern was that annual reviews for people taking long-term antipsychotic medication may not consistently include ECGs despite recognised risks of QT interval prolongation and lethal cardiac arrhythmias.
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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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of clear and consistent guidance on ECGs during annual monitoring of long-term antipsychotic medication
Wider context from the report “Whilst Aaron had annual GP reviews related to prescription of anti-psychotic medication (Risperidone, although the inquest heard that prescription of Ritalin was also a relevant factor, particularly in combination with Risperidone), to check for signs of adverse side effects and physical health complications, those reviews did not include ECGs (electrocardiograms) to check for signs of adverse effects on electrical activity of the heart. On the medical evidence before the inquest antipsychotic medication carries recognised risk of QT interval prolongation and lethal cardiac arrhythmias.
It does not appear that the recognised risk of QT interval prolongation and lethal cardiac arrhythmias from long term prescription of antipsychotic medication is reflected in guidance to medical practitioners and prescribers, nationally or locally in terms of performing ECGs.
The relevant NICE (National Institute for Clinical Excellence) guidance (web link below) refers to ECG testing under How should I monitor someone taking antipsychotics? and recommends Electrocardiography (ECG) - after dose changes. Ideally, also annually.
The local Derbyshire Integrated Care Board guidance (web link below) does not identify need for ECG to be included in annual monitoring in primary care unless if new medicines or changes to physical health have increased the risk of prolonged QTc arrange ECG.
It appears there is lack of clarity and consistency for annual reviews to include ECGs where people are prescribed antipsychotic medication long term. Given the recognised risks explained at inquest then not providing annual ECGs for long term users of those medications appears to pose risk of death.
NICE web link: https://cks.nice.org.uk/topics/bipolar-disorder/prescribing-information/antipsychotics/
Derbyshire web link (DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC)): https://www.derbyshiremedicinesmanagement.nhs.uk/assets/Clinical_Guidelines/Formulary_by_BNF_chapter_prescribing_guidelines/BNF_chapter_4/Antipsychotics_Prescribing_and_Management.pdf
” 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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to include ECGs in annual reviews for people prescribed antipsychotic medication long term
Wider context from the report “Whilst Aaron had annual GP reviews related to prescription of anti-psychotic medication (Risperidone, although the inquest heard that prescription of Ritalin was also a relevant factor, particularly in combination with Risperidone), to check for signs of adverse side effects and physical health complications, those reviews did not include ECGs (electrocardiograms) to check for signs of adverse effects on electrical activity of the heart . On the medical evidence before the inquest antipsychotic medication carries recognised risk of QT interval prolongation and lethal cardiac arrhythmias.
It does not appear that the recognised risk of QT interval prolongation and lethal cardiac arrhythmias from long term prescription of antipsychotic medication is reflected in guidance to medical practitioners and prescribers, nationally or locally in terms of performing ECGs.
The relevant NICE (National Institute for Clinical Excellence) guidance (web link below) refers to ECG testing under How should I monitor someone taking antipsychotics? and recommends Electrocardiography (ECG) - after dose changes. Ideally, also annually.
The local Derbyshire Integrated Care Board guidance (web link below) does not identify need for ECG to be included in annual monitoring in primary care unless if new medicines or changes to physical health have increased the risk of prolonged QTc arrange ECG.
It appears there is lack of clarity and consistency for annual reviews to include ECGs where people are prescribed antipsychotic medication long term . Given the recognised risks explained at inquest then not providing annual ECGs for long term users of those medications appears to pose risk of death .
NICE web link: https://cks.nice.org.uk/topics/bipolar-disorder/prescribing-information/antipsychotics/
Derbyshire web link (DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC)): https://www.derbyshiremedicinesmanagement.nhs.uk/assets/Clinical_Guidelines/Formulary_by_BNF_chapter_prescribing_guidelines/BNF_chapter_4/Antipsychotics_Prescribing_and_Management.pdf
” 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 Review NICE’s response and implement any necessary local updates or further actions arising from changes to national ECG monitoring guidance.
Verbatim wording from the response “2. Await NICE response” Source location 2025-0329- Response from NHS Derby and Derbyshire Integrated Care Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the ratified learning report and guidance updates with primary-care clinicians and relevant system networks through existing communications and governance meetings.
Verbatim wording from the response “3. Shared learning” Source location 2025-0329- Response from NHS Derby and Derbyshire Integrated Care Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update local antipsychotic prescribing guidance to recommend ECG monitoring after dose changes and ideally annually.
Verbatim wording from the response “Our considered position is that the ICB will amend the JAPC recommendation to align with the NICE CKS by advising ECG monitoring for all patients on antipsychotics after dose changes and ideally, also annually. This local change will be implemented while awaiting any future national guidance revisions from NICE, which would require country-wide adoption.” Source location 2025-0329- Response from NHS Derby and Derbyshire Integrated Care Board
Open published response
25 Nov 2024 Margaret Mary Feeney · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 1 Lack of measures to prevent excess prescribing to patients at risk of overdose during longer bank holiday periods 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
Margaret Mary Feeney · 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
Margaret Mary Feeney was found deceased at home after taking excess prescribed medication, with pneumonia also contributing to her death. The principal concern was that prescribing and pharmacy arrangements around longer bank holiday periods allowed excess medication to be supplied to a patient recognised as being at risk of overdose.
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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of measures to prevent excess prescribing to patients at risk of overdose during longer bank holiday periods
Wider context from the report “I am concerned that measures are not in place at Macklin Street Surgery and Daynight pharmacy to prevent prescription of excess medication to patient’s recognised to be at risk of overdose, either intentional or unintentional , who are ordinarily issued shorter period repeat prescriptions to reduce those risks. This situation arises when early prescriptions are issued due to statutory holiday periods when most pharmacies are likely to be closed. I have been informed that measures have been introduced to prevent excess prescribing by taking account of single day bank holidays, but there are no measures relating to longer bank holiday periods (e.g. Easter) . With electronic patient record and data systems it seems a reasonable presumption that suitable solutions can be identified.
” 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 Share learning and concerns with clinical-system providers, requesting consideration and implementation of solutions to prevent recurrence.
Verbatim wording from the response “We acknowledge that updates to provider clinical systems could play a crucial role in addressing the issues identified. However, given the operational and developmental oversight of these systems lies with their respective clinical system providers, we believe they are best positioned to evaluate and enact the necessary changes.” Source location Response from Derby and Derbyshire 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 Disseminate collated learning and prescribing-safety updates through pharmacy newsletters, GP messages, medicines-safety communications and prescribing-leads forums.
Verbatim wording from the response “We recommend promoting the use of this feature across all practices as part of a broader effort to strengthen the scheduled prescription process. Sharing this learning with system users can help make prescription management more robust and prevent potential medication-related risks.” Source location Response from Derby and Derbyshire 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 Review the community pharmacy investigation, lessons learned and identified actions, and determine required support with controlled drugs and commissioning teams.
Verbatim wording from the response “Action number | Overview of DDICB actions | Proposed completion date
INVESTIGATION AND SUPPORT
1a | Review investigation and lessons learnt/ actions identified by the practice. With support of the ICB primary care quality team and ICB patient safety team, identify support required | 7/2/25
1b | Review investigation and lessons learnt/ actions at community pharmacy. With support of Midlands controlled drugs area team and primary care commissioning team, identify support required. | 7/2/25
REVIEW AND COMMUNICATIONS
2a | Extract shared learning from the practice and community pharmacy reports and add lessons to be shared additionally to those raised above, into an incident report, ready to be shared with system colleagues. Learning report ratified | 14/2/25” Source location Response from Derby and Derbyshire 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 Review the GP practice investigation, lessons learned and identified actions, and determine required support with primary care quality and patient safety teams.
Verbatim wording from the response “Action number | Overview of DDICB actions | Proposed completion date
INVESTIGATION AND SUPPORT
1a | Review investigation and lessons learnt/ actions identified by the practice. With support of the ICB primary care quality team and ICB patient safety team, identify support required | 7/2/25
1b | Review investigation and lessons learnt/ actions at community pharmacy. With support of Midlands controlled drugs area team and primary care commissioning team, identify support required. | 7/2/25
REVIEW AND COMMUNICATIONS
2a | Extract shared learning from the practice and community pharmacy reports and add lessons to be shared additionally to those raised above, into an incident report, ready to be shared with system colleagues. Learning report ratified | 14/2/25” Source location Response from Derby and Derbyshire Integrated Care Board
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 Clinical system providers are responsible for evaluating and implementing necessary updates because they control operational and developmental oversight.
Verbatim wording from the response “We acknowledge that updates to provider clinical systems could play a crucial role in addressing the issues identified. However, given the operational and developmental oversight of these systems lies with their respective clinical system providers, we believe they are best positioned to evaluate and enact the necessary changes.” Source location Response from Derby and Derbyshire Integrated Care Board
Open published response
11 Nov 2024 Vera SPENCER · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 2 Unavailability of an out-of-hours local falls service or team View source Delays in ambulance attendance for people who have fallen at home View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Vera SPENCER · 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
Vera Spencer fell at home and waited approximately 11 hours for an ambulance before being taken to hospital with a fractured hip and chest infection. Her condition deteriorated after surgery, and she died on 11 December 2023; the medical cause of death included pneumonia and a fall. The principal concern was that people who fall at home may wait many hours for paramedic attendance during periods of ambulance service pressure, with no local out-of-hours falls service to assist them off the floor.
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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of an out-of-hours local falls service or team
Wider context from the report “At times when the ambulance service is under extreme pressure, individuals who have fallen at home can wait many hours on the floor before paramedics can attend. This is usually because falls are given a lower categorisation by the ambulance service because it is not a life-threatening situation. Resultant long lies can increase the risk of pneumonia, pressure damage and Rhabdomyolysis. The court heard evidence that other than the ambulance service, there is no local falls service or team operating out of hours to assess patients and assist them off the floor following a fall .
” 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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance attendance for people who have fallen at home
Wider context from the report “At times when the ambulance service is under extreme pressure, individuals who have fallen at home can wait many hours on the floor before paramedics can attend . This is usually because falls are given a lower categorisation by the ambulance service because it is not a life-threatening situation. Resultant long lies can increase the risk of pneumonia, pressure damage and Rhabdomyolysis. The court heard evidence that other than the ambulance service, there is no local falls service or team operating out of hours to assess patients and assist them off the floor following a fall.
” 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 Implement area-wide options to further mitigate the risk of prolonged waits on the floor after a fall.
Verbatim wording from the response “Further options that the ICB will consider for alternative ambulance response out of hours:” Source location Response from Derby NHS ICB
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 multi-agency work with local authorities and voluntary-sector partners to minimise ambulance response times.
Verbatim wording from the response “In this critical incident the local NHS worked together with the local authorities and the voluntary sector to reduce the response times for patients in the community. In the short term we will continue to work as a multi-agency group to try and minimise response times by EMAS. In the medium term we recognise that we will need to identify ways in which the demand for healthcare and healthcare beds can be reduced. This will require a blended approach that looks at:” Source location Response from Derby NHS ICB
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 Proposed alternative out-of-hours responders cannot safely recover people with suspected hip fractures because they have only seated-lifter equipment; ambulance attendance remains necessary.
Verbatim wording from the response “Option A: DHU have staff trained in falls recovery as they provide some cover for the Team Up / UCR provision. Their falls response provision could be extended to cover 20:00-08:00, and Team Up and step-up virtual wards would provide the continuation of clinical support next day. If this was in situ, this individual could have been responded to by a team, observations completed, ambulance need confirmed through on-screen head to toe assessment, perhaps an urgent visit arranged from DHU medic for pain relief. It is likely that with a hip fracture suspected, the responders would not be able to safely lift the individual off the floor (teams only have seated lifter equipment). This option would offer the person in person support, confirmation of need and pain and other symptom management, but not remove the need for ambulance attendance in this case.” Source location Response from Derby NHS ICB
Open published response
15 Oct 2024 Stephen Charles Stringer · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Failure to maintain holistic oversight of patients receiving care from multiple practitioners View source Failure to recognise persistent hoarse voice as a potential laryngeal cancer red flag View source Failure to provide clear electronic patient enquiry routing information View source Failure to transfer administrative patient enquiries to the patient record and make them available to doctors View source Limited public awareness of voice change as a potential cancer symptom View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stephen Charles Stringer · 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
Stephen Charles Stringer developed a hoarse voice from January 2023, but its persistence and deterioration were not recognised as a potential cancer warning sign until October 2023. He was diagnosed in January 2024 with stage 4 squamous cell carcinoma of the glottis and treated palliatively. The report identified concerns about delayed referral, gaps in electronic patient enquiry systems, fragmented oversight of his care, and limited awareness of persistent hoarseness as a possible cancer symptom.
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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain holistic oversight of patients receiving care from multiple practitioners
Wider context from the report “3. A number of different health professionals had input into his care. This meant that there was no one health professional who had a good insight into his overall deterioration and symptoms. Where multiple practitioners were involved one person needed to maintain oversight or the electronic patient record needed to have easily accessible clear action plans and notes were required so that a patient and their symptoms could be seen holistically rather than a one off.
” 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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise persistent hoarse voice as a potential laryngeal cancer red flag
Wider context from the report “2. The evidence from the ENT consultant was that it was important that where a patient presented with a hoarse voice that all health professionals explored for how long it had been an issue and whether there was a realistic treatable cause for it .In the absence of any clear cause such as a throat infection or where there was no clear response to treatment then a hoarse voice should be seen as a red flag symptom for laryngeal cancers and result in a referral on the 2 week wait. It was clear from the evidence at the inquest that unlike other cancer red flags such as blood in urine the significance of a persistent hoarse voice was not recognised by a number of different healthcare professionals who saw him.
The inquest was told that early detection of laryngeal cancers through early referrals on the 2 week wait significantly improves the outcomes for patients because far more treatment options are open to clinicians.
” 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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear electronic patient enquiry routing information
Wider context from the report “1. The inquest heard evidence that the GP practice had in accordance with the local requirements introduced an electronic patient enquiry service alongside a telephone service. Patients contacting the surgery had to select which stream within the practice their enquiry went to. It was not always clear from the headings whether the query would be seen by a GP or the admin team. Information that went into the admin work stream from a patient did not go onto the patient record and was not seen by a doctor.
The GPs at the practice were unaware of this and patients had no way of knowing that the information they had sent in was not in the patient record. The practice involved in this inquest had taken steps since identifying the issue to mitigate the risks. However the evidence before the inquest was that the software in question was widely used by GP practices within Derbyshire and nationally.
” 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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer administrative patient enquiries to the patient record and make them available to doctors
Wider context from the report “1. The inquest heard evidence that the GP practice had in accordance with the local requirements introduced an electronic patient enquiry service alongside a telephone service. Patients contacting the surgery had to select which stream within the practice their enquiry went to. It was not always clear from the headings whether the query would be seen by a GP or the admin team. Information that went into the admin work stream from a patient did not go onto the patient record and was not seen by a doctor.
The GPs at the practice were unaware of this and patients had no way of knowing that the information they had sent in was not in the patient record. The practice involved in this inquest had taken steps since identifying the issue to mitigate the risks. However the evidence before the inquest was that the software in question was widely used by GP practices within Derbyshire and nationally.
” 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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Limited public awareness of voice change as a potential cancer symptom
Wider context from the report “4. There was also evidence that there is limited public awareness of how significant a change in voice can be and recognising it as a potential cancer symptom. Greater public awareness of symptoms of laryngeal cancers would ensure the public were better placed to seek help at an early stage.
” 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 Deliver an educational head and neck cancer session for PCN Cancer Leads.
Verbatim wording from the response “• LMC
Record a webinar with Head & Neck Consultants and the DDICB Clinical Lead in a Q&A style to share across primary care around signs & symptoms.
Raise awareness at the next PCN Cancer Leads meeting.
Work with Communications to develop some public facing comms around recognising signs and symptoms.” Source location Response from Derby and Derbyshire 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 Discuss adding record-keeping resources to the Hub Plus online information and support suite.
Verbatim wording from the response “The DDICB will also liaise with HUB+ to discuss the possibility of Record Keeping being added to their suite of online information and support for general practice.” Source location Response from Derby and Derbyshire 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 Discuss high-quality patient-record and medical-record guidance at a Clinical Governance Leads patient-safety agenda item.
Verbatim wording from the response “At the Clinical Governance Leads meeting with general practice the below documents will be discussed as part of the Patient safety standard agenda item.” Source location Response from Derby and Derbyshire 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 Record and share a head and neck cancer signs-and-symptoms webinar with primary care.
Verbatim wording from the response “The DDICB Clinical Lead for Cancer and Senior Commissioning Manager Cancer will. Promote the GatewayC module for Head and Neck (education Package) through the following channels.” Source location Response from Derby and Derbyshire Integrated Care Board
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 and disseminate public-facing and stakeholder communications about recognising head and neck cancer signs and symptoms.
Verbatim wording from the response “• LMC
Record a webinar with Head & Neck Consultants and the DDICB Clinical Lead in a Q&A style to share across primary care around signs & symptoms.
Raise awareness at the next PCN Cancer Leads meeting.
Work with Communications to develop some public facing comms around recognising signs and symptoms.” Source location Response from Derby and Derbyshire Integrated Care Board
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 Promote head and neck cancer education through primary care, Hub Plus, and Local Medical Council communication channels.
Verbatim wording from the response “The DDICB Clinical Lead for Cancer and Senior Commissioning Manager Cancer will. Promote the GatewayC module for Head and Neck (education Package) through the following channels.” Source location Response from Derby and Derbyshire Integrated Care Board
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 Online consultation tools are delivered nationally at scale, leaving little or no local capability to vary their layout or contents.
Verbatim wording from the response “The online consultation tools are delivered nationally and at scale with the support of the National Procurement Hub and frameworks, with little or no capability to vary the layout, contents, etc on a local basis. There is a wide range of functionality available across the online consultation solutions we have within our system ranging from simple forms, through to more complex systems which aim to direct the patient to self-care.” Source location Response from Derby and Derbyshire Integrated Care Board
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 GP practices choose which online consultation tool to use and may opt out of automated integration with electronic patient records.
Verbatim wording from the response “While the ICB is currently the contract holder for online consultation tools in use within Primary Care, the choice of which online consultation to utilise resides with the GP Practice.” Source location Response from Derby and Derbyshire Integrated Care Board
Open published response
Concerns raised 3 Failure to check Red Bag contents for relevant information View source Failure to implement and routinely use the Red Bag scheme across care and hospital admissions View source Failure to make systematic enquiries for care plans and other relevant documentation between agencies 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
Mark SUMNALL · 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
Mark Sumnall died in hospital on the morning of 21 December 2020 after choking and aspirating on a sandwich given by hospital staff. He had a recognised choking risk, but hospital staff were not aware of it despite his care plan being sent with him in a Red Bag. The report raised concerns about failures to identify and use the Red Bag and to transfer relevant care and risk information between the care home, ambulance service and hospital.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to check Red Bag contents for relevant information
Wider context from the report “The Derbyshire wide Red Bag scheme is an initiative designed to ensure that when care home residents are admitted to hospital, key health and social care information travels with them by way of documentation such as care plans (as well as medication and essential personal items). I understand that the County Council and the CCG are the primary agencies responsible for the scheme. On the evidence considered at Mr Sumnall's inquest: -
1. The scheme does not appear to be widely used in Derbyshire, although the scheme was in response to NICE guidance for improving patient care and safety when transferring between health and care settings (NG27: Transition between inpatient hospital setting and community or care homes). The inquest heard that Mr Sumnall’s care home only had one bag for use on the premises, and that ambulance and hospital staff did not routinely deal with admissions where care home patients were sent with Red Bags.
2. The Red Bag travelled with Mr Sumnall and was found with his clothes when he died. Despite being with him there is no evidence that anyone looked in the bag to check for relevant information . This being the case it appears to me that there is lack of awareness of how the bag should be used , but also, as no enquiries were separately made for care plan and other relevant documentation, that the thrust of the NICE guidance for improving patient care and safety is not being addressed systematically between agencies.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to implement and routinely use the Red Bag scheme across care and hospital admissions
Wider context from the report “The Derbyshire wide Red Bag scheme is an initiative designed to ensure that when care home residents are admitted to hospital, key health and social care information travels with them by way of documentation such as care plans (as well as medication and essential personal items). I understand that the County Council and the CCG are the primary agencies responsible for the scheme. On the evidence considered at Mr Sumnall's inquest: -
1. The scheme does not appear to be widely used in Derbyshire , although the scheme was in response to NICE guidance for improving patient care and safety when transferring between health and care settings (NG27: Transition between inpatient hospital setting and community or care homes). The inquest heard that Mr Sumnall’s care home only had one bag for use on the premises , and that ambulance and hospital staff did not routinely deal with admissions where care home patients were sent with Red Bags .
2. The Red Bag travelled with Mr Sumnall and was found with his clothes when he died. Despite being with him there is no evidence that anyone looked in the bag to check for relevant information. This being the case it appears to me that there is lack of awareness of how the bag should be used, but also, as no enquiries were separately made for care plan and other relevant documentation, that the thrust of the NICE guidance for improving patient care and safety is not being addressed systematically between agencies.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to make systematic enquiries for care plans and other relevant documentation between agencies
Wider context from the report “The Derbyshire wide Red Bag scheme is an initiative designed to ensure that when care home residents are admitted to hospital, key health and social care information travels with them by way of documentation such as care plans (as well as medication and essential personal items). I understand that the County Council and the CCG are the primary agencies responsible for the scheme. On the evidence considered at Mr Sumnall's inquest: -
1. The scheme does not appear to be widely used in Derbyshire, although the scheme was in response to NICE guidance for improving patient care and safety when transferring between health and care settings (NG27: Transition between inpatient hospital setting and community or care homes). The inquest heard that Mr Sumnall’s care home only had one bag for use on the premises, and that ambulance and hospital staff did not routinely deal with admissions where care home patients were sent with Red Bags.
2. The Red Bag travelled with Mr Sumnall and was found with his clothes when he died. Despite being with him there is no evidence that anyone looked in the bag to check for relevant information. This being the case it appears to me that there is lack of awareness of how the bag should be used, but also, as no enquiries were separately made for care plan and other relevant documentation , that the thrust of the NICE guidance for improving patient care and safety is not being addressed systematically between agencies .
” Open source report
Concerns raised 2 Delays in transferring patients' medical notes and history to GP practices View source Failure to ensure clinicians know patients' full medical history before treating and prescribing View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mrs Christine Forbes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Christine Forbes, a 72-year-old woman with a history of oxycodone stockpiling and misuse, died on 2 February 2020 after taking oxycodone and zolpidem. The principal concern was that patients registering with GP surgeries may be prescribed medication before their medical notes and relevant history are available.
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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring patients' medical notes and history to GP practices
Wider context from the report “1. That when patients register at GP surgeries (across England) they do so without their medical notes and history . This material can take a significant amount of time to be sent to a GP practice after a request is sent to Primary Care Support England . Doctors and other medical practitioners are therefore treating and prescribing in situations where a full medical history is not known.
” 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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure clinicians know patients' full medical history before treating and prescribing
Wider context from the report “1. That when patients register at GP surgeries (across England) they do so without their medical notes and history. This material can take a significant amount of time to be sent to a GP practice after a request is sent to Primary Care Support England. Doctors and other medical practitioners are therefore treating and prescribing in situations where a full medical history is not known .
” 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 Offer Ashbourne Medical Practice additional GP2GP and electronic record transfer training.
Verbatim wording from the response “• Offer additional GP2GP/ Record Transfer training to Ashbourne Medical Practice” Source location 2020-0181-Response-from-NHS-Derby-and-Derbyshire-Clinical-Commissioning-Group-Redacted.pdf
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 Offer Ashbourne Medical Practice additional note summarisation training.
Verbatim wording from the response “• Offer additional training Note Summarisation to Ashbourne Medical Practice” Source location 2020-0181-Response-from-NHS-Derby-and-Derbyshire-Clinical-Commissioning-Group-Redacted.pdf
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 Enable all Derby and Derbyshire general practices to use GP2GP electronic record transfer.
Verbatim wording from the response “All general practices across Derby and Derbyshire are enabled for GP2GP electronic record transfer; this is an electronic system which allows patients' electronic health records to be transferred between their old and new practices within a matter of minutes (at most 24hrs) , when a patient registers with a new GP practice.” Source location 2020-0181-Response-from-NHS-Derby-and-Derbyshire-Clinical-Commissioning-Group-Redacted.pdf
Open published response
12 May 2018 CHARLES EVAN GRAINGER · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 2 Failure of multi-agencies to share patients' past medical history, including previous falls history View source Failure to undertake basic and proper investigations of falls risk assessments 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
CHARLES EVAN GRAINGER · 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
Charles Evan Grainger was admitted to Milford House Residential Unit after a fall and later sustained injuries in a witnessed fall there on 24 November 2013. The inquest concluded that his death was accidental, with the medical cause recorded as bronchopneumonia and central cord syndrome. Concerns included failures to share his history of falls between relevant agencies and inadequate investigation of the circumstances surrounding his fall.
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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of multi-agencies to share patients' past medical history, including previous falls history
Wider context from the report “(1) Relevant information regarding Mr Grainger's falls history could not be shared by his Social Worker with other relevant Multi Agencies such as Milford House or the Health Team at the time his Pre Admission Assessment was undertaken as the process/system did not allow it . Milford House, the Local Authority and the Health Team should have all worked together, more cohesively to ensure they were working in Mr Grainger's best interests. Failure of Multi Agencies to work more cohesively in the future by sharing a patients past medical history, including previous falls history could result in vital information being missed and future deaths occurring.
” 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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake basic and proper investigations of falls risk assessments
Wider context from the report “(2) ████████ did not consider it important or necessary to request, review or retain copies of Mr Grainger's falls risk assessment as part of her basic investigation enquiries . Failure to undertake a basic and proper investigation could result in future deaths occurring.
” Open source report
Concerns raised 1 Delays in emergency vehicle responses 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
BERNARD LESLIE GERRARD · 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
Bernard Leslie Gerrard sustained injuries in an unwitnessed fall at the care home, was found to have a left fractured neck of femur, and died on 2 December 2017 despite treatment. The principal concern was a prolonged ambulance response, including delays to both the initial Category 3 response and the later Category 2 response, which EMAS attributed to insufficient resources and funding.
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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in emergency vehicle responses
Wider context from the report “(1) There was a 10 hour vehicle response delay to attend to a Category 3 call. When the call was eventually upgraded to a Category 2 response, there was a further 50 minute delay . EMAS report that they cannot cope with the current demands placed on their service due to insufficient funding which is resulting in unacceptable vehicle response times
” Open source report
Concerns raised 2 Insufficient ambulance service resources and staffing capacity View source Delays in hospital handover of ambulance patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Peter Scott · 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
Peter Scott suffered an aortic dissection at home on 3 December 2015 and experienced a substantial delay in ambulance attendance after a call was prioritised as Green 2. The principal concern was that resource shortages, frequent use of Capacity Management Plans, recruitment problems and delayed hospital handovers posed a serious risk to the public and could contribute to future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient ambulance service resources and staffing capacity
Wider context from the report “I remain very concerned about resource issues for this ambulance service . I raised similar concerns in a Prevention of Future Deaths Report in the case of MG, dated 11 May 2016.
We heard evidence from a senior manager at EMAS during the inquest. I asked the service to advise me to what extent they had had to invoke Capacity Management Plans in the last 12 months. I was advised that EMAS has had to invoke such a Plan (to at least level 3) for 9 out of the last 12 months .
The issue in this case and that of MG was essentially a matter of resource. In essence, I found that there is only so much an ambulance service can do where they simply do not have an ambulance to send . Demand is clearly greater than the resources they have most of the time , given that a CMP has been in place for 75% of the last 12 month period.
I am very concerned that this poses a serious risk to the public served by this ambulance service . We heard also that recruitment is an ongoing problem – which may be exacerbated by the huge demand placed on its employees by this resource issue.
Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals. I believe the trust is already working to improve this, and I include EMAS in this report in this respect only. Other recipients of the report are required to respond with regard to matters of resourcing only.
1. I consider that there is a risk of future deaths as set out above unless an urgent review of resources is undertaken.
2. Consideration should be given to strategies to improve handover times at hospitals.
” 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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in hospital handover of ambulance patients
Wider context from the report “I remain very concerned about resource issues for this ambulance service. I raised similar concerns in a Prevention of Future Deaths Report in the case of MG, dated 11 May 2016.
We heard evidence from a senior manager at EMAS during the inquest. I asked the service to advise me to what extent they had had to invoke Capacity Management Plans in the last 12 months. I was advised that EMAS has had to invoke such a Plan (to at least level 3) for 9 out of the last 12 months.
The issue in this case and that of MG was essentially a matter of resource. In essence, I found that there is only so much an ambulance service can do where they simply do not have an ambulance to send. Demand is clearly greater than the resources they have most of the time, given that a CMP has been in place for 75% of the last 12 month period.
I am very concerned that this poses a serious risk to the public served by this ambulance service. We heard also that recruitment is an ongoing problem – which may be exacerbated by the huge demand placed on its employees by this resource issue.
Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals . I believe the trust is already working to improve this, and I include EMAS in this report in this respect only. Other recipients of the report are required to respond with regard to matters of resourcing only.
1. I consider that there is a risk of future deaths as set out above unless an urgent review of resources is undertaken.
2. Consideration should be given to strategies to improve handover times at hospitals.
” Open source report
Concerns raised 4 Failure to schedule ambulance crew meal breaks to maintain emergency availability View source Lack of training on placental abruption presentations and fetal risk despite reassuring maternal signs View source Insufficient availability of ambulance resources for urgent emergencies View source Failure to issue open-mic reports to mobilise available ambulance crews View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mia Gibson · 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
Mia Gibson was born in very poor condition after her mother suffered a sudden placental abruption on 16 November 2015 and died later that day. The report identifies delays in ambulance availability and transfer to hospital, alongside concerns about recognition of the risk to the baby, ambulance crew availability and meal-break planning.
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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to schedule ambulance crew meal breaks to maintain emergency availability
Wider context from the report “3. Dispatchers appear to have allowed a situation to arise whereby the only 2 DCAs not attending other jobs were both on compulsory meal breaks and therefore unavailable at the same time . Whilst meal breaks are vital for staff, planning the timing of these, by ambulance control, is critical for patient safety . Meal break management is already under review by EMAS.
” 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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of training on placental abruption presentations and fetal risk despite reassuring maternal signs
Wider context from the report “1. It appears that great reliance was placed on the fact that ████████ was not in pain and had normal observations. Little consideration appears to have been given to the ‘second patient’ (Mia), whose condition could not be monitored by paramedics. We heard evidence that in fact not all placental abruptions cause the mother significant pain, or concerning observations, but for the baby, it can be akin to a cardiac arrest. This factor appears to have been overlooked in the trust’s subsequent investigation report, which refers several times to how reassuring ████████ clinical condition was, and was repeated in evidence by the paramedic witnesses. This is a clear training issue, and may well apply nationally.
” 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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of ambulance resources for urgent emergencies
Wider context from the report “5. It is clear that resources played a part in these tragic events. No DCA was available to attend this emergency until 30 minutes after the call, and it took a further 12 minutes for a DCA to arrive after that. The time between the 999 call and ████████ being handed over to maternity staff was an hour and 15 minutes. It was clear from the outset that ████████ would require urgent transfer to hospital – a mere 4 miles from her home address – but no resource was available. The evidence of those ‘on the ground’ clearly showed that this is far from an isolated incident , and I remain concerned that there is a risk of future deaths if this is not addressed .
” 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 Derby and Derbyshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to issue open-mic reports to mobilise available ambulance crews
Wider context from the report “2. No ‘open mic’ report was put out to see if other crews could make themselves available to attend this emergency.
” Open source report
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Addressed to NHS Derby and Derbyshire Clinical Commissioning Group, now represented here by NHS Derby and Derbyshire Integrated Care Board.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations