11 Mar 2025 Marta Elena Vento · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 5 Failure of some mental healthcare trusts to accept referrals for homeless prisoners on release View source Unavailability of National Record Locator access for South West ambulance care in Dorset View source Lack of guidance and tools for assessing violence risk in MOSOVO-managed offenders View source Lack of a process for sharing remanded prisoners’ risk information with sentencing courts View source Lack of practical national guidance for continuity of prisoners’ healthcare on release 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
Marta Elena Vento · 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
Marta Elena Vento was working alone as a hotel receptionist in Bournemouth when she was fatally beaten in an unprovoked attack on 9 December 2020. The report raises concerns about the sharing of remand prisoners’ risk information with sentencing courts, continuity of mental healthcare after release from prison, risk assessment of violent offenders managed by MOSOVO units, and access to patient information through the National Record Locator.
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 Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of some mental healthcare trusts to accept referrals for homeless prisoners on release
Wider context from the report “Evidence was given that this is not the process nationally in that some mental healthcare trusts will not accept a referral if a person is homeless . There is no national guidance about the continuity of care for prisoners upon release from prison when homeless .
I am concerned that this lack of continuity of care could lead to future deaths.
” 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 Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of National Record Locator access for South West ambulance care in Dorset
Wider context from the report “Evidence was given by the Head of Clinical Development and Organisational Development at South West Ambulance Service NHS Foundation Trust (SWAST) that in the South West region all Integrated Care Boards (ICBs), apart from the ICB in Dorset, NHS Dorset, are at some stage of implementing the use of NRL so that SWAST can access this information to assist in the provision of care to those they treat.
Evidence was given that as this would limit the information SWAST had access to about a patient in Dorset , this would impact upon the care provided to those in Dorset by SWAST which could lead to a future death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance and tools for assessing violence risk in MOSOVO-managed offenders
Wider context from the report “The risk assessments detailed in the guidance are aimed at the assessment of the sexual risk of offenders and evidence was given that there is no bespoke risk assessment tool or guidance to assess the violence of such offenders to assist staff within MOSOVO units to undertake their role . There is, therefore, a lack of guidance on how to risk assess and manage offenders who are managed under MOSOVO when they present with the risk of violence, or an escalating risk of violence .
I am concerned that this will result in a failure to identify the risk of violence, or the increasing risk of violence, in those being managed by MOSOVO which may lead to a further death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a process for sharing remanded prisoners’ risk information with sentencing courts
Wider context from the report “Evidence was given by the Head of the Offender Management Unit (OMU) at HMP Winchester, a Senior Probation Officer, that there is currently no formal process or guidance in place for the sharing of information by a prison with the Criminal Courts to provide an update of the person's behaviour in prison which may increase their risk of harm or risk offending .
It was explained that the person who could enquire about this at Court, if asked, would be the duty Probation Officer, and that this is especially more challenging to complete when a fast delivery report is requested.
There is currently no process from a prison perspective to share information to the sentencing Court other than that contained within the Prison Escort Record (PER), which is not provided to the sentencing Judge, the lawyers at Court or Probation staff .
I am concerned that the full extent of a remanded prisoner’s risk of harm to the public may not be appreciated by the sentencing Judge, which could impact upon the sentence imposed upon a prisoner and I am concerned that this lack of sharing of information could lead to future deaths.
” 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 Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of practical national guidance for continuity of prisoners’ healthcare on release
Wider context from the report “There is a lack of national guidance to assist all healthcare providers to ensure continuity of care for a prisoner with health care needs, whether physical or mental health needs, upon release from prison . There are national standards of care and NICE guidelines in place, however none of these provide practical guidance around the delivery of care to ensure continuity of care .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish Dorset Care Record capability to share information through the National Record Locator and begin sharing records with other services.
Verbatim wording from the response “Meanwhile in the absence of this capability DCR is looking to have the technical capability to share information with others using NRL from March 2026 onwards. Currently our system supplier has not been able to deliver this capability. Importantly, this will meet the national deadline set by NHS England, which is important because the benefit of using a single system to share is enjoyed when all parties are consistent. Shortly after this, DCR will then start sharing records to others using NRL, which will mean that SWASFT can access the data through this method.” Source location Response from NHS Dorset ICB
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue participating in regional and national work to adopt National Record Locator information sharing.
Verbatim wording from the response “NHS Dorset and the Dorset Care Record (DCR) Partnership are involved in the regional and national work to adopt sharing information via the National Recorder Locator and were in fact founding members of the One South West Programme. This is a complex area and although a number of ICSs in the South-West are making progress, there is much work to be done. The issue is not as simple as suggested, and the current focus of the work across the One South West programme is supporting ambulance crews to access care plans supporting patients with frailty and palliative care. The One South West programme would need to expand their activity significantly to also support the sharing of mental health care plans. We would actively support the expansion of this work.” Source location Response from NHS Dorset ICB
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with Dorset Healthcare to transfer its information into the Dorset Care Record during 2025.
Verbatim wording from the response “The DCR partnership is continuing to work with Dorset Healthcare to share their information to DCR in 2025, another critical part of the solution. This has been highlighted as an urgent area of focus for the Dorset Healthcare team.” Source location Response from NHS Dorset ICB
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The system supplier has not delivered the technical capability needed to share Dorset Care Record information through the National Record Locator.
Verbatim wording from the response “Meanwhile in the absence of this capability DCR is looking to have the technical capability to share information with others using NRL from March 2026 onwards. Currently our system supplier has not been able to deliver this capability. Importantly, this will meet the national deadline set by NHS England, which is important because the benefit of using a single system to share is enjoyed when all parties are consistent. Shortly after this, DCR will then start sharing records to others using NRL, which will mean that SWASFT can access the data through this method.” Source location Response from NHS Dorset ICB
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Solutions to information visibility across system partners lie with multiple organisations rather than solely within the Integrated Care Board.
Verbatim wording from the response “However, it is recognised that this is not the first Prevention of Future Deaths notice that has been issued where the lack of visibility/accessibility of important information across system partners has been raised. The solutions to this lie across different partner organisations and not within the ICB. In order to ensure that there is active scrutiny of this area and to ensure that progress is being made a risk has been opened on the system risk register where all system partners have a role in ensuring active mitigation of any ongoing risk.” Source location Response from NHS Dorset ICB
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The allegations about NHS Dorset’s involvement in National Record Locator work are not factually accurate.
Verbatim wording from the response “It is important to point out that some of the allegations made are not factually accurate regarding the involvement of Dorset ICB in addressing the issues of connection to the National Record Locator.” Source location Response from NHS Dorset ICB
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Dorset Healthcare must share mental health care plans, while SWASFT must improve ambulance-crew uptake of its existing information-sharing system.
Verbatim wording from the response “Although this technical capability is essential, there are other critical requirements, including that Dorset Healthcare NHS Trust shares the mental health care plans (and other data), and that SWASFT themselves make sure that their existing system has a significantly improved uptake by their ambulance crews.” Source location Response from NHS Dorset ICB
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation SWASFT’s prioritisation of the National Record Locator approach has delayed delivery of direct Dorset Care Record access.
Verbatim wording from the response “NHS Dorset remain keen to work with SWASFT to enable access to Dorset Care Record directly, which is a possibility today, meaning that SWASFT personnel could access all the information held on our ICS shared care record (DCR). However, SWASFT have prioritised the NRL approach to sharing data, meaning that the delivery is pushed back.” Source location Response from NHS Dorset ICB
Open published response
26 Nov 2024 Emma Victoria Sanders · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 2 Lack of care plans in Summary Care Records View source Delays in paramedic-arrived patients’ access to hospital records and history View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Emma Victoria Sanders · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Emma Victoria Sanders died on 19 March 2023 after being found unresponsive in a hospital toilet with a ligature fashioned from nasal cannula tubing around her neck. The report raised concerns about delays in accessing hospital records and care plans, particularly when patients are placed in cohorting areas, and about the absence of care-plan information from Summary Care Records.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of care plans in Summary Care Records
Wider context from the report “ii. The Summary Care Record does not detail care plans in place for individuals in Dorset, the wider South West region and may be nationally . Lack of access to these plans could impact on patient care and lead to a future death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in paramedic-arrived patients’ access to hospital records and history
Wider context from the report “i. There can be a delay in accessing a patient’s hospital record and history when they are taken to hospital by a paramedic depending on the method of booking in and triage which could impact on patient care, especially if there are delays in them being assessed such as when they are placed in cohorting areas , and this could lead to a future death.
” Open source report
×
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 Uploading patient records into the national summary care record is outside NHS Dorset’s control, preventing it from addressing that issue.
Verbatim wording from the response “1. As per Paragraph 2 (ii) of your report outlining your concerns, a review has taken place on the process of identification of patients with High Intensity Care Plans. The uploading of patient records into the national summary care record remains an issue and is out of the control of NHS Dorset. However, we will enforce the use of the Dorset Care Record in line with our contractual commitments in 2025/2026 and onwards.” Source location Response from NHS Dorset
Open published response
Concerns raised 3 Lack of access to patients’ prescribed medication and medication review information View source Lack of interoperability between Adult Social Care and NHS information systems View source Lack of access to GP-held information about medication management concerns View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Derek Larkin · 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
Derek Larkin was found deceased at home on 2 June 2021 after returning from a care home, and a post-mortem examination demonstrated an overdose of prescription morphine. The report raises concerns that Adult Social Care did not have sufficient information about his prescribed medication, medication management, or concerns raised by family and healthcare professionals, including because its computer system could not communicate with the NHS SystemOne system.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of access to patients’ prescribed medication and medication review information
Wider context from the report “There is no evidence that the Dorset Council Adult Social Care computer system Mosaic can communicate with the NHS SystemOne. The Adult Social Care team would benefit from having information about the medication being prescribed to a patient, with the patient’s consent, and when that medication was last reviewed. Dorset Council Adult Social Care would benefit from information held by a current or former GP practice as to a patient’s medication and how to manage any particular concerns raised by health care professionals or family where a patient is able to independently manage his medication.
” 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 Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of interoperability between Adult Social Care and NHS information systems
Wider context from the report “There is no evidence that the Dorset Council Adult Social Care computer system Mosaic can communicate with the NHS SystemOne. The Adult Social Care team would benefit from having information about the medication being prescribed to a patient, with the patient’s consent, and when that medication was last reviewed. Dorset Council Adult Social Care would benefit from information held by a current or former GP practice as to a patient’s medication and how to manage any particular concerns raised by health care professionals or family where a patient is able to independently manage his medication.
” 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 Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of access to GP-held information about medication management concerns
Wider context from the report “There is no evidence that the Dorset Council Adult Social Care computer system Mosaic can communicate with the NHS SystemOne. The Adult Social Care team would benefit from having information about the medication being prescribed to a patient, with the patient’s consent, and when that medication was last reviewed. Dorset Council Adult Social Care would benefit from information held by a current or former GP practice as to a patient’s medication and how to manage any particular concerns raised by health care professionals or family where a patient is able to independently manage his medication.
” 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 the Coroner’s findings with relevant teams to inform future Dorset Care Record improvements.
Verbatim wording from the response “The DCR continues to be developed and refined and I have shared your findings with the relevant teams to inform any future improvements. Further information related to the DCR is available via the following link: Dorset Care Record (dorsetccouncil.gov.uk)” Source location Response from Dorset Integrated Care Board
Open published response
21 Jul 2022 Gaia Kima Pope-Sutherland · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 12 Failure of Mental Health teams to provide assessment information directly to GPs View source Lack of policy for handling sexual harassment or assault in DHUFT inpatient units View source Lack of police officer knowledge of life-threatening illnesses and their behavioural impact View source Failure to flag key information on DHUFT RiO records View source Ambiguity in Dorset Police policies for welfare concerns, missing persons, and call handling, grading and deployment View source Lack of DHUFT policy for contact with patients’ families View source Failure to create, complete and store Dorset Police records appropriately View source Delay in AMHP feedback of Mental Health Act assessment information to GPs View source Lack of staff knowledge of Dorset Police welfare, missing persons, and call handling policies View source Lack of resourcing of epilepsy services View source Ambiguity and inconsistency in access to Community Mental Health care processes View source Lack of communication between neurology and psychiatric teams View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Gaia Kima Pope-Sutherland · 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
Gaia Kima Pope-Sutherland, who had epilepsy and mental health conditions, left her aunt’s address in a psychotic state on 7 November 2017 and was later found deceased on 18 November 2017. The jury concluded that she probably died from hypothermia between 15.59 on 7 November and 10.00 on 8 November 2017. Principal concerns included under-resourcing and poor communication between epilepsy, neurology and mental health services, as well as issues concerning police training, missing-person policies and record keeping, and communication and information sharing within mental health services.
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 Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of Mental Health teams to provide assessment information directly to GPs
Wider context from the report “x. As per paragraph 1(xiii) above, when a Mental Health Act assessment is undertaken, there is a possibility that information may not be fed back to the GP in the best way or in a timely manner, if it is not fed back by those from the Mental Health team, and I therefore request that consideration is given to the DHUFT representatives forwarding information, directly to the GP, rather than through the discharging team at the acute hospital . This may include their RiO record notes, or their assessment notes.
” 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 Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of policy for handling sexual harassment or assault in DHUFT inpatient units
Wider context from the report “vi. As per paragraph 1(ix) above, the occurrence of sexual harassment or assault whilst an inpatient at one of DHUFT’s inpatient units could have a detrimental effect on a person’s mental health which could have fatal consequences. I request that consideration is given to a policy being put into place to provide guidance to staff as to how to deal with this situation.
” 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 Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of police officer knowledge of life-threatening illnesses and their behavioural impact
Wider context from the report “iii. As per paragraph 1(iv) above, there could be future deaths due to the lack of knowledge Police Officers in England and Wales have around life threatening illnesses , such as epilepsy and mental health illness, and I request that consideration is given by the College of Policing to providing national training to all staff across all police forces, on illnesses such as epilepsy and mental health illness, and the impact they have on individuals and their behaviour. I also request consideration to be given to these topics forming part of the syllabus for the College of Policing induction training for Police Officers.
” 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 Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to flag key information on DHUFT RiO records
Wider context from the report “viii. As per paragraph 1(xi) above, information could be lost on lengthy RiO records held by DHUFT if there is a significant number of records, and I therefore request that consideration is given to a guidance document dealing with how and what information should be flagged on RiO which could be provided to all staff at DHUFT. I would further request consideration is given to training staff how to record information, so it is flagged on the record.
” 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 Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Ambiguity in Dorset Police policies for welfare concerns, missing persons, and call handling, grading and deployment
Wider context from the report “iv. As per paragraphs 1(v-vi) above, there could be future deaths that occur as a result of current Dorset Police policies around concern for welfare reports, missing persons reports, and the call handling, grading and deployment of resources and I request that consideration is given to a thorough review of these policies to reduce ambiguity and prevent future deaths. I would further request that consideration is given to providing a comprehensive training package to all Police Officers and control room staff within Dorset Police, around the missing persons policy, concern for welfare policy, and for control room staff only, the call handling, grading and deployment policy.
” 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 Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of DHUFT policy for contact with patients’ families
Wider context from the report “vii. As per paragraph 1(x) above, there is no specific policy in place within DHUFT around how to engage with the family or dealing with the Think Family approach. A lack of contact with family members , who know the patient best, could lead to information gaps, which could lead to future deaths. I request that consideration is given to a policy being created around contact both to, and from, a patient’s family.
” 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 Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to create, complete and store Dorset Police records appropriately
Wider context from the report “v. As per paragraphs 1(vii-viii) above, there is currently a risk that Dorset Police records are not being created, completed or stored in an appropriate way . This could result in a lack of detail, or incorrect information being recorded and relied upon , which could lead to a future death. I therefore request that consideration is given to reviewing how all Dorset Police records are held, to ensure integrity of the information, and that consideration is given to providing a training session on record keeping for all Dorset Police staff, across all areas of the Force.
” 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 Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delay in AMHP feedback of Mental Health Act assessment information to GPs
Wider context from the report “xi. As per paragraph 1(xiv) above, in respect of the feeding back of information to the GP by the AMHP which is detailed at paragraph 2.10 of Standard Operating Procedure for the flow of information following Mental Health Act assessments, I would request that consideration is given by Dorset County Council, BCP Council and DHUFT to reducing this timeframe from 7 days to 72 hours . Although this is a decision for Dorset County Council and BCP Council, the document is a DHUFT document and so will require their consideration too.
” 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 Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge of Dorset Police welfare, missing persons, and call handling policies
Wider context from the report “iv. As per paragraphs 1(v-vi) above, there could be future deaths that occur as a result of current Dorset Police policies around concern for welfare reports, missing persons reports, and the call handling, grading and deployment of resources and I request that consideration is given to a thorough review of these policies to reduce ambiguity and prevent future deaths. I would further request that consideration is given to providing a comprehensive training package to all Police Officers and control room staff within Dorset Police, around the missing persons policy, concern for welfare policy , and for control room staff only, the call handling, grading and deployment policy .
” 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 Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of resourcing of epilepsy services
Wider context from the report “i. As per paragraphs 1(i-iii) above, there could be future deaths locally and across the country due to the lack of resourcing of epilepsy services . I request consideration is given to a review of the nursing resources in epilepsy care locally in Dorset Epilepsy Service, and generally nationally across England and Wales.
” 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 Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Ambiguity and inconsistency in access to Community Mental Health care processes
Wider context from the report “ix. As per paragraph 1(xii) above, I would request that consideration is given to providing training to all staff on the access to Community Mental Health services which could also cover the processes regarding discharge planning from the care of the mental health teams.
” 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 Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of communication between neurology and psychiatric teams
Wider context from the report “ii. Further I am concerned that there could be future deaths as a result of the lack of communication between neurology and psychiatric teams and request that there is consideration as to how to ensure effective lines of communication between the 2 disciplines.
” 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 Undertake an eight-week review of Dorset epilepsy nursing resources, provision across care settings, relevant specialty interactions, and neurology–psychiatry communication processes.
Verbatim wording from the response “1. As per Paragraph 2 (i) of your report outlining your concerns, a review will be undertaken of the nursing resources in epilepsy care locally within the Dorset Epilepsy Service. The review will:” Source location Response from NHS Dorset Integrated Care
Open published response
Concerns raised 4 Lack of compliant bids for the replacement non-emergency transfer service View source Failure to meet non-emergency patient transfer collection standards View source Lack of available high dependency transport provision View source Failure to resource emergency ambulance transport to minimum performance standards View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
William George Irvin Watson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
William George Irvin Watson was admitted with worsening angina, underwent triple coronary artery bypass surgery, and experienced post-operative complications including an infected sternal wound. He died after difficulties and delays in emergency, high-dependency and non-emergency patient transfers. The principal concerns were inadequate ambulance and patient-transport resources, performance gaps, and the potential risk of avoidable deaths or deterioration when transfers are delayed.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of compliant bids for the replacement non-emergency transfer service
Wider context from the report “I was told at inquest that this service, commissioned by NHS Kernow, was being provided by a company called Eezel. I was further advised that its performance requirements are to collect 95% of patients within 1 hour and for short notice bookings, 50% were to be collected with 1 hour and 95% within 2 hours. I was informed that these targets are not being met.
The inquest was advised that a new service provider will be taking on this business from April 2019 . Of great concern to me was the revelation made at inquest that there are currently no compliant bids .
It seems obvious that a patient who would ordinarily require a non-emergency transfer but who is kept waiting beyond acceptable performance standards may deteriorate and potentially have their life put at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to meet non-emergency patient transfer collection standards
Wider context from the report “I was told at inquest that this service, commissioned by NHS Kernow, was being provided by a company called Eezel. I was further advised that its performance requirements are to collect 95% of patients within 1 hour and for short notice bookings, 50% were to be collected with 1 hour and 95% within 2 hours . I was informed that these targets are not being met .
The inquest was advised that a new service provider will be taking on this business from April 2019. Of great concern to me was the revelation made at inquest that there are currently no compliant bids.
It seems obvious that a patient who would ordinarily require a non-emergency transfer but who is kept waiting beyond acceptable performance standards may deteriorate and potentially have their life put at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of available high dependency transport provision
Wider context from the report “I heard that the only provider of this service in Cornwall is Lifestar. I was informed that on occasions when Lifestar has no available resource it is necessary to contact providers from out of country .
The evidence I heard from ████████ was that there was a definite gap in service provision . Given that this involves the transport of patients with a High Dependency there is again a real risk that fatalities may arise in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Dorset Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to resource emergency ambulance transport to minimum performance standards
Wider context from the report “It is equally clear that a significant performance gap remains indeed, as I understand the position, it is accepted that minimum performance standards cannot be met under the current financial position . The obvious implication is that where an adequate response cannot be made because of insufficient funding to resource the service appropriately , the consequent delays may result in lives being lost. These could be avoidable deaths.
” Open source report
Pin
Request correction
Addressed to NHS Dorset Clinical Commissioning Group, now represented here by NHS Dorset Integrated Care Board.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations