8 Jul 2026 Marie Bell · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 1 Failure to explore alternative investigations when an initial investigation is unsuitable View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Marie Bell · 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
Marie Bell underwent surgery for a bowel obstruction on 25 July 2025. An unrecognised small-bowel perforation developed into faecal peritonitis, and she died in hospital on 29 July 2025. The report also raises concern that being unable to undergo colonoscopy was treated as declining all investigations, rather than prompting consideration of alternative methods.
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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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to explore alternative investigations when an initial investigation is unsuitable
Wider context from the report “Where one means of investigation is not suitable for a patient due to comorbidities or conditions this does not mean that the patient is declining all investigations and an alternative should be explored.
” Open source report
Concerns raised 2 Failure of trust systems to provide an integrated view of doctors’ timing, sequencing, and cumulative workload across employers View source Failure to safely dispose of small volumes of medicines in sharps bins 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
Naeem Ahmed · 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
Naeem Ahmed, a Consultant Anaesthetist, was found dead in a hospital rest room on 21 June 2025 after using alcohol and a substance that is redacted in the report. The concerns included access to potentially fatal medicines from sharps bins and fragmented systems for managing doctors’ working patterns, secondary employment and cumulative workload across providers.
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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 England; that does not assign responsibility.
PFD Monitor interpretation Failure of trust systems to provide an integrated view of doctors’ timing, sequencing, and cumulative workload across employers
Wider context from the report “The review and the coronial investigation also revealed that Naeem died whilst working the 9th shift in a run of 11 night shifts for UHD which began on 12th June 2025 and that in June 2025 he undertook clinical work for more than one provider on the same calendar day on different occasions, and on one occasion he undertook daytime work for an external provider before commencing a resident overnight shift for the Trust later the same day. The review also identified that trust systems for job planning, rostering, appraisal, and secondary employment operated independently and were not designed to provide an integrated view of timing, sequencing, or cumulative workload across employers, whether over short periods or across an annual cycle . Whilst UHD have undertaken work to resolve this issue, I am concerned that this practice exists at other Trusts in England and Wales and could lead to fatigue and fatal outcomes to patients and doctors.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to safely dispose of small volumes of medicines in sharps bins
Wider context from the report “Evidence at the Inquest revealed that at the time of Naeem’s death a process in place at Poole Hospital that if there were small volumes of medicines to be disposed of by representatives of the Trust which were less than 50ml in volume, such as after surgery had taken place, these would be squirted into the sharps bins and then the needles would also be disposed of in the sharps bin too. This was identified in the independent review which concluded that this practice posed a risk that fatal medicines could be accessed from the sharps bin . As a result, UHD now use gels in the sharps bins which immediately denature and destroy the liquids squirted into the sharps bins. I am concerned that what was happening at the time of Naeem’s death continues to happen at other Trusts across England and Wales and could lead to future deaths.
” 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 Raise the disposal issue through the national controlled-drugs accountable-officer network and share the learning with regional NHS England colleagues.
Verbatim wording from the response “NHS England’s South West regional colleagues have been in contact with the South West CDAO who has informed us that the following actions have been taken:” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Address controlled-drug disposal at the national learning event and remind designated bodies of their secure-disposal obligations.
Verbatim wording from the response “The National Controlled Drugs Accountable Officer (CDAO) function will address this matter again at an upcoming national learning event on 22nd September 2026. We will remind designated bodies of their obligations under both the misuse of drugs and health and safety legislation which require that controlled drugs are securely disposed of and not ordinarily capable of being accessed accidentally or deliberately.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise controlled-drug disposal with the Care Quality Commission for inclusion in medicines-governance inspections.
Verbatim wording from the response “NHS England will also raise this case with the Care Quality Commission as the medicines governance component of their inspection will include the disposal of controlled drugs in operating departments.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Write to South West controlled-drugs accountable officers about learning on medicine disposal.
Verbatim wording from the response “NHS England’s South West regional colleagues have been in contact with the South West CDAO who has informed us that the following actions have been taken:” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing appraisal, responsible-officer, clinical-management and Working Time Regulations arrangements are relied on to manage doctors’ declared work and rest compliance.
Verbatim wording from the response “NHS England would expect doctors to declare and review their full scope of practice to their appraiser, for the purpose of licensing and revalidation. This forms part of their appraisal which is shared with their Responsible Officer (RO) which should include appraisal of any work they are undertaking, including the location and frequency of any work. This includes any private work they are undertaking. As Dr Ahmed was working in secondary care their RO would be a senior clinician (typically the Medical Director) of their main clinical employer, which is usually their NHS Trust where they have their substantive NHS contract.” Source location Response from NHS England
Open published response
Concerns raised 1 Failure to prevent or clearly identify automatic deactivation of an active SystmOne patient record by access from a previously involved organisation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
JOHN EDWARD BRYNMOR PHILLIPS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Edward Brynmor Phillips, aged 37, died by suicide in his cell at HMP Dartmoor on 29 October 2022 after using a ligature. A referral to the prison mental health team was cancelled when his electronic health records were deactivated during a records-uploading process, causing a delay of approximately 2.5 months in his mental health assessment and treatment. The principal concern was that SystmOne could deactivate an active record and cancel current clinical tasks and referrals without this being apparent, creating a risk of unsafe care.
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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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent or clearly identify automatic deactivation of an active SystmOne patient record by access from a previously involved organisation
Wider context from the report “The national SystmOne electronic patient record operates in an unsafe way because it appears to allow a patient’s record to be accessed (which might be for a necessary administrative reason) by a member of staff in an organisation previously involved in the patient’s care, which seems to have the automatic effect of deactivating the patient’s active record in an organisation currently involved in the patient’s care (and associated appointments, tasks, treatment plans etc), without this being obvious to anyone – this leads to the removal of important and current tasks, referrals and appointments for the patient whilst they are being cared for by the current organisation and will likely result in unsafe clinical care being provided by NHS Trusts.
” 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 Share the investigation findings and learning with relevant health and justice organisations, highlighting the need to avoid inappropriate record re-registration.
Verbatim wording from the response “In order to ensure that all healthcare providers are aware of this investigation and any learning, we will be sharing the findings with the NHS England Regional Health and Justice Commissioning Teams, the Welsh Health Board and HMP Parc. We will highlight to them that when accessing the records of a patient who has left a prison, healthcare staff are mindful of the movement of records and not requesting the re-registering of the patient that is no longer a resident in that prison.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The events were attributed to human error rather than a systemic SystmOne issue.
Verbatim wording from the response “Once a patient has transferred between prisons and their SystmOne record is accessed for purposes such as updating, it does not automatically pull the patient and records back to the previous site when they are accessed. A request to re-register the patients record is required for this. If the re-register request is made, the deactivation or deactivation of the record at the “new” prison then takes place. This appears to be what happened in this case and was human error, not an automatic process. We therefore do not believe that the events in this tragic case were due to a systemic issue within SystmOne.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record movement does not affect patients’ clinical care or treatment plans.
Verbatim wording from the response “To further reassure you, this does not impact on clinical care and treatment plans. Once the request to correct the re-registration is made, the patient’s records remain as they were and are unaffected by this movement of their clinical record.” Source location Response from NHS England
Open published response
17 Jun 2026 Muluembet (“Mulu”) Yohanes · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to ask post-discharge surgery patients about surgical-team discharge, worsening or red-flag advice View source Lack of an appropriate dedicated neurosurgery pathway for elective, non-trauma surgery 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
Muluembet (“Mulu”) Yohanes · 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
Muluembet Yohanes underwent surgery to remove a pituitary tumour and was discharged with advice that repeated vomiting required immediate medical attention. After developing vomiting, NHS 111 and Clinical Assessment Service calls resulted in home management advice, and she later suffered a seizure and cardiac arrest due to severe hyponatraemia before dying from hypoxic brain injury. The principal concerns were the absence of a dedicated neurosurgery pathway and the failure to ask about post-surgical discharge or red-flag advice during the calls.
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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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to ask post-discharge surgery patients about surgical-team discharge, worsening or red-flag advice
Wider context from the report “3. Pathways does not include a question for post-discharge surgery patients about whether they have been given discharge, worsening or red flag advice by their surgical team .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of an appropriate dedicated neurosurgery pathway for elective, non-trauma surgery
Wider context from the report “2. I am concerned that without a dedicated pathway for “neurosurgery”, it is left to call handlers to choose the most appropriate pathway . To me, “head injury” is not reflective of elective, non-trauma surgery .
” 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 predetermined-management-plan training to clarify how call handlers identify relevant post-operative advice and escalate complex cases.
Verbatim wording from the response “Instead, to address risks that may arise from such situations, and to cover the issue as in this case, where a patient has had recent treatment or been given specific advice in advance, NHS Pathways also has a clear route for callers who have what is referred to as ‘Predetermined management plans.’ All health advisors must complete training associated with this within their mandatory core module training. This includes scenarios of when this route applies including: ‘Recent hospital discharge; Medical devices fitted e.g. pacemaker; chronic, terminal, rare or serious illnesses; Patient with other special needs’.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A dedicated post-discharge advice question is unnecessary because predetermined management plans and existing surgical-procedure questions address relevant callers.
Verbatim wording from the response “The ‘Predetermined management plans’ route described above does provide a route for those who have been given specific post-operative advice or a plan in the event of certain criteria. In view of this case, this route and the associated training is also being re-examined to ensure that it is considered by call handlers in cases where a caller does not specifically mention their recent surgery, or in case the potential relevance of this is not obvious, to ensure that the call is identified as complex and passed to a clinician for review.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A specific neurosurgery pathway or key point is unnecessary because symptom-based triage and predetermined management plans address relevant risks.
Verbatim wording from the response “However, a specific situation such as previous neurosurgery would not generally be added as a key point, and so the NHS Pathways team do not consider that this specific change should be made. The triage system uses a symptom-based approach rather than having separate specific routes for every possible medical procedure or medical condition, as it would not be practical or possible to add a question on every single possible scenario. This means that within the triage assessment different questions will be presented to establish symptoms of concern, and as noted above, serious and potentially life-threatening symptoms are assessed first to ensure rapid escalation, such as reaching an ambulance outcome or involving a clinician. The assessment then progresses to less urgent symptoms to identify the most appropriate level of care. The tool is not diagnostic.” Source location Response from NHS England
Open published response
Concerns raised 9 Lack of careline policy, guidance and training for third-party emergencies View source Failure to recontact the EMA when a caller reports deterioration View source Failure to record clinically relevant information in EMA notes View source Lack of awareness of available careline technology for direct patient contact and emergency-service conferencing View source Failure to check and improve the quality of clinical note taking View source Inadequate quality of the call auditing system View source Failure to obtain and pass on key emergency information from careline callers View source Lack of effective liaison between careline companies and ambulance trusts on note-taking improvement View source Failure to obtain or provide basic clinical advice during careline emergency calls View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Derek Thomas Burt · 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 Thomas Burt died at home on 15 May 2025 after a spontaneous rupture of an arterio-venous malformation at the back of his right ankle caused severe bleeding. The report raises concerns about communication between the careline service and ambulance services, including failure to pass on key information, delays in escalating the emergency, inadequate recording of information, and the loss of opportunities to provide basic first-aid advice.
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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 England; that does not assign responsibility.
PFD Monitor interpretation Lack of careline policy, guidance and training for third-party emergencies
Wider context from the report “2) I also heard from the careline centre manager that Appello does not have any specific documentation, training material or guidance that considers calls for assistance made by the service user for people other than themselves. It was good to learn that both careline operators did respond positively to the cry for help from Mrs Burt. I remained concerned, however, that there is no policy or guidance available for operators to cover this type of emergency or life threatening situation and no training has yet been devised to learn from the unusual circumstances that occurred here .
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to recontact the EMA when a caller reports deterioration
Wider context from the report “In addition, the first careline operator did not call the EMA back when she learned Mr Burt was non responsive and had developed breathing problems . The CSN confirmed to me that if a second call had been made at that point then the call would have been upgraded to category 1 . This would have been at approx 22:50. In other words around the same time the EMA was trying to call Mrs Burt back. The clinical review was allocated at 22:55 and the second 999 call was logged at 23:15 so approximately 20-25 mins had elapsed.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to record clinically relevant information in EMA notes
Wider context from the report “4) Likewise I heard from the SECAMB CSN that she had carried out an audit of the EMA notes added to their system when speaking to the first careline operator. She did so from a clinical perspective and she discovered missing information that was given but not recorded at all namely: that there had already been 20 minutes of bleeding at the time of the first call (approx. 22:43); Mr Burt was not responding normally/groaning; and Mrs Burt was bedbound therefore could not assist Mr Burt. None of this information was therefore available to the CSN who carried out the clinical review .
In addition I heard that the end to end review carried out by SECAMB and focused on the dispatch difficulties that existed on 14 May 2025. I appreciate that the dispatch and clinical review systems were different at that time and have now been changed but I remain concerned that the quality of note taking has not been properly checked and action taken to rectify then make improvements with any individual concerned as well as capturing learning points for others. Here vital information was missing and was needed to ensure an effective clinical review could take place and thereby ensure that the category of call response is accurate.
I was told this call had been audited and was found to be 95% compliant. This also calls into question the quality of the call auditing system
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of available careline technology for direct patient contact and emergency-service conferencing
Wider context from the report “1) I heard evidence from the call centre manager of Appello Careline and the first careline operator that their system had the capability to speak directly to Mrs Burt without her pressing her wrist alarm button as this could have been done via the digital base unit that was in her bedroom. The system can also set up a 3 way conversation or conference call to include any of the emergency services. Indeed the operator told me she has done this in the past if asked to do so by the emergency services or she has suggested it but she did not do so in this case as she took heed from the EMA.
Conversely, I heard from a CSN with South East Coast Ambulance Service (SECAMB) that she did not know careline companies could set up 3 way conference calls for a CSN to speak to the patient or helper directly. She knew that Police and Fire Services used 3 way conference calls using careline systems but not Ambulance Trusts.
This case had moved from the dispatch to the clinical stack and from the timeline of calls supplied it seems 15 calls were made between 22:52 and 23:23 to the landline and mobile numbers supplied but of course, it was impossible for Mrs Burt to answer them.
No one thought to go back through the digital base unit to offer the basic clinical advice that was needed. I am concerned that both Ambulance Trusts generally as well as Careline companies may not be aware of the potential to save lives using available technology.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to check and improve the quality of clinical note taking
Wider context from the report “4) Likewise I heard from the SECAMB CSN that she had carried out an audit of the EMA notes added to their system when speaking to the first careline operator. She did so from a clinical perspective and she discovered missing information that was given but not recorded at all namely: that there had already been 20 minutes of bleeding at the time of the first call (approx. 22:43); Mr Burt was not responding normally/groaning; and Mrs Burt was bedbound therefore could not assist Mr Burt. None of this information was therefore available to the CSN who carried out the clinical review.
In addition I heard that the end to end review carried out by SECAMB and focused on the dispatch difficulties that existed on 14 May 2025. I appreciate that the dispatch and clinical review systems were different at that time and have now been changed but I remain concerned that the quality of note taking has not been properly checked and action taken to rectify then make improvements with any individual concerned as well as capturing learning points for others . Here vital information was missing and was needed to ensure an effective clinical review could take place and thereby ensure that the category of call response is accurate.
I was told this call had been audited and was found to be 95% compliant. This also calls into question the quality of the call auditing system
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequate quality of the call auditing system
Wider context from the report “4) Likewise I heard from the SECAMB CSN that she had carried out an audit of the EMA notes added to their system when speaking to the first careline operator. She did so from a clinical perspective and she discovered missing information that was given but not recorded at all namely: that there had already been 20 minutes of bleeding at the time of the first call (approx. 22:43); Mr Burt was not responding normally/groaning; and Mrs Burt was bedbound therefore could not assist Mr Burt. None of this information was therefore available to the CSN who carried out the clinical review.
In addition I heard that the end to end review carried out by SECAMB and focused on the dispatch difficulties that existed on 14 May 2025. I appreciate that the dispatch and clinical review systems were different at that time and have now been changed but I remain concerned that the quality of note taking has not been properly checked and action taken to rectify then make improvements with any individual concerned as well as capturing learning points for others. Here vital information was missing and was needed to ensure an effective clinical review could take place and thereby ensure that the category of call response is accurate.
I was told this call had been audited and was found to be 95% compliant. This also calls into question the quality of the call auditing system
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and pass on key emergency information from careline callers
Wider context from the report “3) I also remain concerned that the first careline operator did not pass on a key piece of information to the EMA, namely that the caller did not have access to a phone . Nor did she ask if the blood was spurting or dribbling . Although, it was relayed that Mrs Burt was bedbound, the EMA would not have realised that Mrs Burt couldn’t get to the phone as it was in another room.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Lack of effective liaison between careline companies and ambulance trusts on note-taking improvement
Wider context from the report “6) I was told that SECAMB is taking part in a pilot called Tortoise looking at using AI to improve the accuracy of note taking. It was unclear whether a similar scheme is being explored by careline companies or if there is effective liaison between careline companies and ambulance trusts.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain or provide basic clinical advice during careline emergency calls
Wider context from the report “5) I heard that an EMA can hold a call and speak to a CSN to get basic first aid advice or join the CSN into the call . Given the volume of blood that had already been lost in this case, I am concerned that this opportunity to give clinical advice was lost especially as the call had come in via a careline operator.
” Open source report
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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 Apello Careline is best placed to respond to concerns about its emergency-call guidance, information handling and artificial intelligence trials.
Verbatim wording from the response “Concerns 2,3, and 6 relate to the Apello Careline company, and as such are not within NHS England’s remit to comment on. As your Report has also been addressed to the Apello Careline company they will be best placed to respond to these concerns.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operational concerns about ambulance care are the responsibility of SECAMB, which is best placed to respond directly.
Verbatim wording from the response “NHS England’s Ambulance Team have reviewed this Report and have advised that the concerns raised relate to operational matters, which are the responsibility of the local ambulance service; SECAMB NHS Foundation Trust, who will be best placed to respond to the concerns raised. We note that SECAMB have also been addressed in your Report and will respond directly to the concerns.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Concerns about Apello Careline’s emergency-call guidance, information handling and artificial intelligence trials are outside NHS England’s remit.
Verbatim wording from the response “Concerns 2,3, and 6 relate to the Apello Careline company, and as such are not within NHS England’s remit to comment on. As your Report has also been addressed to the Apello Careline company they will be best placed to respond to these concerns.” Source location Response from NHS England
Open published response
Concerns raised 2 Inability to provide callers with estimated ambulance attendance times View source Failure to inform callers when no ambulance is being arranged 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
Daniel Charles FORREST · 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
Daniel Charles Forrest, aged 85, suffered a witnessed fall outside his home on 30 September 2025 and later an unwitnessed fall at home on 1 October 2025. Ambulance attendance was delayed and subsequently cancelled before the second fall, after which he was taken to hospital and died from an unsurvivable head injury. The concerns were that callers were told an ambulance was being arranged and were not given reliable information about expected waiting times, potentially limiting informed decisions about waiting or escalating worsening symptoms.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inability to provide callers with estimated ambulance attendance times
Wider context from the report “I heard that the NHS Pathways system tells call handlers to advise callers that an ambulance is being arranged. However I heard that within SECAMB category 3 and category 4 dispositions are validated by clinical staff before being added to the Dispatch queue for an Ambulance to be allocated. I heard that this was in line with National Guidance from The Association of Ambulance Chief Executives. Therefore, callers are not informed that no ambulance is being arranged at the time of their call.
I also heard that the NHS Pathways does not allow callers to be advised of the estimated time that they may have to wait for ambulance attendance . The evidence was that SECAMB have requested that the wordings provided by NHS Pathways be altered so that there is provision to give further information to callers about how long they may wait for an ambulance to attend but this has previously been declined by NHS England.
I consider that both of the above matters mean that patients cannot make informed decisions about whether they wait for the arrival of an ambulance or escalate worsening symptoms on the basis that they anticipate that an ambulance is being arranged so will be with them shortly when this may not be the case.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to inform callers when no ambulance is being arranged
Wider context from the report “I heard that the NHS Pathways system tells call handlers to advise callers that an ambulance is being arranged . However I heard that within SECAMB category 3 and category 4 dispositions are validated by clinical staff before being added to the Dispatch queue for an Ambulance to be allocated. I heard that this was in line with National Guidance from The Association of Ambulance Chief Executives. Therefore, callers are not informed that no ambulance is being arranged at the time of their call .
I also heard that the NHS Pathways does not allow callers to be advised of the estimated time that they may have to wait for ambulance attendance. The evidence was that SECAMB have requested that the wordings provided by NHS Pathways be altered so that there is provision to give further information to callers about how long they may wait for an ambulance to attend but this has previously been declined by NHS England.
I consider that both of the above matters mean that patients cannot make informed decisions about whether they wait for the arrival of an ambulance or escalate worsening symptoms on the basis that they anticipate that an ambulance is being arranged so will be with them shortly when this may not be the case.
” 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 Work with ambulance services to develop standard scripts for situations where Ambulance Response Programme standards will not be met.
Verbatim wording from the response “For 999 calls, all ambulance services should have in place call exit scripts and procedures for dealing with response delays when under operational pressure. NHS England has Resource Escalation Action Plan (REAP) levels which are used to manage operational pressures across ambulance services. NHS England supports a position that callers should be provided with sufficient information to make informed decisions, including whether an ambulance has been dispatched to the patient.” Source location Response from NHS England & NHS Improvement
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 Operational information, including ambulance waiting times, falls outside the remit of NHS Pathways triage.
Verbatim wording from the response “For the reasons provided above, operation information, such as wait times within emergency operations centres sits outside the remit of triage and is best placed to be dealt with locally by individual Ambulance Trusts.” Source location Response from NHS England & NHS Improvement
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 Individual ambulance services are responsible for managing operational delays and associated caller information under local governance and procedures.
Verbatim wording from the response “Therefore, these circumstances are now managed locally, by the individual ambulance services, following their own internal governance and Standard Operating Procedures (SOPs).” Source location Response from NHS England & NHS Improvement
Open published response
Concerns raised 4 Lack of a designated lead with oversight and authority over coordinated care View source Failure to coordinate alerts and subsequent treatment or long-term intervention View source Fragmented information sharing and updating across healthcare providers View source Lack of an easily recognised national risk designator across patient records View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alex Ganski · 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
Alex Ganski, aged 19, died from fatal injuries after jumping from a bridge while under the influence of ketamine and diazepam, following a relapse in drug misuse and longstanding mental health difficulties. The principal concerns were the absence of a designated lead with oversight and authority across services, fragmented information sharing, and no clear national mechanism to identify and communicate his wider mental health and drug-misuse risks.
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 England; that does not assign responsibility.
PFD Monitor interpretation Lack of a designated lead with oversight and authority over coordinated care
Wider context from the report “The evidence disclosed that whilst there were multiple agencies, organisations and healthcare providers who had been treating or triaging Alex’s mental and physical health conditions, including his misuse of illicit drugs:
a. There was no – and nationally there appears to be no - policy, guidance or structure which would enable a designated lead, or ‘single point of contact’ with full oversight of, and (more importantly) authority over, Alex’s care – taking particular account of his young age.
b. This represents a ‘care gap’ and missed opportunity whereby a nominated lead could ensure that each incident, attendance, relapse or overdose was alerted to those other agencies, organisations or providers who would need to know or who may benefit from knowing of the occurrence. And then – critically - directing and assuring the right treatment or long-term intervention to follow.
c. The sharing and updating of information regarding Alex’s multiple health and drug issues was fragmented, in the absence of clear, national protocols and requirements as to the informing and alerting of new incidents, treatment, or other change in mental or physical health or addiction.
d. I was encouraged to learn of the Plexus Care Record initiative in this local area (Plexus Care Record) but the evidence was that this is voluntary, and that not all providers or agencies are able or willing to connect or provide their records and share information. Moreover, I heard evidence that this is a local but not national initiative and hence information and record sharing elsewhere may be worse. As such the situation is ameliorated by local changes but appears to be a wider and national issue.
I found that these factors were exacerbated in Alex’s case as a vulnerable 19 year old who had clearly been suffering with poor mental health and drug misuse whilst, and since, a child, noting that he lacked the experience and knowledge to successfully advocate for himself, or insight into his own needs.
My further concern is that there was no simple mechanism or designation across those patient record systems for those who may become involved with Alex, to know of the significant wider and historical health and drug misuse issues, in the absence of his own willingness or ability to fully disclose these at each turn. Especially when he may have been under the influence of substances. This meant repeated opportunities to better address Alex’s serious underlying conditions and issues were not taken.
This lack of an easily recognised national designator, shown across systems and records,such as ‘person at [serious] risk’ gives rise to an incomplete understanding of, and risks a failure to sufficiently enquire into, someone’s full condition as and when services become intermittently involved, and creates a risk of further similar deaths.
I add that I am very conscious of the Chief Coroner’s guidance to consider what can practically be achieved and not to engage with ‘ideal world’ scenarios, as well as considering the realistic prospect, including on resources grounds, that this report will be acted upon.
I respectfully see no such barriers as regards the ‘lead point of contact’. I recognise information sharing will be subject to data protection and handling, consent, privacy and confidentiality issues, but progress has been made locally within existing resource and I consider that these issues need to be better addressed in the national healthcare context, else they will continue to be barriers to preventing deaths, rather than enablers to save lives.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate alerts and subsequent treatment or long-term intervention
Wider context from the report “The evidence disclosed that whilst there were multiple agencies, organisations and healthcare providers who had been treating or triaging Alex’s mental and physical health conditions, including his misuse of illicit drugs:
a. There was no – and nationally there appears to be no - policy, guidance or structure which would enable a designated lead, or ‘single point of contact’ with full oversight of, and (more importantly) authority over, Alex’s care – taking particular account of his young age.
b. This represents a ‘care gap’ and missed opportunity whereby a nominated lead could ensure that each incident, attendance, relapse or overdose was alerted to those other agencies, organisations or providers who would need to know or who may benefit from knowing of the occurrence . And then – critically - directing and assuring the right treatment or long-term intervention to follow .
c. The sharing and updating of information regarding Alex’s multiple health and drug issues was fragmented, in the absence of clear, national protocols and requirements as to the informing and alerting of new incidents, treatment, or other change in mental or physical health or addiction.
d. I was encouraged to learn of the Plexus Care Record initiative in this local area (Plexus Care Record) but the evidence was that this is voluntary, and that not all providers or agencies are able or willing to connect or provide their records and share information. Moreover, I heard evidence that this is a local but not national initiative and hence information and record sharing elsewhere may be worse. As such the situation is ameliorated by local changes but appears to be a wider and national issue.
I found that these factors were exacerbated in Alex’s case as a vulnerable 19 year old who had clearly been suffering with poor mental health and drug misuse whilst, and since, a child, noting that he lacked the experience and knowledge to successfully advocate for himself, or insight into his own needs.
My further concern is that there was no simple mechanism or designation across those patient record systems for those who may become involved with Alex, to know of the significant wider and historical health and drug misuse issues, in the absence of his own willingness or ability to fully disclose these at each turn. Especially when he may have been under the influence of substances. This meant repeated opportunities to better address Alex’s serious underlying conditions and issues were not taken.
This lack of an easily recognised national designator, shown across systems and records,such as ‘person at [serious] risk’ gives rise to an incomplete understanding of, and risks a failure to sufficiently enquire into, someone’s full condition as and when services become intermittently involved, and creates a risk of further similar deaths.
I add that I am very conscious of the Chief Coroner’s guidance to consider what can practically be achieved and not to engage with ‘ideal world’ scenarios, as well as considering the realistic prospect, including on resources grounds, that this report will be acted upon.
I respectfully see no such barriers as regards the ‘lead point of contact’. I recognise information sharing will be subject to data protection and handling, consent, privacy and confidentiality issues, but progress has been made locally within existing resource and I consider that these issues need to be better addressed in the national healthcare context, else they will continue to be barriers to preventing deaths, rather than enablers to save lives.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Fragmented information sharing and updating across healthcare providers
Wider context from the report “The evidence disclosed that whilst there were multiple agencies, organisations and healthcare providers who had been treating or triaging Alex’s mental and physical health conditions, including his misuse of illicit drugs:
a. There was no – and nationally there appears to be no - policy, guidance or structure which would enable a designated lead, or ‘single point of contact’ with full oversight of, and (more importantly) authority over, Alex’s care – taking particular account of his young age.
b. This represents a ‘care gap’ and missed opportunity whereby a nominated lead could ensure that each incident, attendance, relapse or overdose was alerted to those other agencies, organisations or providers who would need to know or who may benefit from knowing of the occurrence. And then – critically - directing and assuring the right treatment or long-term intervention to follow.
c. The sharing and updating of information regarding Alex’s multiple health and drug issues was fragmented , in the absence of clear, national protocols and requirements as to the informing and alerting of new incidents, treatment, or other change in mental or physical health or addiction .
d. I was encouraged to learn of the Plexus Care Record initiative in this local area (Plexus Care Record) but the evidence was that this is voluntary, and that not all providers or agencies are able or willing to connect or provide their records and share information . Moreover, I heard evidence that this is a local but not national initiative and hence information and record sharing elsewhere may be worse. As such the situation is ameliorated by local changes but appears to be a wider and national issue.
I found that these factors were exacerbated in Alex’s case as a vulnerable 19 year old who had clearly been suffering with poor mental health and drug misuse whilst, and since, a child, noting that he lacked the experience and knowledge to successfully advocate for himself, or insight into his own needs.
My further concern is that there was no simple mechanism or designation across those patient record systems for those who may become involved with Alex, to know of the significant wider and historical health and drug misuse issues, in the absence of his own willingness or ability to fully disclose these at each turn. Especially when he may have been under the influence of substances. This meant repeated opportunities to better address Alex’s serious underlying conditions and issues were not taken.
This lack of an easily recognised national designator, shown across systems and records,such as ‘person at [serious] risk’ gives rise to an incomplete understanding of, and risks a failure to sufficiently enquire into, someone’s full condition as and when services become intermittently involved, and creates a risk of further similar deaths.
I add that I am very conscious of the Chief Coroner’s guidance to consider what can practically be achieved and not to engage with ‘ideal world’ scenarios, as well as considering the realistic prospect, including on resources grounds, that this report will be acted upon.
I respectfully see no such barriers as regards the ‘lead point of contact’. I recognise information sharing will be subject to data protection and handling, consent, privacy and confidentiality issues, but progress has been made locally within existing resource and I consider that these issues need to be better addressed in the national healthcare context, else they will continue to be barriers to preventing deaths, rather than enablers to save lives.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Lack of an easily recognised national risk designator across patient records
Wider context from the report “The evidence disclosed that whilst there were multiple agencies, organisations and healthcare providers who had been treating or triaging Alex’s mental and physical health conditions, including his misuse of illicit drugs:
a. There was no – and nationally there appears to be no - policy, guidance or structure which would enable a designated lead, or ‘single point of contact’ with full oversight of, and (more importantly) authority over, Alex’s care – taking particular account of his young age.
b. This represents a ‘care gap’ and missed opportunity whereby a nominated lead could ensure that each incident, attendance, relapse or overdose was alerted to those other agencies, organisations or providers who would need to know or who may benefit from knowing of the occurrence. And then – critically - directing and assuring the right treatment or long-term intervention to follow.
c. The sharing and updating of information regarding Alex’s multiple health and drug issues was fragmented, in the absence of clear, national protocols and requirements as to the informing and alerting of new incidents, treatment, or other change in mental or physical health or addiction.
d. I was encouraged to learn of the Plexus Care Record initiative in this local area (Plexus Care Record) but the evidence was that this is voluntary, and that not all providers or agencies are able or willing to connect or provide their records and share information. Moreover, I heard evidence that this is a local but not national initiative and hence information and record sharing elsewhere may be worse. As such the situation is ameliorated by local changes but appears to be a wider and national issue.
I found that these factors were exacerbated in Alex’s case as a vulnerable 19 year old who had clearly been suffering with poor mental health and drug misuse whilst, and since, a child, noting that he lacked the experience and knowledge to successfully advocate for himself, or insight into his own needs.
My further concern is that there was no simple mechanism or designation across those patient record systems for those who may become involved with Alex, to know of the significant wider and historical health and drug misuse issues , in the absence of his own willingness or ability to fully disclose these at each turn. Especially when he may have been under the influence of substances. This meant repeated opportunities to better address Alex’s serious underlying conditions and issues were not taken.
This lack of an easily recognised national designator, shown across systems and records,such as ‘person at [serious] risk’ gives rise to an incomplete understanding of, and risks a failure to sufficiently enquire into, someone’s full condition as and when services become intermittently involved , and creates a risk of further similar deaths.
I add that I am very conscious of the Chief Coroner’s guidance to consider what can practically be achieved and not to engage with ‘ideal world’ scenarios, as well as considering the realistic prospect, including on resources grounds, that this report will be acted upon.
I respectfully see no such barriers as regards the ‘lead point of contact’. I recognise information sharing will be subject to data protection and handling, consent, privacy and confidentiality issues, but progress has been made locally within existing resource and I consider that these issues need to be better addressed in the national healthcare context, else they will continue to be barriers to preventing deaths, rather than enablers to save lives.
” 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 Continue supporting interoperable shared care records and their development toward a joined-up Single Patient Record.
Verbatim wording from the response “The NCRS complements Connecting Care Records (ConCR), also known as Shared Care Records. Every Integrated Care Board (ICB) has a shared care record (ShCR) in place, which provides, through different suppliers, a mechanism to access shared information between NHS Trusts and general practice. Shared Care Records will include prescribed medications and will typically hold more information about an individual than a Summary Care Record.” Source location Response from NHS England
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 Facilitate collaborative sharing of patient data across care settings and geographic boundaries through Connecting Care Records.
Verbatim wording from the response “NHS England is committed to supporting the sharing of critical clinical information across NHS organisations. This is discussed in more detail at point 3 below.” Source location Response from NHS England
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 Provide the National Care Records Service for secure access to national patient information, including Summary Care Records and additional clinical information.
Verbatim wording from the response “The National Care Records Service (NCRS) provides a quick, secure way to access national patient information to improve clinical decision making and healthcare outcomes, and it is free to use. NCRS is internet based, accessible via a web browser. NHS England’s national digital team have advised that they would expect the local Mental Health Trust, and the local Drug and Alcohol treatment service to have access to patient’s summary care records via NCRS however utilisation of this resource will vary according to the local business processes. Further information on NCRS can be available here: National Care Records Service - NHS England Digital.” Source location Response from NHS England
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 rolling out Neighbourhood Mental Health Centres across England to provide more joined-up care and oversight.
Verbatim wording from the response “As part of a national pilot to transform mental health care, six new neighbourhood mental health hubs are being developed across England.” Source location Response from NHS England
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 Provide the National Record Locator service to help care professionals locate and retrieve patient information and identify organisations involved in care.
Verbatim wording from the response “NHS England’s National Record Locator (NRL) service allows health or social care workers to find and access patient information shared by other health and social care organisations across England, to support the direct care of a patient. It does this by recording the location of digital (and paper) records within the NHS and provides an index of pointers/bookmarks that contain the information required to retrieve key patient information from the source. The vision is to improve cross-border interoperability and help make data sharing possible by allowing healthcare professionals, such as Care Coordinators within a Mental Health Trust to securely and remotely retrieve information from source at the point of need so that they can get a longitudinal view of a patient’s records and an indication of their treatment history.” Source location Response from NHS England
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 Responsibility for delivering shared care records sits with local Integrated Care Boards, based on local health and care needs and existing systems.
Verbatim wording from the response “Responsibility for delivering shared care records sits with local Integrated Care Boards (ICBs). Each ICB’s shared care record are developed in response to the health and care needs of the local area, existing systems, and future planning. This means some of their shared care records are available to neighbouring ICBs, while others are only supported within their own ICB. Future plans include making shared care records link together regardless of where you live or receive care in England.” Source location Response from NHS England
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 Referral routes, specialist service availability and information-sharing arrangements for ambulance clinicians are determined locally, not through a single national model.
Verbatim wording from the response “Where a patient consents, or where information sharing is otherwise justified for direct care, ambulance clinicians may contact other healthcare professionals or specialist services involved in a patient's care. However, the availability of referral routes, specialist services and information-sharing arrangements is determined locally and is not subject to a single nationally mandated model.” Source location Response from NHS England
Open published response
12 Jun 2026 Suzanne FREDERICKS · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1 Failure to provide clinicians caring for transplant patients with reliably up-to-date blood test results 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
Suzanne FREDERICKS · 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
Suzanne FREDERICKS, who had previously undergone a liver transplant, was admitted to Colchester General Hospital with liver and kidney problems and died there on 4 November 2024 after treatment was unsuccessful. The principal concern was whether clinicians caring for transplant patients in non-specialist hospitals could obtain sufficiently up-to-date blood test results, as delays in processing laboratory results might affect treatment and survival.
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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clinicians caring for transplant patients with reliably up-to-date blood test results
Wider context from the report “There is a concern as to how clinicians caring for transplant patients in non-specialist hospitals such as Colchester General Hospital can obtain sufficiently up- to- date blood test results . Not having reliably up- to- date results can, with the complexities that such patients present, mean that a patient’s chance of survival is affected. The arrangements for taking, processing and returning sample results in Colchester General Hospital (and for that matter, other hospitals in the UK) may need to be improved .
” Open source report
5 Jun 2026 Prabhabi Cangi · Prevention of Future Deaths report North London
View report summary
Concerns raised 4 Lack of guidance for clear and readable photographs of ECGs uploaded to attendance records View source Lack of a clear pathway for specialist doctor interpretation of ECG traces when paramedics decide not to convey patients to hospital View source Failure to convey patients with intermittent chest pain, breathlessness or abnormal ECG with ST elevation to the nearest emergency hospital View source Failure to advise patients with abnormal ECGs to show the ECG copy to their GP View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Prabhabi Cangi · 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
Prabhabi Cangi died in Harefield Hospital on 12 August 2025 after an ST elevation myocardial infarction, following an ambulance attendance at her home where she had chest pain, breathlessness and an abnormal ECG. The principal concerns were the lack of a clear pathway for specialist interpretation of abnormal ECGs when paramedics did not convey patients to hospital, and the failure to ensure that intermittent chest pain, breathlessness and abnormal ECG findings resulted in hospital assessment.
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 England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for clear and readable photographs of ECGs uploaded to attendance records
Wider context from the report “That there is no guidance on photograph of the ECG uploaded to the record of attendance being clear and readable .
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear pathway for specialist doctor interpretation of ECG traces when paramedics decide not to convey patients to hospital
Wider context from the report “That there is no clear pathway for interpretation of ECG traces to a specialist doctor , when attending paramedics decide, where an ECG trace taken at the scene show abnormal automated interpretations, not to convey a patient to hospital.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to convey patients with intermittent chest pain, breathlessness or abnormal ECG with ST elevation to the nearest emergency hospital
Wider context from the report “That Intermittent symptoms of:-
- Chest Pain
- Breathlessness
- Abnormal ECG with some ST elevation (using one or more leads)
did not result in the patient being taken to the nearest emergency hospital .
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to advise patients with abnormal ECGs to show the ECG copy to their GP
Wider context from the report “That where the ECG is abnormal, the patient was not advised should show the copy of the ECG to their GP (unless the patient is taken to hospital).
” 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 Local ambulance services are responsible for the operational concerns and are best placed to respond to them.
Verbatim wording from the response “Having reviewed these concerns, and shared them with the ambulance team for comment, we consider that they relate to specific operational matters, which are the responsibility of the local ambulance service. We note that your report has also been addressed to London Ambulance Service, and so we have agreed that they are best placed to respond to your concerns.” Source location Response from London Ambulance Service
Open published response
5 Jun 2026 Keith Richard Gandy · Prevention of Future Deaths report North London
View report summary
Concerns raised 2 Delays in referral waiting times for specialist evaluation View source Lack of guidance to GPs on previous cancer as a red flag requiring referral for specialist opinion without waiting for further tests View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Keith Richard Gandy · 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
Keith Richard Gandy died in hospital on 29 October 2025 after deterioration following a fall and was found to have a rare radiation-induced osteosarcoma of the pelvis. The concerns were that guidance did not clearly identify previous cancer as a red flag requiring specialist referral without waiting for further tests, and that specialist evaluation waiting times could be between six and twelve months.
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 England; that does not assign responsibility.
PFD Monitor interpretation Delays in referral waiting times for specialist evaluation
Wider context from the report “There was no guidance to GPs that underlines that previous cancer is a red flag and a referral for a specialist opinion should be made without waiting for further tests.
That referral waiting times for specialist evaluation in these circumstances are between 6 months to 12 months
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance to GPs on previous cancer as a red flag requiring referral for specialist opinion without waiting for further tests
Wider context from the report “There was no guidance to GPs that underlines that previous cancer is a red flag and a referral for a specialist opinion should be made without waiting for further tests.
That referral waiting times for specialist evaluation in these circumstances are between 6 months to 12 months
” 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 Specialist referral waiting times are primarily the responsibility of regional commissioners and local providers, not NHS England centrally.
Verbatim wording from the response “Referral waiting times
This is primarily a matter for the region and the commissioners and providers in the locality. However, we would note that in this instance, the patient was seen by the sarcoma Multi Disciplinary Team very soon after the imaging suggested the diagnosis of sarcoma. The interval between the raised alkaline phosphatase noted in primary care and his first admission was 3 weeks, and he went on to the sarcoma service rapidly thereafter.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing NICE guidance and clinicians’ recognition of previous cancer risks are considered sufficient without specific additional GP guidance.
Verbatim wording from the response “A lack of guidance for GPs
National Institute for Health and Care Excellence (NICE) guidance NG12 Suspected cancer: recognition and referral, advises that clinicians use judgement when symptoms present in people with higher baseline cancer risk. Whilst it does not specifically list previous cancer as a red flag, a history of cancer is widely recognised clinically as such a factor.” Source location Response from NHS England
Open published response
5 Jun 2026 Neeshat Dalal · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 1 Lack of appropriately qualified dietitian provision for inpatients undergoing psychiatric care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Neeshat Dalal · 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
Neeshat Dalal was admitted for severe depression after experiencing difficulty eating and drinking and undergoing three attempts to end her life with an insulin overdose. She collapsed during her third ECT treatment on 13 December 2022, was transferred to the emergency department, and died in the Acute Medicine Unit in the early hours of 14 December 2022. The concerns included inadequate consideration of her nutritional needs and vomiting, insufficient medical information before ECT, and delays or omissions in aspects of her acute hospital care.
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 England; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriately qualified dietitian provision for inpatients undergoing psychiatric care
Wider context from the report “Funding is required for the specific provision of appropriately qualified dieticians who can meet the nutritional needs of inpatients undergoing psychiatric care in SPFT and in other Trusts where such support does not already exist .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop safer staffing standards for Allied Health Professionals, including principles applicable to mental health services.
Verbatim wording from the response “There are currently no AHP safer staffing standards, but these are being developed by NHS England. They will be considered by NHS England’s National Quality Board in September 2026. This guidance will include principles that would apply to mental health services.” Source location Response from NHS England
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 supporting multidisciplinary and integrated approaches to care through published specifications and guidance.
Verbatim wording from the response “Workforce models and local arrangements for dietetic provision are determined by providers and commissioners. NHS England will continue to support multidisciplinary and integrated approaches to care through its published specifications and guidance.” Source location Response from NHS England
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 Providers and commissioners determine workforce models and local arrangements for dietetic provision.
Verbatim wording from the response “Workforce models and local arrangements for dietetic provision are determined by providers and commissioners. NHS England will continue to support multidisciplinary and integrated approaches to care through its published specifications and guidance.” Source location Response from NHS England
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 ICBs are responsible for commissioning appropriate nutritional care for psychiatric inpatients and should answer enquiries about local provision.
Verbatim wording from the response “Integrated Care Boards (ICBs) are responsible for commissioning services in line with population need. This includes providing appropriate care for people with additional nutritional needs when they are admitted to hospital whether their primary issue is due to a physical or mental health need. NHS England also published coproduced Culture of Care Standards for mental health inpatient services in 2024 which sets the expectation that “Staff (working in psychiatric hospitals) are equipped to support people with their physical health needs, and understand the higher risk of premature mortality and co-morbidities ...”. NHS England also delivered a two year Culture of Care Improvement Programme which all NHS and major independent mental health providers participated in.” Source location Response from NHS England
Open published response
28 May 2026 Lacey Carole Anne HEATH · Prevention of Future Deaths report Essex
View report summary
Concerns raised 13 Inadequate clinical records of the patient’s presentation, INR results and medication dose View source Lack of General Practitioner funding for at-home anticoagulation testing supplies View source Unavailability of at-home anticoagulation monitoring for daily readings and individualised dosing View source Failure to apply for funding for at-home anticoagulation monitoring View source Failure to clarify the nature and clinical impact of reported illness in records View source Use of alternative anticoagulation medication associated with high INR readings and bleeding risk View source Insufficient trial of Warfarin View source Failure to provide medical review or haematology referral for prolonged non-therapeutic INR View source Failure to consider learning difficulties when providing anticoagulation care View source Unaffordability of at-home anticoagulation monitoring View source Failure to achieve a therapeutic INR for a prolonged period View source Failure to explain available funding to the patient View source Failure of alternative anticoagulation regimes to maintain a therapeutic range View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lacey Carole Anne HEATH · 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
Lacey Carole Anne HEATH died on 16 February 2025 after collapsing at home and suffering cardiac arrest en route to hospital. The death followed thrombosis and complete stenosis of her mechanical aortic valve in the context of sub-therapeutic anticoagulation. Concerns included difficulty maintaining therapeutic anticoagulation, lack of access to affordable at-home monitoring, absence of a funding application, insufficient medical review or haematology referral, and inadequate clinical 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 England; that does not assign responsibility.
PFD Monitor interpretation Inadequate clinical records of the patient’s presentation, INR results and medication dose
Wider context from the report “7. There was an absence of appropriate medical records recorded for Ms Heath to understand her clinical presentation other than very basic information on the INR platform on INR results and medication dose . Evidence was these records are not compliant with the requirements of healthcare regulators and led to a lack of appreciation of Ms Heath’s concerns and complexity of her case. One entry stated Ms Heath had been “unwell” with no clarification or further information on what the problem was and/or how this may have impacted on her condition.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Lack of General Practitioner funding for at-home anticoagulation testing supplies
Wider context from the report “4. Ms Heath could not afford to fund the at home monitor as this was financially prohibitive for her being on a low income. The monitor was expensive and there is no obligation for General Practitioners to fund the testing strips and incidentals required to facilitate testing . As this would be a lifelong commitment for a woman who was only 34 years-old, Ms Heath was not able to take the advice of her expert clinical team and was compelled to have alternative prescribing that was not successful in keeping her INR within therapeutic range.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Unavailability of at-home anticoagulation monitoring for daily readings and individualised dosing
Wider context from the report “3. Ms Heath’s experienced clinical team did not consider that there had been a sufficient trial of Warfarin and recommended at-home monitoring to permit daily readings to be taken to manage the significant risks associated with anticoagulation and to find an individualised dose for Ms Heath. Clinicians were not concerned about medication non-compliance and that the difficulties were clinical.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to apply for funding for at-home anticoagulation monitoring
Wider context from the report “5. No application for funding was made on behalf of Ms Heath by the Trust nor was this explained to Ms Heath who a very quiet, shy lady who always relied on her very loving family to assist her with appointments and could not advocate for herself. There was no consideration if Ms Heath had any learning difficulties and it was noted that there was a developmental delay in her medical records. Evidence at the inquest was Ms Heath experienced this as clinicians not caring about her and she became very despondent about the failure to achieve a therapeutic range.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to clarify the nature and clinical impact of reported illness in records
Wider context from the report “7. There was an absence of appropriate medical records recorded for Ms Heath to understand her clinical presentation other than very basic information on the INR platform on INR results and medication dose. Evidence was these records are not compliant with the requirements of healthcare regulators and led to a lack of appreciation of Ms Heath’s concerns and complexity of her case. One entry stated Ms Heath had been “unwell” with no clarification or further information on what the problem was and/or how this may have impacted on her condition .
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Use of alternative anticoagulation medication associated with high INR readings and bleeding risk
Wider context from the report “2. Due to the complexity of her case, Ms Heath’s anticoagulation was under the care of the acute hospital team. Alternative anticoagulation medication had resulted in high INR readings and significant risks associated with bleeding .
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Insufficient trial of Warfarin
Wider context from the report “3. Ms Heath’s experienced clinical team did not consider that there had been a sufficient trial of Warfarin and recommended at-home monitoring to permit daily readings to be taken to manage the significant risks associated with anticoagulation and to find an individualised dose for Ms Heath. Clinicians were not concerned about medication non-compliance and that the difficulties were clinical.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide medical review or haematology referral for prolonged non-therapeutic INR
Wider context from the report “6. Ms Heath did not manage to achieve a therapeutic INR for a protracted period of time putting her at increased risk of developing complications and did have a medical review or a haematology referral .
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to consider learning difficulties when providing anticoagulation care
Wider context from the report “5. No application for funding was made on behalf of Ms Heath by the Trust nor was this explained to Ms Heath who a very quiet, shy lady who always relied on her very loving family to assist her with appointments and could not advocate for herself. There was no consideration if Ms Heath had any learning difficulties and it was noted that there was a developmental delay in her medical records. Evidence at the inquest was Ms Heath experienced this as clinicians not caring about her and she became very despondent about the failure to achieve a therapeutic range.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Unaffordability of at-home anticoagulation monitoring
Wider context from the report “4. Ms Heath could not afford to fund the at home monitor as this was financially prohibitive for her being on a low income. The monitor was expensive and there is no obligation for General Practitioners to fund the testing strips and incidentals required to facilitate testing. As this would be a lifelong commitment for a woman who was only 34 years-old, Ms Heath was not able to take the advice of her expert clinical team and was compelled to have alternative prescribing that was not successful in keeping her INR within therapeutic range.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to achieve a therapeutic INR for a prolonged period
Wider context from the report “6. Ms Heath did not manage to achieve a therapeutic INR for a protracted period of time putting her at increased risk of developing complications and did have a medical review or a haematology referral.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to explain available funding to the patient
Wider context from the report “5. No application for funding was made on behalf of Ms Heath by the Trust nor was this explained to Ms Heath who a very quiet, shy lady who always relied on her very loving family to assist her with appointments and could not advocate for herself. There was no consideration if Ms Heath had any learning difficulties and it was noted that there was a developmental delay in her medical records. Evidence at the inquest was Ms Heath experienced this as clinicians not caring about her and she became very despondent about the failure to achieve a therapeutic range.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure of alternative anticoagulation regimes to maintain a therapeutic range
Wider context from the report “1. Ms Heath was noted to be warfarin resistant and alternative medication regimes were not successful in keeping Ms Heath within a therapeutic range for her required lifelong requirement to have anticoagulation to prevent a significant risk of death. The GP and hospital clinicians trailed different combinations of appropriate therapy which included additional injections when required. This was not considered to be clinically appropriate long-term.
” 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 Mid and South Essex NHS Foundation Trust is best placed to address the medical-records concern because it concerns specific practitioners’ practice.
Verbatim wording from the response “Concern 4: Medical Records Non-Compliance” Source location Response from NHS England
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 Mid and South Essex NHS Foundation Trust is best placed to address the concern about escalation because it concerns specific practitioners’ practice.
Verbatim wording from the response “Concern 3: Lack of escalation” Source location Response from NHS England
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 responsible anticoagulation service or specialist clinician must submit funding requests for exceptional at-home INR monitoring to the Integrated Care Board.
Verbatim wording from the response “This case is exceptional, however, as there was a clear clinical need for an INR home testing machine. As such an approach for funding should have been made by the anticoagulation service to the ICB for this individual, if not routinely included in the service specification.” Source location Response from NHS England
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 Commissioning responsibility for at-home INR monitoring rests with Integrated Care Boards, varying according to the clinical pathway and service specification.
Verbatim wording from the response “Funding responsibility for at-home INR monitoring, can sit across different parts of the system depending on the clinical pathway and who held responsibility for ongoing anticoagulation management. From an anticoagulation perspective, commissioning of services is the responsibility of Integrated Care Boards (ICBs).” Source location Response from NHS England
Open published response
Concerns raised 1 Failure to provide a designated clinical area for emergency department patients when capacity is reached View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David John Smart · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David John Smart developed a life-threatening rectal bleed after a polypectomy and required surgery after conservative management continued to be unsuccessful. He died from known complications of Andexanet Alfa, used to reverse Rivaroxaban so that surgery could be performed. The inquest raised concerns about patients being cared for in corridors when the Emergency Department reached capacity, including the continued use of corridors despite actions intended to improve patient flow.
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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a designated clinical area for emergency department patients when capacity is reached
Wider context from the report “During the inquest I heard evidence that at the of Mr Smart's attendance to the Emergency Department of the Royal Sussex County Hospital, Brighton that there were around 20 patients in the corridor as the Department had reached capacity and there was no clinical area available to do so . I understand from previous inquests that the area is not designated as a clinical area .
I have heard in other inquests relating to deaths prior to June 2025 that is being taken by University Hospitals Sussex NHS Foundation Trust currently to (1) reduce the number of patients who present to the Emergency Department who could be seen by other services in the community and (2) to create an improved patient flow through the Royal Sussex County Hospital.
The evidence in this inquest was that, despite these actions, the corridor continues to be used when the Emergency Department reaches capacity .
I was also advised that the use of corridors to care for patients is not only an issue at the Royal Sussex County Hospital, Brighton but is used throughout the country .
Prevention of Future Death reports in relation to the use of the corridor for patient care was made during investigations into deaths which occurred in December 2022 and February 2025 and the use of the corridor remains ongoing .
” 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 Support providers and Integrated Care Boards to improve hospital flow through faster senior decisions, same-day emergency care and virtual wards.
Verbatim wording from the response “Alongside this, NHS England has been and continues to support providers and Integrated Care Boards (ICBs) to improve internal hospital flow through faster senior clinical decision-making, increased use of same day emergency care and virtual wards, and more effective management of patient pathways. The plan also aims to reduce demand on emergency departments through improved access to community and primary care alternatives and strengthened admission avoidance pathways, so that patients can be assessed and treated in the most appropriate setting.” Source location Response from NHS England
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 Provide targeted regional support to systems experiencing the highest levels of patient-flow pressure.
Verbatim wording from the response “To strengthen oversight and drive improvement, NHS England is working through regional teams to provide targeted support to systems experiencing the highest levels of flow pressure. From May 2026, the routine publication of corridor care data has begun, increasing transparency and enabling more focused intervention where risks to patient safety are greatest.” Source location Response from NHS England
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 Support providers and Integrated Care Boards to strengthen discharge processes through criteria-led discharge and discharge-to-assess models.
Verbatim wording from the response “A key element of improving patient flow is reducing delays in discharging patients who no longer require acute hospital treatment. Delayed discharges contribute to high bed occupancy, reducing capacity for emergency admissions and increasing pressure on emergency departments. NHS England is supporting providers and ICBs to strengthen” Source location Response from NHS England
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 Model Discharge guidance to reduce discharge delays and improve patient flow.
Verbatim wording from the response “discharge processes, including through the consistent use of criteria-led discharge and discharge to assess models. NHS England is also developing “Model Discharge” guidance to support trusts in reducing delays and improving patient flow.” Source location Response from NHS England
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 Support providers and Integrated Care Boards to reduce emergency-department demand through community and primary-care alternatives and strengthened admission-avoidance pathways.
Verbatim wording from the response “Alongside this, NHS England has been and continues to support providers and Integrated Care Boards (ICBs) to improve internal hospital flow through faster senior clinical decision-making, increased use of same day emergency care and virtual wards, and more effective management of patient pathways. The plan also aims to reduce demand on emergency departments through improved access to community and primary care alternatives and strengthened admission avoidance pathways, so that patients can be assessed and treated in the most appropriate setting.” Source location Response from NHS England
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 Publish corridor-care data routinely to increase transparency and enable focused intervention where patient-safety risks are greatest.
Verbatim wording from the response “To strengthen oversight and drive improvement, NHS England is working through regional teams to provide targeted support to systems experiencing the highest levels of flow pressure. From May 2026, the routine publication of corridor care data has begun, increasing transparency and enabling more focused intervention where risks to patient safety are greatest.” Source location Response from NHS England
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 Publish the Urgent and Emergency Care Plan and Medium-Term Planning Framework setting national expectations to eliminate corridor care.
Verbatim wording from the response “Since your previous Reports to us, the NHS England Urgent and Emergency Care Plan for 2025/26 has been published (in June 2025) and supported by the Medium-Term Planning Framework, which sets out a national expectation that systems take coordinated action to eliminate corridor care by improving end-to-end patient flow, reducing avoidable hospital congestion and improving timely discharge from hospital.” Source location Response from NHS England
Open published response
13 May 2026 Nigel John KEENAN · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 3 Lack of 7-day mental health support for prisoners in crisis View source Incentive for prisoners in crisis to underreport self-harm intent View source Insufficient staffing capacity for constant observation of prisoners in crisis View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nigel John KEENAN · 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
Nigel John Keenan died by hanging at HMP Haverigg between 8 pm on 12 March 2025 and 4:20 am on 13 March 2025; the inquest concluded suicide. Concerns included the lack of seven-day mental health support at the prison, limited staffing for constant observation, and a possible incentive for prisoners in crisis to minimise their suicidal intent.
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 England; that does not assign responsibility.
PFD Monitor interpretation Lack of 7-day mental health support for prisoners in crisis
Wider context from the report “In the course of hearing evidence in this inquest I was told that: 1) Mental health provision is only commissioned within HMP Haverigg during the week and is not available at the weekends. I was told that in the event that a prisoner experienced a crisis during the weekend they would be cared for by prison staff using the ACCT procedure, but that mental health input would not be available until Monday morning. 2) Because HMP Haverigg is a Category D 'open' prison it has far fewer staff available to monitor prisoners. As such it is not able to place prisoners on 'constant watch'. As a result if a prisoner requires very regular or constant observation (as a result of being in crisis) they would have to be transferred to a closed prison. 3) This means that prisoners who are in crisis have something of an incentive to deny their intent to self harm because to admit it would result in their being transferred to a closed prison.
I am concerned that the decision not to commission 7 day a week mental health support at HMP Haverigg is therefore counterproductive. Because of the limited number of prison officers at the establishment it gives rise to a higher risk than would be the case at a closed prison. In particular, it risks providing an incentive for prisoners in crisis to play down the true extent of their 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 England; that does not assign responsibility.
PFD Monitor interpretation Incentive for prisoners in crisis to underreport self-harm intent
Wider context from the report “In the course of hearing evidence in this inquest I was told that: 1) Mental health provision is only commissioned within HMP Haverigg during the week and is not available at the weekends. I was told that in the event that a prisoner experienced a crisis during the weekend they would be cared for by prison staff using the ACCT procedure, but that mental health input would not be available until Monday morning. 2) Because HMP Haverigg is a Category D 'open' prison it has far fewer staff available to monitor prisoners. As such it is not able to place prisoners on 'constant watch'. As a result if a prisoner requires very regular or constant observation (as a result of being in crisis) they would have to be transferred to a closed prison. 3) This means that prisoners who are in crisis have something of an incentive to deny their intent to self harm because to admit it would result in their being transferred to a closed prison .
I am concerned that the decision not to commission 7 day a week mental health support at HMP Haverigg is therefore counterproductive. Because of the limited number of prison officers at the establishment it gives rise to a higher risk than would be the case at a closed prison. In particular, it risks providing an incentive for prisoners in crisis to play down the true extent of their 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 England; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing capacity for constant observation of prisoners in crisis
Wider context from the report “In the course of hearing evidence in this inquest I was told that: 1) Mental health provision is only commissioned within HMP Haverigg during the week and is not available at the weekends. I was told that in the event that a prisoner experienced a crisis during the weekend they would be cared for by prison staff using the ACCT procedure, but that mental health input would not be available until Monday morning. 2) Because HMP Haverigg is a Category D 'open' prison it has far fewer staff available to monitor prisoners . As such it is not able to place prisoners on 'constant watch' . As a result if a prisoner requires very regular or constant observation (as a result of being in crisis) they would have to be transferred to a closed prison . 3) This means that prisoners who are in crisis have something of an incentive to deny their intent to self harm because to admit it would result in their being transferred to a closed prison.
I am concerned that the decision not to commission 7 day a week mental health support at HMP Haverigg is therefore counterproductive. Because of the limited number of prison officers at the establishment it gives rise to a higher risk than would be the case at a closed prison. In particular, it risks providing an incentive for prisoners in crisis to play down the true extent of their situation.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and finalise the national NHS England health and justice service specifications, incorporating learning to support tailored prison healthcare provision.
Verbatim wording from the response “A review of the NHS England national health and justice service specifications is currently underway, with a view to finalising this in Summer 2026, and any learning from this case will be used to ensure that the primary care specification continues to support commissioners to be able to tailor services to meet the needs of their prison population. They ensure providers are clear on core service delivery and standards they are expected to prioritise which includes access to Out of Office Hours services. Delivery of these specifications is the responsibility of regionally regional commissioners under contract management processes” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review weekend on-site healthcare provision over six months against patient need and demand.
Verbatim wording from the response “Further communications and meetings have occurred with HM Prison and Probation Service (HMPPS) to outline the offer and this has been agreed. The North West Health & Justice will review the provision over the next 6 months, looking at need and demand for weekend on site presence.” Source location Response from NHS England
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 Rectify communication of weekend and out-of-hours healthcare arrangements to the primary care provider.
Verbatim wording from the response “Practitioners are contactable via an on-call number and will attend the prison to see anyone who requires assessment or intervention. There have been some issues with communicating this to the primary care provider and this has been rectified.” Source location Response from NHS England
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 Regional commissioners, rather than NHS England nationally, are responsible for delivering the national health and justice service specifications under contract management.
Verbatim wording from the response “A review of the NHS England national health and justice service specifications is currently underway, with a view to finalising this in Summer 2026, and any learning from this case will be used to ensure that the primary care specification continues to support commissioners to be able to tailor services to meet the needs of their prison population. They ensure providers are clear on core service delivery and standards they are expected to prioritise which includes access to Out of Office Hours services. Delivery of these specifications is the responsibility of regionally regional commissioners under contract management processes” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing out-of-hours community access and HMP Haverigg’s seven-day on-call service are considered sufficient despite no overnight healthcare provision.
Verbatim wording from the response “With regards to overnight staffing levels and the lack of clinical presence overnight, outside of weekday hours, the commissioning and provision of healthcare services across the England prison estate is based on a national service specification and health needs assessment for each establishment. It is overseen by the NHS England regional health and justice commissioning team.” Source location Response from NHS England
Open published response
11 May 2026 Oliver Charles Major Shelley · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Misleading public impression created by the Emergency Medical Advisor role title View source Failure to provide compliant and timely follow-up call management View source Lack of a sepsis algorithm pathway for emergency medical advisors during 111/999 calls View source Limited clinical capability of Emergency Medical Advisors to recognise serious illness View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Oliver Charles Major Shelley · 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
Oliver Charles Major Shelley became seriously unwell on 22 July 2024 with symptoms including a non-blanching rash, vomiting and reduced consciousness. After no ambulance was dispatched, his parents took him to hospital, where he was treated for meningococcal septicaemia but died approximately 7.5 hours after arrival. The report identified concerns about the lack of a sepsis algorithm for emergency medical advisors and the training and description of those advisors’ role.
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 England; that does not assign responsibility.
PFD Monitor interpretation Misleading public impression created by the Emergency Medical Advisor role title
Wider context from the report “2. Emergency Medical Advisors
Other than some in-house training, Emergency Medical Advisors (EMA’s), generally have no qualifications in medicine or nursing. As such, the use of this title to describe their role raises a real concern they are misleading the public who use the 111/999 service . Oliver’s parents gave an extreme clear assessment of Oliver’s condition and also informed the EMA that they were concerned it was meningitis. However, this was not recognised by the EMA reaffirming their limited abilities. This reinforces the need to provide further assistance to all EMA’s who use NHS Pathways by providing an appropriate ‘sepsis’ algorithm to assist in their role.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide compliant and timely follow-up call management
Wider context from the report “1. The lack of a sepsis algorithm pathway to assist the emergency medical advisor (EMA) during 111/999 calls
At 14:51 hours on 22nd July 2024, Oliver’s parents called 999 indicating their concern that Oliver was suffering from meningitis as he was suffering from a non-blanching rash, vomiting and reduced level of consciousness. The EMA began a triage using NHS Pathways algorithm but as they were unable to prioritise any of the listed symptoms, they requested operational support at 14:57 hours, to ask if there was a meningitis pathway within the system. This call was concluded at 15:51 with the EMA indicating to Oliver’s parents that a call back was scheduled within 20 minutes.
A call back was not undertaken until 1 hr and 41 minutes later and in the absence of a response a further unsuccessful call was made 2 hrs and 18 minutes later before Secamb closed the referral . In the meantime, Oliver’s parents made the decision to convey Oliver to hospital arriving there at around 15:55 hours. On attendance it was recognised that Oliver was gravely unwell and despite maximal supportive management sadly died from overwhelming meningococcal septicaemia 7.5 hours after his arrival.
In their investigation, Secamb acknowledged that the EMA’s management of the 999 call was not compliant and have taken the opportunity to offer ongoing training. However, it was also recognised EMA’s found it challenging to triage individuals when multiple signs and symptoms were present in relation to a possible sepsis diagnosis and that having a dedicated sepsis algorithm would assist them in being able to provide an appropriate response to callers and to ensure appropriate management. This has important implications for prioritising ambulance disposition, which may also include the ability of a paramedic to attend at the earliest opportunity to give antibiotics.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Lack of a sepsis algorithm pathway for emergency medical advisors during 111/999 calls
Wider context from the report “1. The lack of a sepsis algorithm pathway to assist the emergency medical advisor (EMA) during 111/999 calls
At 14:51 hours on 22nd July 2024, Oliver’s parents called 999 indicating their concern that Oliver was suffering from meningitis as he was suffering from a non-blanching rash, vomiting and reduced level of consciousness. The EMA began a triage using NHS Pathways algorithm but as they were unable to prioritise any of the listed symptoms, they requested operational support at 14:57 hours, to ask if there was a meningitis pathway within the system. This call was concluded at 15:51 with the EMA indicating to Oliver’s parents that a call back was scheduled within 20 minutes.
A call back was not undertaken until 1 hr and 41 minutes later and in the absence of a response a further unsuccessful call was made 2 hrs and 18 minutes later before Secamb closed the referral. In the meantime, Oliver’s parents made the decision to convey Oliver to hospital arriving there at around 15:55 hours. On attendance it was recognised that Oliver was gravely unwell and despite maximal supportive management sadly died from overwhelming meningococcal septicaemia 7.5 hours after his arrival.
In their investigation, Secamb acknowledged that the EMA’s management of the 999 call was not compliant and have taken the opportunity to offer ongoing training. However, it was also recognised EMA’s found it challenging to triage individuals when multiple signs and symptoms were present in relation to a possible sepsis diagnosis and that having a dedicated sepsis algorithm would assist them in being able to provide an appropriate response to callers and to ensure appropriate management . This has important implications for prioritising ambulance disposition, which may also include the ability of a paramedic to attend at the earliest opportunity to give antibiotics.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Limited clinical capability of Emergency Medical Advisors to recognise serious illness
Wider context from the report “2. Emergency Medical Advisors
Other than some in-house training, Emergency Medical Advisors (EMA’s), generally have no qualifications in medicine or nursing . As such, the use of this title to describe their role raises a real concern they are misleading the public who use the 111/999 service. Oliver’s parents gave an extreme clear assessment of Oliver’s condition and also informed the EMA that they were concerned it was meningitis. However, this was not recognised by the EMA reaffirming their limited abilities . This reinforces the need to provide further assistance to all EMA’s who use NHS Pathways by providing an appropriate ‘sepsis’ algorithm to assist in their role.
” Open source report
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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 A separate sepsis algorithm pathway is unnecessary because sepsis screening is embedded across multiple symptom-based NHS Pathways.
Verbatim wording from the response “It is noted that the health advisor sought advice from a Senior Non-Clinician as they wanted to know if there was a specific Pathway for meningitis before then passing the case to the clinical queue for inability to prioritise a main symptom. It is important to highlight that as NHS Pathways is a non-diagnostic clinical assessment tool 'Meningitis' (or any other condition) would not present as a pathway option, however, questions regarding septicaemia and meningitis are covered in a variety of symptom-based pathways and when answered positively result in an ambulance dispatch. In essence, rather than one ‘sepsis algorithm’ pathway, NHS Pathways has embedded a ‘sepsis’ algorithm into a wide range of symptom-based pathways where sepsis could” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS Pathways does not oversee local service delivery or response times, which must be managed locally.
Verbatim wording from the response “NHS Pathways recognise there may be operational delays which must be managed locally. NHS Pathways is not able to take account of these as they and the local management of them can vary, and thus NHS Pathway’s expectations are based on what should happen in absence of such delays.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ambulance service providers locally determine alternative role titles, including whether to use “Emergency Medical Advisor.”
Verbatim wording from the response “The terminology used to describe call-takers using the NHS Pathways system is described in the background and training section above. For clarity, the term Health Advisor is set by the NHS 111 service specification. 999 services can determine this per service.” Source location Response from NHS England
Open published response
10 May 2026 Glen Edward Robert Jay · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1 Failure to contraindicate Preoperative Progressive Pneumoperitoneum for patients with a history of adhesional small bowel obstruction 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
Glen Edward Robert Jay · 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
Glen Edward Robert Jay was admitted to Broomfield Hospital for planned preoperative preparation and subsequently underwent emergency abdominal surgery for small bowel obstruction with suspected ischaemia. He did not regain consciousness after further surgery and died following severe sepsis; the principal concern was that Preoperative Progressive Pneumoperitoneum may induce adhesional small bowel obstruction in patients with a history of recurrent adhesional small bowel obstruction, and the Trust updated its protocol to list this as a contraindication.
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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to contraindicate Preoperative Progressive Pneumoperitoneum for patients with a history of adhesional small bowel obstruction
Wider context from the report “- There are other clinics nationally who may be offering patients Preoperative Progressive Pneumoperitoneum (PPP) to patients who have a history of adhesional small bowel obstruction (ASBO). Mid & South Essex NHS Foundation Trust have updated their protocol to include a prior history of recurrent ASBO, as a contraindication to PPP. This is because it can induce ASBO due to stretching of any intra-abdominal or hernia sac adhesions and consequent obstruction of involved loops of small bowel.
” 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 Compile a warning notice requiring enhanced governance, MDT review, local PPP protocols, safety provisions, outcome audit and patient-safety reporting.
Verbatim wording from the response “As a result of the concerns, raised NHS England plans to compile a warning notice to Chief Medical Officers/Medical Directors of all Trusts currently providing or considering PPP to state:” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the British Hernia Society to disseminate the PPP warning notice to relevant NHS trusts.
Verbatim wording from the response “NHS England plans to work with the British Hernia Society to disseminate the warning notices.” Source location Response from NHS England
Open published response
8 May 2026 Jake Daniel Taylor · Prevention of Future Deaths report West London
View report summary
Concerns raised 6 Lack of airway equipment View source Lack of airway training for staff View source Unavailability of a defibrillator on site View source Lack of individual emergency planning for service users with high-tier needs and life-threatening risk profiles View source Staff misunderstanding of defibrillator function View source Inadequate staff training to conduct CPR unless a contrary decision exists View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jake Daniel Taylor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jake Daniel Taylor, aged 19, suffered a cardiac arrest at his care home on 16 January 2025 and died in Kingston hospital on 20 January 2025. The report identified delays in first aid and concerns about the lack of individual emergency planning, staff training, immediately available equipment, and airway training and equipment.
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 England; that does not assign responsibility.
PFD Monitor interpretation Lack of airway equipment
Wider context from the report “No planning for this foreseeable emergency.
Inadequate staff training (to always conduct CPR if no decision to the contrary)
No defibrillator on site and staff misunderstanding of the function of a defibrillator.
No airway training and equipment although Registered Nursing staff have this within their competencies .
I consider that individual emergency planning for those service users with recognised high tier needs and life-threatening risk profiles is essential to ensure best possible outcomes and care tailored to their needs. Medical emergencies in this cohort of patients are predictable but are likely to happen suddenly and unexpectedly. In this case the staff were not able to respond and their evidence to the court demonstrated that they felt unprepared and uncertain about what to do.
This is a situation that could be replicated throughout the services that care for individuals such as Jake. Those commissioning the services should consider if the individual emergency care planning is comprehensive and complete and reviewed where appropriate.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Lack of airway training for staff
Wider context from the report “No planning for this foreseeable emergency.
Inadequate staff training (to always conduct CPR if no decision to the contrary)
No defibrillator on site and staff misunderstanding of the function of a defibrillator.
No airway training and equipment although Registered Nursing staff have this within their competencies.
I consider that individual emergency planning for those service users with recognised high tier needs and life-threatening risk profiles is essential to ensure best possible outcomes and care tailored to their needs. Medical emergencies in this cohort of patients are predictable but are likely to happen suddenly and unexpectedly. In this case the staff were not able to respond and their evidence to the court demonstrated that they felt unprepared and uncertain about what to do.
This is a situation that could be replicated throughout the services that care for individuals such as Jake. Those commissioning the services should consider if the individual emergency care planning is comprehensive and complete and reviewed where appropriate.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a defibrillator on site
Wider context from the report “No planning for this foreseeable emergency.
Inadequate staff training (to always conduct CPR if no decision to the contrary)
No defibrillator on site and staff misunderstanding of the function of a defibrillator.
No airway training and equipment although Registered Nursing staff have this within their competencies.
I consider that individual emergency planning for those service users with recognised high tier needs and life-threatening risk profiles is essential to ensure best possible outcomes and care tailored to their needs. Medical emergencies in this cohort of patients are predictable but are likely to happen suddenly and unexpectedly. In this case the staff were not able to respond and their evidence to the court demonstrated that they felt unprepared and uncertain about what to do.
This is a situation that could be replicated throughout the services that care for individuals such as Jake. Those commissioning the services should consider if the individual emergency care planning is comprehensive and complete and reviewed where appropriate.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Lack of individual emergency planning for service users with high-tier needs and life-threatening risk profiles
Wider context from the report “No planning for this foreseeable emergency.
Inadequate staff training (to always conduct CPR if no decision to the contrary)
No defibrillator on site and staff misunderstanding of the function of a defibrillator.
No airway training and equipment although Registered Nursing staff have this within their competencies.
I consider that individual emergency planning for those service users with recognised high tier needs and life-threatening risk profiles is essential to ensure best possible outcomes and care tailored to their needs. Medical emergencies in this cohort of patients are predictable but are likely to happen suddenly and unexpectedly. In this case the staff were not able to respond and their evidence to the court demonstrated that they felt unprepared and uncertain about what to do.
This is a situation that could be replicated throughout the services that care for individuals such as Jake. Those commissioning the services should consider if the individual emergency care planning is comprehensive and complete and reviewed where appropriate .
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Staff misunderstanding of defibrillator function
Wider context from the report “No planning for this foreseeable emergency.
Inadequate staff training (to always conduct CPR if no decision to the contrary)
No defibrillator on site and staff misunderstanding of the function of a defibrillator .
No airway training and equipment although Registered Nursing staff have this within their competencies.
I consider that individual emergency planning for those service users with recognised high tier needs and life-threatening risk profiles is essential to ensure best possible outcomes and care tailored to their needs. Medical emergencies in this cohort of patients are predictable but are likely to happen suddenly and unexpectedly. In this case the staff were not able to respond and their evidence to the court demonstrated that they felt unprepared and uncertain about what to do.
This is a situation that could be replicated throughout the services that care for individuals such as Jake. Those commissioning the services should consider if the individual emergency care planning is comprehensive and complete and reviewed where appropriate.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Inadequate staff training to conduct CPR unless a contrary decision exists
Wider context from the report “No planning for this foreseeable emergency.
Inadequate staff training (to always conduct CPR if no decision to the contrary)
No defibrillator on site and staff misunderstanding of the function of a defibrillator.
No airway training and equipment although Registered Nursing staff have this within their competencies.
I consider that individual emergency planning for those service users with recognised high tier needs and life-threatening risk profiles is essential to ensure best possible outcomes and care tailored to their needs. Medical emergencies in this cohort of patients are predictable but are likely to happen suddenly and unexpectedly. In this case the staff were not able to respond and their evidence to the court demonstrated that they felt unprepared and uncertain about what to do.
This is a situation that could be replicated throughout the services that care for individuals such as Jake. Those commissioning the services should consider if the individual emergency care planning is comprehensive and complete and reviewed where appropriate.
” 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 Oversight of AED defibrillators in healthcare settings is assigned to the Care Quality Commission.
Verbatim wording from the response “The Care Quality Commission (CQC) are responsible for the oversight of AED defibrillators in health care settings. Whilst the CQC does not mandate that care homes have to have an AED onsite, they do require care homes to be able to handle medical emergencies. The CQC Regulation 12 (Safe Care and Treatment) further mandates that providers assess and mitigate risks, ensuring staff are appropriately trained and equipped. This includes consideration of emergency equipment such as AEDs, particularly in settings with residents at increased cardiac risk, as encouraged by NHS England and RC UK guidance. Failure to provide necessary training, equipment, or clear documentation represents a breach of expected standards of safe and effective care.” Source location Response from NHS England
Open published response
Concerns raised 9 Lack of national guidance for cross-Trust transfer of complex cases View source Commissioning arrangements failing to accommodate overlapping eating and emotional needs View source Lack of training on national guidance for complex case transfers View source Lack of clear escalation procedures during complex case transfers View source Failure to conduct risk assessments at the time of complex case transfer View source Failure to assess and manage overlapping needs using a formulation-led approach View source Lack of a national treatment pathway for co-existing eating disorders and complex emotional needs View source Failure to disseminate learning and address identified concerns nationally View source Lack of senior management oversight of complex case transfers View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sunny Elise EYMOND · 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
Sunny Elise EYMOND died at Winchester Hospice on 27 May 2024 after a long history of anorexia nervosa, personality disorder and complex post-traumatic stress disorder, including hospital admissions and periods of forced feeding. The report identified communication and oversight failings during her transfer of care between Hampshire and Bristol services, including the absence of a robust care package, planned 1:1 professional support and a suitable risk management plan. Concerns were raised about the lack of national guidance and treatment pathways for cross-Trust transfers involving people with eating disorders and complex emotional needs.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for cross-Trust transfer of complex cases
Wider context from the report “1. While the two trusts involved in the inquest (Southern Health and Avon & Wiltshire Mental Health Partnership NHS Trust) have undertaken reviews, learned lessons and implemented changes following Sunny’s death, the same has not happened at a national level/England wide Trust level.
2. Firstly, I am concerned that a risk of death may arise in the future if the concerns raised are not addressed more widely and brought to the attention of other Trusts and consideration is not given to the production of national guidance on cross Trust transfer of complex cases, particularly those involving patients with a diagnosis of an eating disorder and complex Post Traumatic Stress Disorder/Emotionally Unstable Personality Disorder/complex emotional needs.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Commissioning arrangements failing to accommodate overlapping eating and emotional needs
Wider context from the report “5. There is currently no national specified treatment pathway for individuals who present with co-existing eating difficulties and complex emotional needs. This, in turn, impacts how services are commissioned, as commissioning arrangements are largely organised around set, diagnosis-specific pathways . To ensure patient safety and national consistency, there is a need for national guidance addressing:
a) How to develop a pathway/protocol for patients with eating disorders and complex emotional needs
b) When bespoke services (such as the creation of Willow Ward at Parklands Hospital in Sunny's case) are required
c) How patients with overlapping needs should be assessed and managed using a formulation-led approach, where single- diagnosis pathways are not appropriate
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Lack of training on national guidance for complex case transfers
Wider context from the report “4. There is currently no national guidance on how best to manage and plan for Trust to Trust transfers of highly complex cases (in particular those involving patients with both a diagnosed eating disorder such as AN and complex emotional needs). Guidance is therefore required as to the need for:
a) Senior management oversight of the transfer
b) Risk assessments at the time of transfer
c) Clear escalation procedures if concerns are raised during the transfer and
d) Training on any such national guidance
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of clear escalation procedures during complex case transfers
Wider context from the report “4. There is currently no national guidance on how best to manage and plan for Trust to Trust transfers of highly complex cases (in particular those involving patients with both a diagnosed eating disorder such as AN and complex emotional needs). Guidance is therefore required as to the need for:
a) Senior management oversight of the transfer
b) Risk assessments at the time of transfer
c) Clear escalation procedures if concerns are raised during the transfer and
d) Training on any such national guidance
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct risk assessments at the time of complex case transfer
Wider context from the report “4. There is currently no national guidance on how best to manage and plan for Trust to Trust transfers of highly complex cases (in particular those involving patients with both a diagnosed eating disorder such as AN and complex emotional needs). Guidance is therefore required as to the need for:
a) Senior management oversight of the transfer
b) Risk assessments at the time of transfer
c) Clear escalation procedures if concerns are raised during the transfer and
d) Training on any such national guidance
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and manage overlapping needs using a formulation-led approach
Wider context from the report “5. There is currently no national specified treatment pathway for individuals who present with co-existing eating difficulties and complex emotional needs. This, in turn, impacts how services are commissioned, as commissioning arrangements are largely organised around set, diagnosis-specific pathways. To ensure patient safety and national consistency, there is a need for national guidance addressing:
a) How to develop a pathway/protocol for patients with eating disorders and complex emotional needs
b) When bespoke services (such as the creation of Willow Ward at Parklands Hospital in Sunny's case) are required
c) How patients with overlapping needs should be assessed and managed using a formulation-led approach, where single- diagnosis pathways are not appropriate
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Lack of a national treatment pathway for co-existing eating disorders and complex emotional needs
Wider context from the report “3. Secondly, I am concerned that there is a gap at a national level (identified by both SH and AWP) in terms of a pathway for those with a diagnosis of both an eating disorder and complex emotional needs . This lack of a pathway created difficulties when Sunny was transferred from SH (Hampshire) to AWP (Bristol) in order to attend university. It meant that there was an inability to appropriately 'map' her treatment needs to the available mental health services in Bristol. I believe that this needs to be addressed at a national level and not just left for each Trust in England. It is a real concern, given the very high risk of death associated with those with both Anorexia Nervosa and a personality disorder, as was the case here.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to disseminate learning and address identified concerns nationally
Wider context from the report “1. While the two trusts involved in the inquest (Southern Health and Avon & Wiltshire Mental Health Partnership NHS Trust) have undertaken reviews, learned lessons and implemented changes following Sunny’s death, the same has not happened at a national level/England wide Trust level .
2. Firstly, I am concerned that a risk of death may arise in the future if the concerns raised are not addressed more widely and brought to the attention of other Trusts and consideration is not given to the production of national guidance on cross Trust transfer of complex cases, particularly those involving patients with a diagnosis of an eating disorder and complex Post Traumatic Stress Disorder/Emotionally Unstable Personality Disorder/complex emotional needs.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Lack of senior management oversight of complex case transfers
Wider context from the report “4. There is currently no national guidance on how best to manage and plan for Trust to Trust transfers of highly complex cases (in particular those involving patients with both a diagnosed eating disorder such as AN and complex emotional needs). Guidance is therefore required as to the need for:
a) Senior management oversight of the transfer
b) Risk assessments at the time of transfer
c) Clear escalation procedures if concerns are raised during the transfer and
d) Training on any such national guidance
” 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 Publish and apply national guidance integrating Children and Young People Eating Disorder Services with mental health teams for young people with co-occurring needs.
Verbatim wording from the response “In January 2026, NHS England published National Guidance for eating disorder services for children and young people. The guidance highlights that Children and Young People Eating Disorder Services (CEDS) are integral to the integrated care pathway. The guidance states it is important that all care pathways are locally co-produced with stakeholders, including Children and Young People and their families, and that they are also involved in care planning with other key stakeholders, as this ensures optimal pathway integration and delivery of evidence-based, outcomes-focused care.” Source location Response from NHS England
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 Publish the Mental Health Personalised Care Framework, including expectations for transfers of care between services.
Verbatim wording from the response “NHS England expects to publish the Mental Health Personalised Care Framework shortly. The Mental Health Personalised Care Framework sets out the approach and related principles and actions for delivering personalised care for adults and older people with severe mental health problems. The framework includes a section on expectations for any transfer of care between services including the following:” Source location Response from NHS England
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 Discuss Prevention of Future Deaths reports through the Regulation 28 Working Group and share relevant learning across national and regional NHS services.
Verbatim wording from the response “I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Sunny, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.” Source location Response from NHS England
Open published response
30 Apr 2026 Poppy Hope LOMAS · Prevention of Future Deaths report North London
View report summary
Concerns raised 4 Use of terminology failing to convey the gravity and unsafe nature of delivery against medical advice View source Unavailability of a pulse oximeter for maternal heart rate in the home delivery kit View source Failure to hold a multidisciplinary risk discussion for an unsafe home birth View source Failure to obtain consent documenting the risks of an unsafe home birth View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Poppy Hope LOMAS · 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
Poppy Hope LOMAS died in hospital on 26 October 2022, aged 7 days, after being born in poor condition following a home delivery. The report describes multiple unrecognised risk factors during the delivery and identifies concerns about consent and risk communication, multidisciplinary review, terminology used for unsafe deliveries, and the absence of a maternal pulse oximeter from the home delivery kit.
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 England; that does not assign responsibility.
PFD Monitor interpretation Use of terminology failing to convey the gravity and unsafe nature of delivery against medical advice
Wider context from the report “It is a matter of concern that the nationally used expression “Out of Guidance” is used in these circumstances, which may fail to convey the gravity of the decisions being taken , rather than an expression that captures all elements:- in particular that the delivery is against medical advice, the Royal College of Obstetricians and Gynaecologists guidance and that as a consequence it is an unsafe delivery.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a pulse oximeter for maternal heart rate in the home delivery kit
Wider context from the report “It is a matter of concern that the Home Delivery kit does not include a pulse oximeter for maternal heart rate .
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to hold a multidisciplinary risk discussion for an unsafe home birth
Wider context from the report “It is a matter of concern that where the patient has chosen to have an unsafe birth at home consideration is not given to holding a Multi-Disciplinary Team Meeting with the consultant obstetrician, hospital midwives & community midwives and the patient , to ensure that the patient receives an understanding of the risks to the baby and to themselves..
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain consent documenting the risks of an unsafe home birth
Wider context from the report “It is a matter of concern that where the patient has chosen to have an unsafe birth at home and has decided to refuse to consent to the care the hospital recommend for the management of the unsafe birth, that consideration is not given to the patient signing a consent form that clearly sets out the risks .
” 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 Set minimum standards for safe homebirth services, including clear terminology, safety and risk assessment, multidisciplinary care planning, consent documentation, and standardised equipment.
Verbatim wording from the response “By autumn 2026, we anticipate setting out the minimum standards that providers and commissioners of maternity services will be expected to meet to support the delivery of a safe, effective, equitable and personalised home birth service. The standards will include the use of appropriate and clear language in discussing women’s preferences, including review of the term “Out of Guidance”. The standards will also include detail on the assessment of safety and risk required, and the need for multi-disciplinary team working in the formulation of care plans and their documentation. This will also include consideration of the use of consent forms which are not currently used in maternity services for any place of birth. It will also include reference to the standardised equipment required for clinical care provided during homebirth.” Source location Response from NHS England
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 NHS Trusts are responsible for ensuring midwives and obstetricians practise in line with relevant maternity guidance.
Verbatim wording from the response “Trusts are responsible for ensuring midwives and obstetricians practice in line with this guidance and the new homebirth standards will take these documents into account to ensure greater clarity and alignment of advice across all organisations.” Source location Response from NHS England
Open published response
29 Apr 2026 Name not published · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 5 Failure of Trusts to fully assess risks View source Failure of NHS England guidance to address prompt police notification View source Failure of NHS England guidance to address discussing and managing an alleged perpetrator who is a member of staff View source Failure of NHS England guidance to address prompt decisions on suspension and withdrawal of easy access to fatal drugs View source Failure of NHS England guidance to address risk assessment of the impact on staff members confronted with serious allegations 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
Name not published · 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
An experienced Operational Department Practitioner was found deceased in on-call accommodation after deliberately injecting himself with anaesthetic medication accessed from a secure hospital drug store. Concerns were raised that NHS England guidance did not adequately address risk assessment, prompt police notification, suspension decisions, or removal of access to potentially fatal drugs following serious allegations.
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 England; that does not assign responsibility.
PFD Monitor interpretation Failure of Trusts to fully assess risks
Wider context from the report “1. The Trust level investigation identified concerns that NHS England guidance - e.g. (a) NHS England Misconduct Policy ‘Every organisation has a duty of care to protect its employees from and prevent incidents of sexual misconduct’; and (b) e-learning ‘Understanding Sexual Misconduct in the Workplace’ – omits to deal with how to discuss and manage the alleged perpetrator when a member of staff. It does not cover when the Trust may need to conduct a risk assessment of the likely impact on the staff member of being confronted with a serious allegation, when they may need to inform the police promptly, or advise on what factors impact the need for a prompt decision on suspension and withdrawal of easy access to fatal drugs. Since this incident the local Trust has updated their policies so that a same day decision is made on these matters and in a similar incident in the future it is likely the staff member would have been immediately suspended and had their access to fatal drugs removed. My concern is that NHS England guidance continues to omit such considerations and at a local level Trusts are not fully assessing the risks .
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure of NHS England guidance to address prompt police notification
Wider context from the report “1. The Trust level investigation identified concerns that NHS England guidance - e.g. (a) NHS England Misconduct Policy ‘Every organisation has a duty of care to protect its employees from and prevent incidents of sexual misconduct’; and (b) e-learning ‘Understanding Sexual Misconduct in the Workplace’ – omits to deal with how to discuss and manage the alleged perpetrator when a member of staff. It does not cover when the Trust may need to conduct a risk assessment of the likely impact on the staff member of being confronted with a serious allegation, when they may need to inform the police promptly , or advise on what factors impact the need for a prompt decision on suspension and withdrawal of easy access to fatal drugs. Since this incident the local Trust has updated their policies so that a same day decision is made on these matters and in a similar incident in the future it is likely the staff member would have been immediately suspended and had their access to fatal drugs removed. My concern is that NHS England guidance continues to omit such considerations and at a local level Trusts are not fully assessing the risks.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure of NHS England guidance to address discussing and managing an alleged perpetrator who is a member of staff
Wider context from the report “1. The Trust level investigation identified concerns that NHS England guidance - e.g. (a) NHS England Misconduct Policy ‘Every organisation has a duty of care to protect its employees from and prevent incidents of sexual misconduct’; and (b) e-learning ‘Understanding Sexual Misconduct in the Workplace’ – omits to deal with how to discuss and manage the alleged perpetrator when a member of staff . It does not cover when the Trust may need to conduct a risk assessment of the likely impact on the staff member of being confronted with a serious allegation, when they may need to inform the police promptly, or advise on what factors impact the need for a prompt decision on suspension and withdrawal of easy access to fatal drugs. Since this incident the local Trust has updated their policies so that a same day decision is made on these matters and in a similar incident in the future it is likely the staff member would have been immediately suspended and had their access to fatal drugs removed. My concern is that NHS England guidance continues to omit such considerations and at a local level Trusts are not fully assessing the risks.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure of NHS England guidance to address prompt decisions on suspension and withdrawal of easy access to fatal drugs
Wider context from the report “1. The Trust level investigation identified concerns that NHS England guidance - e.g. (a) NHS England Misconduct Policy ‘Every organisation has a duty of care to protect its employees from and prevent incidents of sexual misconduct’; and (b) e-learning ‘Understanding Sexual Misconduct in the Workplace’ – omits to deal with how to discuss and manage the alleged perpetrator when a member of staff. It does not cover when the Trust may need to conduct a risk assessment of the likely impact on the staff member of being confronted with a serious allegation, when they may need to inform the police promptly, or advise on what factors impact the need for a prompt decision on suspension and withdrawal of easy access to fatal drugs . Since this incident the local Trust has updated their policies so that a same day decision is made on these matters and in a similar incident in the future it is likely the staff member would have been immediately suspended and had their access to fatal drugs removed. My concern is that NHS England guidance continues to omit such considerations and at a local level Trusts are not fully assessing the risks.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure of NHS England guidance to address risk assessment of the impact on staff members confronted with serious allegations
Wider context from the report “1. The Trust level investigation identified concerns that NHS England guidance - e.g. (a) NHS England Misconduct Policy ‘Every organisation has a duty of care to protect its employees from and prevent incidents of sexual misconduct’; and (b) e-learning ‘Understanding Sexual Misconduct in the Workplace’ – omits to deal with how to discuss and manage the alleged perpetrator when a member of staff. It does not cover when the Trust may need to conduct a risk assessment of the likely impact on the staff member of being confronted with a serious allegation , when they may need to inform the police promptly, or advise on what factors impact the need for a prompt decision on suspension and withdrawal of easy access to fatal drugs. Since this incident the local Trust has updated their policies so that a same day decision is made on these matters and in a similar incident in the future it is likely the staff member would have been immediately suspended and had their access to fatal drugs removed. My concern is that NHS England guidance continues to omit such considerations and at a local level Trusts are not fully assessing the risks.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a national conduct and competence policy framework covering support planning and risk assessment for people involved in processes.
Verbatim wording from the response “NHS England are also taking further steps to ensure that harm arising from going through the process of an employee relations case is mitigated. We are currently reviewing the investigations training offered to every trust HR team in the country, which has a significant focus on sexual misconduct clearly sections on how to reduce harm from these processes for all parties. We are also developing a national conduct and competence policy framework which will have key sections on planning support for those involved in the process and risk assessment.” Source location Response from NHS England
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 Produce the national sexual misconduct policy framework for trusts and integrated care boards to adapt into local policies.
Verbatim wording from the response “NHS England takes the sexual safety of staff and patients very seriously and we have produced a comprehensive suite of documents to ensure that NHS employers are taking their legal responsibilities around sexual harassment prevention seriously. These include:” Source location Response from NHS England
Open published response
29 Apr 2026 Alice, Sarah, Dearden (Alice) · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 1 Commissioning mental health provision for children and adolescents with a strict 18th-birthday cut-off View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alice, Sarah, Dearden (Alice) · 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
Alice had mental health difficulties associated with anorexia nervosa and emotionally unstable personality disorder, including acts of self-harm and overdoses. She died by suicide at age 19. Evidence suggested that a strict commissioning cut-off at age 18 could adversely affect mental health by making transitions from child to adult mental health services insufficiently gradual.
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 England; that does not assign responsibility.
PFD Monitor interpretation Commissioning mental health provision for children and adolescents with a strict 18th-birthday cut-off
Wider context from the report “Evidence received at the above inquest suggested that commissioning mental health provision for children and adolescents with a strict cut off date of the individual’s 18th birthday could be prejudicial to mental health in certain circumstances .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with regulators and royal colleges to clarify clinical responsibilities for 16- and 17-year-olds and inform forthcoming transition guidance.
Verbatim wording from the response “In 2024, NHS England partnered with the NHS Youth Forum to investigate this further, receiving survey responses from young people across the country. The results identified a gap in care for 16–17 year olds with many being discharged from paediatric services before being told they weren't old enough to access adult ones.” Source location Response from NHS England
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 publish transition guidance promoting personalised, planned moves from children’s to adult mental health services without automatic age-based transfer.
Verbatim wording from the response “The NHS is committed to ensuring that every area across the country commissions a comprehensive mental health offer for children and young people, with a clear focus on supporting young adults as they move from children to adult mental health services. A core principle is continuity of care, with transition decisions based on the individual needs and circumstances of the young person, rather than on age alone.” Source location Response from NHS England
Open published response
24 Apr 2026 Edward Muwanga · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 5 Failure to understand the application of section 136 MHA 1980 powers in communal spaces within private accommodation View source Lack of awareness of the section 135 MHA 1980 process View source Fragmented healthcare record systems limiting the visibility and communication of important patient safety information View source Failure to locate and identify information about a section 135 MHA 1980 warrant View source Failure to make a detailed and measured assessment of a person’s situation 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
Edward Muwanga · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Edward Muwanga died after entering the track at Queensway London Underground Station and being struck by a train on 7 August 2023. The concerns included police officers’ failure to understand and use relevant mental health powers, failure to identify a section 135 warrant, incomplete communication of his circumstances and health information to healthcare professionals, and a delay by central line controllers in alerting the train driver.
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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to understand the application of section 136 MHA 1980 powers in communal spaces within private accommodation
Wider context from the report “(1) A failure by the three police officers attending to understand that their powers under section 136 MHA 1980 applied to persons in a communal space within private accommodation and thereafter a failure to make a more detailed and measured assessment of the Eddie’s 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 England; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of the section 135 MHA 1980 process
Wider context from the report “(2) A lack of awareness by the two less experienced officers about the process under section 135 MHA 1980 , and a lack of inquiry by the more experienced officer as to the existence of such a warrant, together with a concern that it was not clear from the evidence where information about the warrant could be obtained by 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 England; that does not assign responsibility.
PFD Monitor interpretation Fragmented healthcare record systems limiting the visibility and communication of important patient safety information
Wider context from the report “(3) The sharing and visibility of important health care records between medical agencies, (held on multiple platforms by multiple health care agencies) in particular here between the treating Trust (SLAM) and NHS 111, and between the Ambulance Service (not NHS 111) and the treating Trust (SLAM). ████████ from London Ambulance Service NHS Trust writes to me in her PFD statement that “it is recognised that there remain challenges with the visibility of information from healthcare settings across London. While advances have been made, the visibility of pertinent information depends on technological developments and the coordination of a complex healthcare system.” In her written evidence to me dated 19th March 2026 ████████ Chief Medical Officer of LAS NHS Trust, writes that “..there is currently no single, comprehensive system that provides universal access to all patient records across NHS organisations. Access is influenced by information governance requirements, system interoperability, commissioning arrangements, and the extent to which partner organisations upload information to shared platforms." Whilst this fragmented situation persists with a multiplicity of systems, platforms, screens, and process in which important patient safety information is embedded the risk such information is not identified or communicated to practitioners making healthcare decisions remains and as such gives rise to a risk of death due to decisions being made on incomplete information where more complete information exists .
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to locate and identify information about a section 135 MHA 1980 warrant
Wider context from the report “(2) A lack of awareness by the two less experienced officers about the process under section 135 MHA 1980, and a lack of inquiry by the more experienced officer as to the existence of such a warrant , together with a concern that it was not clear from the evidence where information about the warrant could be obtained by 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure to make a detailed and measured assessment of a person’s situation
Wider context from the report “(1) A failure by the three police officers attending to understand that their powers under section 136 MHA 1980 applied to persons in a communal space within private accommodation and thereafter a failure to make a more detailed and measured assessment of the Eddie’s situation
” 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 Set a national interoperability initiative and commit investment to enable authorised professionals to access reliable records across England.
Verbatim wording from the response “Building on this and recognising the clinical need, an initiative has been set to achieve national interoperability between shared care records across England. This committed investment aims to enable any authorised health and care professional to have access to safe, reliable, and accurate records, regardless of the patient’s location or where care is provided. It is however, up to local shared care record organisations and participating NHS Trusts, to agree what information, in addition to the core information standard, is held and shared through the local shared care record. It is also up to individual NHS Trusts to negotiate data sharing protocols and agreements to enhance localised information sharing outside of the local shared care record.” Source location Response from NHS England
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 Secure funding for South London and Maudsley NHS Foundation Trust to develop a business case for replacing its non-compliant EPR.
Verbatim wording from the response “This trust uses the CareNotes Electronic Patient Record (EPR) system supplied by OneAdvanced (formerly Advanced). As part of the Frontline Digitisation (FD) Programme, the Trust was assessed as having an EPR that did not meet the Programme’s core standards under the Digital Capability Framework (DCF). Through the FD Programme, the Trust secured funding to support development of a business case to replace its current EPR system.” Source location Response from NHS England
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 lead the Frontline Digitisation Programme, providing EPR adoption support, implementation guidance and safety oversight.
Verbatim wording from the response “NHS England has developed and led the Frontline Digitisation (FD) Programme to support NHS trusts in adopting Electronic Patient Record (EPR) systems, improve digital maturity, and enable better information sharing within and between organisations. In addition to supporting the procurement of EPR systems, the FD Programme provides guidance and oversight to help ensure that implementations are safe and effective.” Source location Response from NHS England
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 Secure funding for London Ambulance Service NHS Trust to add linked dispatch, interoperability, emergency-department record linkage and EPR optimisation functionality.
Verbatim wording from the response “This Trust uses an electronic Patient Care Record (ePCR) system supplied by Cleric Computer Services Ltd. As part of the FD Programme, the Trust was assessed as having an EPR that did not meet the Programme’s core standards under the DCF. Through the FD Programme, the Trust has secured funding to invest in additional functionality to support its EPR, including:” Source location Response from NHS England
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 NHS England states that interoperability is configured and managed locally through provider organisations and technology suppliers, with regional teams considering wider catchment areas.
Verbatim wording from the response “While the FD Programme supports investment in local digital capability, interoperability is generally configured and managed locally, based on agreements between provider organisations and their technology suppliers, with NHS England regional teams taking account of wider catchment areas where appropriate.” Source location Response from NHS England
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 Local Integrated Care Boards are responsible for delivering shared care records according to local needs, systems and plans.
Verbatim wording from the response “Responsibility for delivering shared care records rests with local Integrated Care Boards (ICBs). Each ICB develops its shared care record in response to local health and care needs, existing systems, and future plans. As a result, some shared care records are accessible to neighbouring ICBs, while others operate only within their own area. Future plans include improving connectivity so that shared care records can be used more consistently across England, regardless of where a person lives or receives care.” Source location Response from NHS England
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 Further enquiries about NHS 111 and ambulance access to Summary Care Records through NCRS should be directed to the London Ambulance Service.
Verbatim wording from the response “We would expect both the LAS and NHS 111 to have access to patients’ Summary Care Record (SCR) through NCRS. Any further enquiries about access to SCR through NCRS should therefore be directed to LAS.” Source location Response from NHS England
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 Local shared care record organisations and NHS Trusts must agree additional information sharing and negotiate local data-sharing protocols.
Verbatim wording from the response “Building on this and recognising the clinical need, an initiative has been set to achieve national interoperability between shared care records across England. This committed investment aims to enable any authorised health and care professional to have access to safe, reliable, and accurate records, regardless of the patient’s location or where care is provided. It is however, up to local shared care record organisations and participating NHS Trusts, to agree what information, in addition to the core information standard, is held and shared through the local shared care record. It is also up to individual NHS Trusts to negotiate data sharing protocols and agreements to enhance localised information sharing outside of the local shared care record.” Source location Response from NHS England
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 Responsibility for electronic-record information sharing and management rests with each organisation through established digital governance arrangements.
Verbatim wording from the response “Where multiple digital systems are used within a trust, including EPR systems, robust policies and procedures should be in place to set clear expectations, support appropriate clinical record management, and ensure the timely handover and escalation of abnormal results to the relevant individuals. Responsibility and accountability for the sharing and management of information held within electronic records, including information shared across different systems, rests with each organisation through its established digital governance arrangements.” Source location Response from NHS England
Open published response
16 Apr 2026 Adam Ankers · Prevention of Future Deaths report West London
View report summary
Concerns raised 5 Insufficient understanding of defibrillator use among lay persons and trained first aid persons View source Insufficient dissemination and mandatory coverage of Sudden Cardiac Arrest training across football leagues, clubs, coaches and referees View source Difficulty among lay people and ambulance call handlers in recognising signs of agonal breathing or cardiac arrest View source Unavailability of cardiac screening for all young people and football players aged 14 and upwards View source Failure of cascade communication of genetic or hereditary diseases to reach family members who need to know 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
Adam Ankers · 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
Adam Ankers suffered a cardiac arrest while playing grassroots football on 31 January 2024 due to a previously unidentified inherited cardiac condition, and died in hospital on 4 February 2024 following brain stem death. Agonal breathing and cardiac arrest were not recognised at the pitch or by the 999 call handler, and an AED was brought to the pitch but not used. The report identified concerns about recognition of agonal breathing and cardiac arrest, access to and use of defibrillators, dissemination of sudden cardiac arrest training, cardiac screening, and cascade communication of inherited disease information.
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 England; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding of defibrillator use among lay persons and trained first aid persons
Wider context from the report “POINT C: That there is a need for better understanding of the use of defibrillators particularly by lay persons and trained first aid persons
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Insufficient dissemination and mandatory coverage of Sudden Cardiac Arrest training across football leagues, clubs, coaches and referees
Wider context from the report “POINT B: That the Football Association’s Sudden Cardiac Arrest training is not more widely disseminated or mandatory for all FA Accredited and Affiliated leagues and clubs and all grassroots football coaches and referees .
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Difficulty among lay people and ambulance call handlers in recognising signs of agonal breathing or cardiac arrest
Wider context from the report “POINT A: That there is difficulty in lay people (trained or not) including ambulance call handlers in understanding the signs of agonal breathing or cardiac arrest
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Unavailability of cardiac screening for all young people and football players aged 14 and upwards
Wider context from the report “POINT D: That cardiac screening in those aged 14 and upwards reduces the risk of sudden cardiac death and this is not available to all young people or your football players
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure of cascade communication of genetic or hereditary diseases to reach family members who need to know
Wider context from the report “POINT E: That cascade communication of genetic or hereditary diseases is imperfect and does not reach more than half of those in families that need to know about it .
” 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 Presume cardiac arrest in NHS Pathways when a person collapses and becomes unconscious during exercise or sport, including when fitting is reported.
Verbatim wording from the response “Additional measures have also been taken following learning from this case. In January 2025, NHS Pathways updated the triage so now anyone who collapses and becomes unconscious during exercise or sport, including those reported to be fitting,” Source location Response from NHS England 2
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 Revise the Clinical Genetics service specification.
Verbatim wording from the response “Currently, there is insufficient capacity and infrastructure for Clinical Genetics and/or specialist clinical services (e.g. Cardiology/Inherited Cardiac Conditions services) to actively contact family members outside of situations where a particularly high risk has been identified (e.g. individual potentially displaying symptoms and/or athlete undertaking intensive sporting activities at risk of ARVC). The Clinical Genetics service specification is currently being revised, and this will be considered as part of this work. This is an aspect of the clinical service where additional capacity and infrastructure may have the potential to reduce preventable morbidity and mortality. The "Clinical Genetics Transformation Programme", who are the group working on the new service specification and its implementation, will consider the ways in which this may be achieved.” Source location Response from NHS England 2
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with MPDS and NHS Pathways coding sub-groups to consider further measures supporting recognition of agonal breathing or cardiac arrest.
Verbatim wording from the response “NHS England will work with the MPDS and NHS Pathways coding sub-groups to consider whether further measures should be taken to help members of the public recognise the signs of agonal breathing or cardiac arrest.” Source location Response from NHS England 2
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 Consider how additional Clinical Genetics capacity and infrastructure could be achieved to reduce preventable morbidity and mortality.
Verbatim wording from the response “Currently, there is insufficient capacity and infrastructure for Clinical Genetics and/or specialist clinical services (e.g. Cardiology/Inherited Cardiac Conditions services) to actively contact family members outside of situations where a particularly high risk has been identified (e.g. individual potentially displaying symptoms and/or athlete undertaking intensive sporting activities at risk of ARVC). The Clinical Genetics service specification is currently being revised, and this will be considered as part of this work. This is an aspect of the clinical service where additional capacity and infrastructure may have the potential to reduce preventable morbidity and mortality. The "Clinical Genetics Transformation Programme", who are the group working on the new service specification and its implementation, will consider the ways in which this may be achieved.” Source location Response from NHS England 2
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 Use a breathing-rate threshold to support recognition of agonal breathing in NHS Pathways triage.
Verbatim wording from the response “• A breathing rate of less than one breath every 10 seconds is used as a measure of inadequate breathing as this is a more identifiable and objective marker in remote telephony triage than clinical descriptions of agonal breathing for assessment between a non-clinical health advisor and a member of the public. NHS Pathways introduced this measure in 2020 to support the identification of agonal breathing which was agreed in conjunction with the Resuscitation Council UK.” Source location Response from NHS England 2
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 health-system and community partners to support awareness, accessibility and appropriate use of defibrillators.
Verbatim wording from the response “We will continue to work with partners across the health system and wider community to support awareness, accessibility and appropriate use of defibrillators.” Source location Response from NHS England 2
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 Use a less-than-one-breath-per-ten-seconds threshold in NHS Pathways to support recognition of agonal breathing.
Verbatim wording from the response “• A breathing rate of less than one breath every 10 seconds is used as a measure of inadequate breathing as this is a more identifiable and objective marker in remote telephony triage than clinical descriptions of agonal breathing for assessment between a non-clinical health advisor and a member of the public. NHS Pathways introduced this measure in 2020 to support the identification of agonal breathing which was agreed in conjunction with the Resuscitation Council UK.” Source location Response from NHS England
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 Presume collapse with unconsciousness during exercise or sport, including reported fitting, to be cardiac arrest regardless of apparent regular breathing.
Verbatim wording from the response “Additional measures have also been taken following learning from this case. In January 2025, NHS Pathways updated the triage so now anyone who collapses and becomes unconscious during exercise or sport, including those reported to be fitting,” Source location Response from NHS England
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 health-system and community partners to support defibrillator awareness, accessibility and appropriate use.
Verbatim wording from the response “NHS England works with system partners, including ambulance services and the British Heart Foundation (BHF) particularly through support for The Circuit: the national defibrillator network (which NHS England part-funds in partnership with the BHF). This enables ambulance services to direct bystanders to the nearest registered defibrillator where available.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with MPDS and NHS Pathways coding sub-groups to consider further measures helping the public recognise agonal breathing or cardiac arrest.
Verbatim wording from the response “NHS England will work with the MPDS and NHS Pathways coding sub-groups to consider whether further measures should be taken to help members of the public recognise the signs of agonal breathing or cardiac arrest.” Source location Response from NHS England
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 Revise the Clinical Genetics service specification and consider ways to increase capacity and infrastructure for proactive family contact.
Verbatim wording from the response “Currently, there is insufficient capacity and infrastructure for Clinical Genetics and/or specialist clinical services (e.g. Cardiology/Inherited Cardiac Conditions services) to actively contact family members outside of situations where a particularly high risk has been identified (e.g. individual potentially displaying symptoms and/or athlete undertaking intensive sporting activities at risk of ARVC). The Clinical Genetics service specification is currently being revised, and this will be considered as part of this work. This is an aspect of the clinical service where additional capacity and infrastructure may have the potential to reduce preventable morbidity and mortality. The “Clinical Genetics Transformation Programme”, who are the group working on the new service specification and its implementation, will consider the ways in which this may be achieved.” Source location Response from NHS England
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 claimed evidence that cascade genetic-risk communication fails to reach more than half of affected family members could not be located.
Verbatim wording from the response “NHS England have reviewed your concern that cascade communication of genetic/hereditary disease “does not reach more than half of those in families that need to know about it” but have been unable to locate the literature or evidence where this originated. Information sharing between family members of a particular genetic risk of a condition will be different for different conditions.” Source location Response from NHS England 2
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 Directly mandating or delivering public first-aid training is outside the respondent’s functions.
Verbatim wording from the response “NHS England does not directly mandate or deliver public first aid training. However, we recognise the importance of ensuring that NHS staff have appropriate resuscitation skills. As part of wider statutory and mandatory training reforms, consideration is being given to strengthening BLS and AED training requirements across NHS staff groups, including those in non-patient facing roles (subject to final policy confirmation).” Source location Response from NHS England 2
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 services lack sufficient capacity and infrastructure to proactively contact lower-risk relatives outside specified high-risk situations.
Verbatim wording from the response “Currently, there is insufficient capacity and infrastructure for Clinical Genetics and/or specialist clinical services (e.g. Cardiology/Inherited Cardiac Conditions services) to actively contact family members outside of situations where a particularly high risk has been identified (e.g. individual potentially displaying symptoms and/or athlete undertaking intensive sporting activities at risk of ARVC). The Clinical Genetics service specification is currently being revised, and this will be considered as part of this work. This is an aspect of the clinical service where additional capacity and infrastructure may have the potential to reduce preventable morbidity and mortality. The "Clinical Genetics Transformation Programme", who are the group working on the new service specification and its implementation, will consider the ways in which this may be achieved.” Source location Response from NHS England 2
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 National Screening Committee decides cardiac screening policy, with no UK consensus and review scheduled for 2026/27.
Verbatim wording from the response “There has been no clear UK consensus on the benefits of screening of young people for participation in sport.” Source location Response from NHS England 2
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 Clinical services lack sufficient capacity and infrastructure to contact lower-risk family members proactively.
Verbatim wording from the response “Currently, there is insufficient capacity and infrastructure for Clinical Genetics and/or specialist clinical services (e.g. Cardiology/Inherited Cardiac Conditions services) to actively contact family members outside of situations where a particularly high risk has been identified (e.g. individual potentially displaying symptoms and/or athlete undertaking intensive sporting activities at risk of ARVC). The Clinical Genetics service specification is currently being revised, and this will be considered as part of this work. This is an aspect of the clinical service where additional capacity and infrastructure may have the potential to reduce preventable morbidity and mortality. The “Clinical Genetics Transformation Programme”, who are the group working on the new service specification and its implementation, will consider the ways in which this may be achieved.” Source location Response from NHS England
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 Decisions on screening young people for sports participation are made by the National Screening Committee.
Verbatim wording from the response “This topic is governed/decided by the National Screening Committee (NSC) and was last considered in 2019, at which point there was no UK consensus. It is due to be reviewed in 2026/27.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The evidence supporting the claim that cascade communication fails to reach more than half of affected family members could not be located.
Verbatim wording from the response “NHS England have reviewed your concern that cascade communication of genetic/hereditary disease “does not reach more than half of those in families that need to know about it” but have been unable to locate the literature or evidence where this originated. Information sharing between family members of a particular genetic risk of a condition will be different for different conditions.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Public first-aid training is outside NHS England’s direct mandate and delivery responsibilities.
Verbatim wording from the response “NHS England does not directly mandate or deliver public first aid training. However, we recognise the importance of ensuring that NHS staff have appropriate resuscitation skills. As part of wider statutory and mandatory training reforms, consideration is being given to strengthening BLS and AED training requirements across NHS staff groups, including those in non-patient facing roles (subject to final policy confirmation).” Source location Response from NHS England
Open published response
1 Apr 2026 Hollie Elizabeth Loraine · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 2 Lack of guidance on conducting telephone contact to ameliorate the risk of suicide View source Lack of guidance on maintaining telephone contact with patients expressing suicidal intent 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
Hollie Elizabeth Loraine · 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
Hollie Elizabeth Loraine, who had a history of mental health concerns, suicidal ideation and previous attempts, died at home in Washington on 30 August 2025 by hanging after consuming a large quantity of alcohol. The report raises concern that the NHS pathways telephone triage system provided no guidance on whether, or how, to maintain telephone contact with a patient clearly expressing suicidal intent while awaiting an ambulance.
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 England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on conducting telephone contact to ameliorate the risk of suicide
Wider context from the report “I am concerned that the evidence revealed that the national NHS pathways telephone triage system provides no guidance to health advisers dealing with such calls about whether to maintain telephone contact with a patient who is clearly expressing suicidal intent and, if maintaining contact, how to do so to ameliorate a risk of that patient ending their own life . Hollie made it clear she had a noose around her neck and was going to jump.
” 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 England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on maintaining telephone contact with patients expressing suicidal intent
Wider context from the report “I am concerned that the evidence revealed that the national NHS pathways telephone triage system provides no guidance to health advisers dealing with such calls about whether to maintain telephone contact with a patient who is clearly expressing suicidal intent and, if maintaining contact, how to do so to ameliorate a risk of that patient ending their own life. Hollie made it clear she had a noose around her neck and was going to jump.
” 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 Provide mandatory NHS Pathways training on sensitive management of calls involving mental health conditions, including active listening and when to remain on the phone.
Verbatim wording from the response “NHS Pathways has additionally provided significant training information regarding the assessment of patients suffering from mental health conditions, including training around the sensitive management of calls with a mental health element. This training is included in Core Module One which all Health Advisors must complete. Core Module One includes mandatory assessments which must be passed.” Source location 2026-0193 - Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Whether health advisers remain on calls is an operational decision for each ambulance service, based on its real-time demand levels.
Verbatim wording from the response “However, it is overall an operational decision for each ambulance service whether a health advisor should stay on the line with any caller. Ambulance services have access to their real time demand levels which NHS Pathways does not.” Source location 2026-0193 - Response from NHS England
Open published response
Concerns raised 2 Failure of alarm monitoring equipment to allow new or different alarms to be distinguished audibly View source Failure of alarm monitoring equipment to record recurrent alarm conditions as new alarms 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
Lucy Jane PHELAN · 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
Lucy Jane Phelan was found unresponsive at home after taking prescribed medications with a significant amount of alcohol and was later treated in hospital for likely aspiration pneumonia. She subsequently vomited, suffered cardiopulmonary arrest, and died shortly after midnight on 14 May 2025; the inquest concluded that her death was contributed to by neglect. The principal concern was that latching on Emergency Department monitoring equipment may contribute to alarm fatigue and hinder recognition of new alarms, with its use in other hospitals in England and Wales unknown.
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 England; that does not assign responsibility.
PFD Monitor interpretation Failure of alarm monitoring equipment to allow new or different alarms to be distinguished audibly
Wider context from the report “While in the resuscitation bay within the Emergency Department at the Alexandra Hospital, Redditch, Ms. Phelan was attached to equipment which monitored her physical observations. These observations are visible on a screen at the patient’s bedside and on a screen at the main nursing station. If a patient’s observations rise or fall outside acceptable parameters, the equipment generates notes both on audible alarm and a visual alarm ( red - higher priority; yellow – lower priority ) on each monitor.
The monitoring equipment has a facility known as “latching” which, if activated, means:
(a) an alarm will continue to be displayed and sounded even after the conditions which generated it have ended, until it is acknowledged on the monitor, meaning that any alarm for a new or different indication cannot be distinguished audibly ; and
(b) if the alarm is not acknowledged on the monitor, and the same alarm condition occurs again, this new alarm is not listed in the alarm review or audit log as a new alarm.
The inquest heard evidence that “alarm fatigue” is a recognized phenomenon, and that in a busy environment like a hospital’s Emergency Department, particularly when patient numbers are high, staff find it increasingly difficult to react and respond to the many different types of alarm in use. The use of the “latching” facility on monitoring equipment is likely to contribute to this phenomenon ; this has been recognized by the equipment manufacturer which no longer recommends its use on Emergency Department monitors, and by Worcestershire Acute Hospitals NHS Trust who have switched it off on monitors in its Emergency Departments.
It is not known whether, and to what extent, the “latching” facility remains in use in Emergency Departments in other hospitals in 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 England; that does not assign responsibility.
PFD Monitor interpretation Failure of alarm monitoring equipment to record recurrent alarm conditions as new alarms
Wider context from the report “While in the resuscitation bay within the Emergency Department at the Alexandra Hospital, Redditch, Ms. Phelan was attached to equipment which monitored her physical observations. These observations are visible on a screen at the patient’s bedside and on a screen at the main nursing station. If a patient’s observations rise or fall outside acceptable parameters, the equipment generates notes both on audible alarm and a visual alarm ( red - higher priority; yellow – lower priority ) on each monitor.
The monitoring equipment has a facility known as “latching” which, if activated, means:
(a) an alarm will continue to be displayed and sounded even after the conditions which generated it have ended, until it is acknowledged on the monitor, meaning that any alarm for a new or different indication cannot be distinguished audibly; and
(b) if the alarm is not acknowledged on the monitor, and the same alarm condition occurs again, this new alarm is not listed in the alarm review or audit log as a new alarm .
The inquest heard evidence that “alarm fatigue” is a recognized phenomenon, and that in a busy environment like a hospital’s Emergency Department, particularly when patient numbers are high, staff find it increasingly difficult to react and respond to the many different types of alarm in use. The use of the “latching” facility on monitoring equipment is likely to contribute to this phenomenon ; this has been recognized by the equipment manufacturer which no longer recommends its use on Emergency Department monitors, and by Worcestershire Acute Hospitals NHS Trust who have switched it off on monitors in its Emergency Departments.
It is not known whether, and to what extent, the “latching” facility remains in use in Emergency Departments in other hospitals in England and Wales.
” 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 Engage the MHRA to establish the manufacturer’s position and understand how alarm-latching functionality should be managed clinically.
Verbatim wording from the response “NHS England’s National Patient Safety Team have advised that ‘alarm fatigue’ is a recognised phenomenon and the function ‘alarm latching’ is a setting that requires any triggered alarm to be manually acknowledged and resolved by a member of staff. There are however, other limitations relating to any secondary triggered alarm that may tailor use of this function. The suggestion that ‘the equipment manufacturer no longer recommends the use of alarm latching functionality on the Emergency Department monitors’ is currently subject to further investigation as such information would need to be officially communicated to all users and be part of the medical device manual and Instructions for Use (IFU) documents.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The MHRA is the appropriate authority to advise healthcare organisations on medical-device concerns involving alarm-latching capabilities.
Verbatim wording from the response “The MHRA are the correct authority to advise on concerns regarding medical devices with alarm latching capabilities healthcare organisations. The NHS England National Patient Safety team will continue to engage with the MHRA to understand how latching functionality is best managed in the clinical environment. The MHRA will be coming back to us once they have gathered further information from the manufacturer regarding this specific case.” Source location Response from NHS England
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations