12 Mar 2024 Elizabeth Jane Brown · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Insufficient qualified and trained immunology staffing View source Delays in access to specialist immunology clinics View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Elizabeth Jane Brown · 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
Elizabeth Jane Brown had severe respiratory disease and was diagnosed with mesothelioma, which was attributed on the balance of probabilities to asbestos exposure; she died at Stepping Hill Hospital on 23 January 2023. The inquest heard concerns about lengthy delays in immunology follow-up, linked to a significant national shortage of qualified and trained staff and high vacancy levels.
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 qualified and trained immunology staffing
Wider context from the report “The inquest heard evidence that Elizabeth Jane Brown had been referred to immunology services in 2018 due to low antibody levels and concerns about the overall impact on her health. A treatment plan was developed. She had an appointment on 4th February 2021 when the plan was that she should be followed up in 12 months’ time. She had not been seen again at the date of her death on 23rd January.
Such long waits and delays to see immunologists in specialist clinics were the inquest was told not unusual notwithstanding the role they could play in treating those in need of immunology services. The evidence before the inquest was that the reason for those delays was a significant shortage of qualified /trained staff nationally which had led to services across the country being run with a high level of vacancies . The position was not improving in terms of recruiting to vacant posts the inquest was told
” 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 Delays in access to specialist immunology clinics
Wider context from the report “The inquest heard evidence that Elizabeth Jane Brown had been referred to immunology services in 2018 due to low antibody levels and concerns about the overall impact on her health. A treatment plan was developed. She had an appointment on 4th February 2021 when the plan was that she should be followed up in 12 months’ time. She had not been seen again at the date of her death on 23rd January.
Such long waits and delays to see immunologists in specialist clinics were the inquest was told not unusual notwithstanding the role they could play in treating those in need of immunology services. The evidence before the inquest was that the reason for those delays was a significant shortage of qualified /trained staff nationally which had led to services across the country being run with a high level of vacancies. The position was not improving in terms of recruiting to vacant posts the inquest was told
” 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 Improve workforce culture, leadership and wellbeing to support staff retention in NHS employment.
Verbatim wording from the response “NHS England is also working at a national level to deliver the Long-Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training, and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years.” 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 Deliver the Long-Term Workforce Plan through strategic workforce planning and expanded domestic education, training and recruitment.
Verbatim wording from the response “NHS England is also working at a national level to deliver the Long-Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training, and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years.” 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 Trusts are responsible for ensuring safe staffing levels in the day-to-day operation of their hospitals.
Verbatim wording from the response “These actions will aim to close anticipated staffing shortfalls in the NHS in the long term, however Trusts have a responsibility to ensure safe staffing levels at local level in the current day to day operation of their hospitals. This is in line with Care Quality Commission (CQC) Regulation 18 which states that providers must deploy enough suitably qualified, competent and experienced staff to enable them to meet all other regulatory requirements.” Source location Response from NHS England
Open published response
Concerns raised 3 Lack of a central resource to help families recognise signs of sepsis in patients with darker skin View source Failure of NHS111 health advisers to access GP electronic summaries and background diagnoses View source Knowledge gaps about Down Syndrome-associated immune deficiency and heightened sepsis awareness View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Isaac Onyeka · 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
Isaac Onyeka, a 3-year-old boy with Down’s Syndrome, developed chicken pox followed by painful swellings and signs of sepsis. He became unresponsive at home and died in hospital on 31 May 2023. Concerns included missed clinical information and risk factors during NHS111 and GP assessment, limited access to background diagnoses for NHS111 health advisers, gaps in awareness of the immune deficiency associated with Down Syndrome, and a lack of central resources to help families recognise sepsis in patients with darker skins.
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 central resource to help families recognise signs of sepsis in patients with darker skin
Wider context from the report “(3) The inquest heard that there is no central resource for assisting families to recognise signs of sepsis in patients with darker skins .
” 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 NHS111 health advisers to access GP electronic summaries and background diagnoses
Wider context from the report “(2) Health advisers with NHS111 do not have access to GP electronic summaries. They do not therefore have the background diagnoses of the patient concerned. The inquest heard that a different disposition would have been reached, had the health adviser been aware of the diagnosis of Down Syndrome. Had the health adviser been aware of the diagnosis, Isaac would have been assessed by a clinician during the evening of the 30 May 2023. Had this happened, Isaac’s death would have been avoided.
” 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 Knowledge gaps about Down Syndrome-associated immune deficiency and heightened sepsis awareness
Wider context from the report “(1) There is concern that there is a knowledge gap amongst the public (parents of children with Down Syndrome in particular), and amongst some healthcare practitioners in relation to the immune deficiency associated with Down Syndrome. The paediatric independent expert stated that:
Down Syndrome is the most common genetic disorder associated with immune defects. Children with Down Syndrome need to be managed with a heightened sense of awareness in the setting of sepsis.
This was not however known by Isaac’s parents or by the GP registrar.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update NHS Down’s syndrome information to clarify increased susceptibility to infection and consequences.
Verbatim wording from the response “The NHS website has a page about Other health conditions and Down's syndrome. This page signposts people to annual health checks and states "People with Down's syndrome are more likely to become unwell through an infection..." in the context of encouraging adherence with vaccination programmes. To support the public, the “other health conditions” page has been updated to make clearer the risks of increased susceptibility and consequences of infection. The ‘Who’s most likely to get sepsis’ section of our sepsis pages has also been updated to include genetic disorders such as Down’s syndrome.” 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 Update NHS sepsis guidance to identify genetic disorders, including Down’s syndrome, as increasing sepsis risk.
Verbatim wording from the response “The NHS website has a page about Other health conditions and Down's syndrome. This page signposts people to annual health checks and states "People with Down's syndrome are more likely to become unwell through an infection..." in the context of encouraging adherence with vaccination programmes. To support the public, the “other health conditions” page has been updated to make clearer the risks of increased susceptibility and consequences of infection. The ‘Who’s most likely to get sepsis’ section of our sepsis pages has also been updated to include genetic disorders such as Down’s syndrome.” 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 stakeholders to raise awareness among families and carers about sepsis signs, including how signs may appear on darker skin.
Verbatim wording from the response “NHS England’s Learning Disability and Autism Programme will work with allied stakeholders so that they can help with raising awareness amongst parents/ carers of autistic children and young people and those with a learning disability or special educational needs and disabilities (SEND) families about the signs of sepsis as well as understanding that signs of sepsis may be easier to spot on the palms or feet amongst children and young people with black or darker skin.” 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 whether to add images or videos to the NHS sepsis page to support recognition of visible symptoms.
Verbatim wording from the response “As a result of your Report the Website Team will review whether to include images videos on the sepsis page to support identification of visible symptoms of sepsis.” 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 GP electronic summaries cannot be presented to non-clinical NHS 111 advisers because they lack the training and mandate to interpret clinical information.
Verbatim wording from the response “GP electronic summaries contain clinical terms. Presenting such information to non-clinical Health Advisers would be outside the scope of practice for non-clinical staff. This is because they do not have the clinical training required to interpret the information held in these records, nor do they have a mandate to apply clinical judgement. It is the case, however, that Summary Care Records (SCRs) are visible to clinically trained staff in urgent and emergency care services. This is managed through local records sharing agreements.” Source location Response from NHS England
Open published response
9 Mar 2024 Linda Heath · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 4 Insufficient inquiry into the parameters of care provided by private domiciliary carers View source Failure of immediate discharge summaries to include relevant and sufficient community treatment and nursing information View source Absence of GP follow-up triggers for recently discharged patients with worsening conditions and missed routine appointments View source Failure to make post-discharge referrals for patients needing district nursing care View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Linda 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
Linda Heath was discharged from hospital with a sacral sore, but the discharge information did not include a required district nursing referral and no referral was made. Her condition worsened, she was admitted to hospital, and she died on 31 March 2022 from sepsis caused by an infected sacral sore. The substantive concerns included inadequate discharge information, failure to arrange district nursing care, insufficient follow-up after discharge, and over-reliance on private domiciliary carers without sufficient enquiry into their remit.
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 inquiry into the parameters of care provided by private domiciliary carers
Wider context from the report “(4) An over reliance upon private hygiene care packages with insufficient inquiry into the parameters of care provided by the private domiciliary carers .
” 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 immediate discharge summaries to include relevant and sufficient community treatment and nursing information
Wider context from the report “(1) The Immediate Discharge Summary did not include relevant or sufficient information about treatment in the community needs or a nursing summary .
” 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 Absence of GP follow-up triggers for recently discharged patients with worsening conditions and missed routine appointments
Wider context from the report “(3) No trigger appears to exist whereby GPs conduct follow up enquiries or visits to patients who have recently been discharged from hospital and who are complaining of a condition which may worsen and failing to attend routine appointments due to a worsening of their 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 Failure to make post-discharge referrals for patients needing district nursing care
Wider context from the report “(2) Despite the presence of a difficult sacral sore which would have benefitted from district nursing care, no referral was made post discharge by the GP surgery .
” 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 Advance national programmes to improve access to and sharing of patient information between NHS and private providers.
Verbatim wording from the response “Nationally, there are several programmes of work underway to improve access to and the sharing of patient information between providers, both NHS and private. These include the National Care Records Service and Shared Care Records.” 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 involved in Linda’s care should address the specific care concerns, provide further information, and identify related learning.
Verbatim wording from the response “Your Report raises some concerns that would be more appropriately answered by the providers involved in Linda’s care, who I note you have also addressed your Report to. My response to your focuses on those areas that fall within the remit of NHS England’s national policy and programmes, although my regional colleagues have engaged with the Humber and North Yorkshire Health and Care Partnership on the concerns raised, as this is system in which the providers involved in Linda’s care operate.” Source location Response from NHS England
Open published response
Concerns raised 5 Lack of proactive care consideration during obvious mental health crisis View source Failure to adequately assess the risk of impulsive suicide View source Failure to provide follow-up contact or assessment after an interrupted treatment call View source Inadequate communication between the PCN MDT and psychological treatment providers View source Failure to provide consultant assessment before psychological therapy and when the patient deteriorates 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
Adrian Michael James · 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
Adrian Michael James died after falling from the fourth-floor balcony of his block of flats while experiencing severe and enduring mental illness, including paranoia and a high background risk of suicide. The principal concerns were that he was not assessed by a consultant, proactive care was not considered during his mental health crisis, insufficient attention was given to impulsive suicide risk, no follow-up assessment occurred after a police-interrupted treatment session, and communications between services were inadequate.
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 proactive care consideration during obvious mental health crisis
Wider context from the report “2. That no pro-active care was considered for Adrian whilst he was in obvious mental health crisis in the last 17 days of his life.
” 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 adequately assess the risk of impulsive suicide
Wider context from the report “3. That insufficient consideration appeared to have been given to the risk of impulsive suicide with instead assessment focussing on his denial of increased active suicidal intent .
” 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 follow-up contact or assessment after an interrupted treatment call
Wider context from the report “4. That no follow up call or assessment was made to Adrian when his treatment session was interrupted by police attendance, and the treatment call was cut off .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication between the PCN MDT and psychological treatment providers
Wider context from the report “5. That there were inadequate communications between the PCN MDT and those providing the psychological treatment .
” 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 consultant assessment before psychological therapy and when the patient deteriorates
Wider context from the report “1. That Adrian, despite being a complex patient with multiple psychiatric diagnoses and at high risk of impulsive behaviour and suicide was not seen nor assessed by a consultant either prior to starting psychological therapy or when he deteriorated .
” 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 Provide local areas with funding to develop and begin delivering integrated primary and community mental health care models.
Verbatim wording from the response “All local areas have received funding to develop and begin delivering new models of care that integrate primary care and community mental health services for adults with severe mental health problems, with care provided to at least 370,000 adults per year nationally.” 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 Responding to the Coroner’s specific concerns falls outside NHS England’s remit.
Verbatim wording from the response “It is not within NHS England’s remit to respond to the specific concerns set out by the Coroner in your Report and it is appropriate that Central and North West London NHS Foundation Trust (“the Trust”) respond to these. We understand you have also directed your Report to the Trust to respond to your concerns. NHS England has been asked to be sighted on the Trust’s response to you and will carefully consider this.” 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 Trust is responsible for responding to the Coroner’s specific concerns.
Verbatim wording from the response “It is not within NHS England’s remit to respond to the specific concerns set out by the Coroner in your Report and it is appropriate that Central and North West London NHS Foundation Trust (“the Trust”) respond to these. We understand you have also directed your Report to the Trust to respond to your concerns. NHS England has been asked to be sighted on the Trust’s response to you and will carefully consider this.” Source location Response from NHS England
Open published response
7 Mar 2024 Richard Andrew Collins · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 1 Failure of secondary mental health services to revoke driving licences on medical grounds View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Richard Andrew Collins · 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
Richard Andrew Collins, who had bipolar affective disorder, was struck by an articulated lorry after walking into the eastbound carriageway of the A421 on 9 February 2022, and his death was confirmed despite resuscitation attempts. The report raises concerns that, after his mental health deterioration and hospital admission, his driving fitness and duty to notify the DVLA were not revisited by medical professionals, and that similar missed opportunities may occur nationally.
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 secondary mental health services to revoke driving licences on medical grounds
Wider context from the report “2. I have concerns with regard to the following:
i. Whilst considerable work has been undertaken within the secondary mental health services in Dorset, I am concerned that there may be similar issues or missed opportunities nationally within other trusts which could lead to the lack of revocation of driving licences on medical grounds , putting the patients and other road users at risk of death.
” 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 Ask colleagues in each NHS region to raise awareness of GMC and DVLA fitness-to-drive guidance with local systems and providers.
Verbatim wording from the response “As a result of the concerns highlighted in your Report, colleagues from each of the seven NHS regions will be asked to raise awareness of the GMC and DVLA guidance with their systems and providers.” 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 Individual NHS Trusts are expected to develop local policies addressing duties concerning medical revocation of driving licences.
Verbatim wording from the response “The General Optical Council also issue similar guidance. The GMC are responsible for setting the standards doctors and those who train them need to meet. It is expected that all doctors use their professional judgement to apply the standards set by the GMC in their day-to-day practice. Trusts are expected to have due regard to existing guidance from organisations such as the GMC and Royal Colleges, and to develop their own local policies. We note that in this case, Dorset Healthcare University NHS Foundation Trust (DHUFT) did not have a local policy in place at the time of Richard’s death.” 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 GMC is responsible for setting doctors’ professional standards on fitness to drive and reporting concerns.
Verbatim wording from the response “The General Optical Council also issue similar guidance. The GMC are responsible for setting the standards doctors and those who train them need to meet. It is expected that all doctors use their professional judgement to apply the standards set by the GMC in their day-to-day practice. Trusts are expected to have due regard to existing guidance from organisations such as the GMC and Royal Colleges, and to develop their own local policies. We note that in this case, Dorset Healthcare University NHS Foundation Trust (DHUFT) did not have a local policy in place at the time of Richard’s death.” Source location Response from NHS England
Open published response
4 Mar 2024 Mr Lee Martin Hughes, also known as Martin Lee Hughes · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 6 Failure to consider individual patient applicability when following prescribing guidelines View source Insufficient specialist expertise in prescribing drug treatments for withdrawal View source Failure to withhold or reduce methadone when patients show signs of sedation View source Overreliance on subjective withdrawal symptoms rather than objective signs when assessing methadone need View source Failure to account for reduced opiate tolerance and synergistic agents when prescribing methadone View source Unavailability of near-patient illicit-drug testing for assessing intoxication View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Lee Martin Hughes, also known as Martin Lee Hughes · 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
Lee Martin Hughes was found deceased in his cell at HMP Wandsworth on 25 December 2021 while remanded in custody. The medical cause of death was methadone and benzodiazepine intoxication, and the jury concluded that drug-related misadventure was contributed to by neglect. Concerns included the assessment and prescribing of methadone, failure to respond appropriately to signs of sedation and impaired consciousness, and inadequate communication and escalation between healthcare disciplines.
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 consider individual patient applicability when following prescribing guidelines
Wider context from the report “3. That guidelines are followed without sufficient consideration as to whether they apply to the individual patient .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient specialist expertise in prescribing drug treatments for withdrawal
Wider context from the report “2. That prescribing of drug treatments for withdrawal should only be undertaken by substance misuse practitioners , who should therefore be more experienced as to when, whether and how much to prescribe .
” 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 withhold or reduce methadone when patients show signs of sedation
Wider context from the report “5. That methadone should be withheld and or reduced if the patient/inmate is showing signs of sedation .
” 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 Overreliance on subjective withdrawal symptoms rather than objective signs when assessing methadone need
Wider context from the report “1. That clinicians, wishing to believe their patients, are relying too heavily on what patients tell them (symptoms) rather than looking for evidence (physical signs) of withdrawal , As such, given the particular difficulties of prescribing to prisoners, that objective signs of withdrawal assessments (OWS) should be used to determine whether methadone should be prescribed rather than the COWS score which contains many subjective factors and may be more easily manipulated by an inmate to appear as if that inmate is experiencing withdrawal from drugs necessitating an increase in methadone.
” 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 account for reduced opiate tolerance and synergistic agents when prescribing methadone
Wider context from the report “4. That practitioners when prescribing consider whether time spent in custody prior to remand may have reduced an individual's tolerance to opiates , especially when methadone is to be prescribed with a synergistic agent such as a benzodiazepine .
” 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 near-patient illicit-drug testing for assessing intoxication
Wider context from the report “6. That there should be tests available for illicit drugs from near patient testing to allow a clinician to better assess a patient showing signs of intoxication .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the national service specification using learning from the case to strengthen prescribing and supply of sedating medicines.
Verbatim wording from the response “I am pleased to see from your Report that processes and procedures have been changed within HMP Wandsworth to address learning identified in this case and meet expectations in terms of prescribing and supplying sedating medicines safely.” 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 National standards and case-by-case clinical judgement are considered sufficient; NHS England will not mandate a particular withdrawal assessment tool.
Verbatim wording from the response “NHS England commissioned services use national clinical guidelines and the tools described in these to assess patients for opioid, or other withdrawal from dependence forming medicines. For opioid and benzodiazepines withdrawal this guidance is Drug misuse and dependence: UK guidelines on clinical management - GOV.UK (www.gov.uk) along with guidance issued by the National Institute for Health and Care Excellence (NICE) which is found at Recommendations | Drug misuse in over 16s: opioid detoxification | Guidance | NICE.” 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 urine testing is considered sufficient to inform clinical reviews and substance misuse prescribing decisions.
Verbatim wording from the response “6. There should be tests available for illicit drugs for near patient testing to allow clinicians to better assess a patient showing signs of intoxication.” 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 Employers, rather than NHS England, are responsible for ensuring clinicians’ competencies and training compliance.
Verbatim wording from the response “Responsibility for ensuring competencies is met lies with the clinician’s employer, most often the healthcare provider. This also applies to assuring training 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 Existing competency requirements are considered sufficient; prescribing need not be restricted to substance misuse practitioners.
Verbatim wording from the response “Any clinician assessing and prescribing for substance misuse is expected to have the appropriate competencies to make and action clinical decisions independently. These decisions are made using the clinical system, information and evidence available to the clinician, to consider holistic health considerations. Referral to a colleague seeking advice or support is only necessary where a clinician is uncertain about what actions to take.” 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 National guidance and clinician professional judgement are considered sufficient to ensure guidelines are applied appropriately to individual patients.
Verbatim wording from the response “3. That guidelines are followed without sufficient consider to whether they apply to the individual.” 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 National guidance already addresses reduced opioid tolerance and reducing or withholding methadone when sedation is present.
Verbatim wording from the response “4. That practitioners, when prescribing consider whether time spent in custody before remand, may have reduced an individual’s tolerance to opiates; this is especially when methadone is to be prescribed with a synergistic agent such as benzodiazepines.” Source location Response from NHS England
Open published response
Concerns raised 7 Inadequate allocation of named nurses to patients View source Continuing accessibility of an online suicide forum to vulnerable people in the UK View source Failure of 999 call grading to trigger a category 1 ambulance response for confirmed ingestion of a potent poison View source Failure to record the named nurse appointed to each patient View source Failure of clinical and nursing staff to complete and utilise ward-specific risk assessments and care plans View source Inadequate delivery of regular and effective named nurse 1:1 sessions View source Insufficient staff skills and knowledge for encouraging engagement with patients View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Daniel Mark Edward TUCKER · 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 Mark Edward Tucker was detained under the Mental Health Act and admitted to hospital following self-harm and suicidal thoughts, but was discharged on 22 April 2022 despite ongoing concerns about his mental state and risk. He ingested a lethal quantity of a substance later that evening and died. The report identifies concerns about risk assessment and care planning, named-nurse allocation, staff skills in engaging patients, emergency response to confirmed ingestion, and the accessibility of online suicide forums.
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 allocation of named nurses to patients
Wider context from the report “2. Inadequate system of allocating a named nurse to patients and recording the same
I am concerned that, notwithstanding the existence of a clear, appropriate policy requiring the same, the current system of allocating a named nurse and ensuring patients receive regular and effective 1:1 sessions with them are inadequate. I am also concerned that no record is kept of the named nurse appointed to each patient, thus (as in this case) hindering any investigation where issue around the role and actions of that person arises.
The General Manager of Adult Mental Health at the Trust helpfully and frankly acknowledged that the evidence heard at inquest raised questions about the adequacy of the existing system, of which he was not previously aware of. It remains unclear whether Daniel was appointed a Named Nurse who failed to perform that role effectively, or whether there was a failure to appoint such a nurse at all. The General Manager’s view was that under the existing system, it is possible that a named nurse was appointed without their knowledge. While the Ward Manager gave evidence that she would have no confidence Daniel would have known who his named nurse was, even if one was appointed. The inquest heard evidence that named nurse sessions with Daniel during previous admissions had been important opportunities for engagement with staff and had elicited a substantial amount of information pertinent to his risk and treatment. The General Manager assured me that he has already requested an urgent review of the system, but he was unable to provide any further information upon conclusion of the inquest as to what further action, if any, is proposed.
” 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 Continuing accessibility of an online suicide forum to vulnerable people in the UK
Wider context from the report “1. Continuing accessibility of █████████████████████████████████████████████████████████
Dan was using an online suicide forum, █████████████████████████ Through that forum he was able to engage in discussions with other █████████████████████████ members and obtain information █████████████████████████████████████████████████████████
Notwithstanding the provisions of the Online Safety Act 2023, and apparent attempts to block access to the website, I heard evidence that it remains easily accessible to vulnerable people in the UK . I am concerned that further deaths will occur while this remains 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 of 999 call grading to trigger a category 1 ambulance response for confirmed ingestion of a potent poison
Wider context from the report “1. I am concerned that confirmed ingestion of ████████ during a 999 call does not trigger a category 1 response from the Ambulance Service
Dan ingested ████████ at around 20:30 on 22 April 2022. His friend informed the 999 call handler that he had done so during a first 999 call at 20:39. That call was correctly graded as requiring a category 2 response, as Dan was both conscious and awake. 14 minutes later, at 20:53, Dan collapsed. His friend’s second 999 call was correctly graded as requiring a category 1 response, as Dan had become unconscious, his breathing agon al. The first ambulance crew arrived at 21:04. Dan went into cardiac arrest at approximately 21:24. Consideration was given by the ambulance crew to ‘scoop and run’ to arrange a rendezvous to administer the necessary “drugs to counter ████████”, but this was no considered longer feasible once Dan had gone into cardiac arrest.
The inquest heard evidence from a consultant toxicologist that even in very small quantities ████████ (or ████████) is lethal; it is a potent poison. I understand it is also, tragically, an increasingly common means of suicide. Mental health professionals who gave evidence expressed deep concern at its easy availability and growing popularity for vulnerable people seeking to end their own lives. The expert toxicological evidence indicated that its acute toxic effects can be rapid (as short as 20 minutes after ingestion, depending on dose) and can quickly become irreversible.
This suggests that almost any case involving the ingestion of ████████ or ████████ is likely to be a time critical life-threatening event . Yet it is does not currently fall within that category for the purposes of grading 999 calls, unless the patient is unconscious or not breathing. While there was no evidence that a category 1 response would have prevented Dan’s death, I believe there is a risk that other deaths will occur if ingestion of ████████ continues to require a category 2 response.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to record the named nurse appointed to each patient
Wider context from the report “2. Inadequate system of allocating a named nurse to patients and recording the same
I am concerned that, notwithstanding the existence of a clear, appropriate policy requiring the same, the current system of allocating a named nurse and ensuring patients receive regular and effective 1:1 sessions with them are inadequate. I am also concerned that no record is kept of the named nurse appointed to each patient , thus (as in this case) hindering any investigation where issue around the role and actions of that person arises.
The General Manager of Adult Mental Health at the Trust helpfully and frankly acknowledged that the evidence heard at inquest raised questions about the adequacy of the existing system, of which he was not previously aware of. It remains unclear whether Daniel was appointed a Named Nurse who failed to perform that role effectively, or whether there was a failure to appoint such a nurse at all. The General Manager’s view was that under the existing system, it is possible that a named nurse was appointed without their knowledge. While the Ward Manager gave evidence that she would have no confidence Daniel would have known who his named nurse was, even if one was appointed. The inquest heard evidence that named nurse sessions with Daniel during previous admissions had been important opportunities for engagement with staff and had elicited a substantial amount of information pertinent to his risk and treatment. The General Manager assured me that he has already requested an urgent review of the system, but he was unable to provide any further information upon conclusion of the inquest as to what further action, if any, is proposed.
” 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 clinical and nursing staff to complete and utilise ward-specific risk assessments and care plans
Wider context from the report “1. A continuing practice/culture of minimising the importance of a ward specific risk assessment and care plan
I am concerned that, notwithstanding the existence of a clear, appropriate policy and significant commendable actions by the Trust since Daniel’s death to address this issue, there remain clinical and nursing staff who do not fully recognise or accept the importance of completing and utilising the required risk assessment and care plan . This suggests there may be a persisting training or cultural issue.
The inquest heard evidence that there was (and remains) a clear and robust policy in place which most staff were aware of. This requires a care plan and risk assessment be initiated upon a patient’s admission, completed within 72 hours of admission and updated as necessary during admission. Further, since Dan’s death, the Trust has gone to considerable and commendable lengths to ensure that care plans and risk assessments are in place in every case and to reinforce the requirements of this guidance within the Nursing team; that team hold primary (but not sole) responsibility for creating and updating the risk assessment and care plan document. I also heard that a recent audit found that all current patients had an appropriate care plan in place. The Ward Manager agreed this is “a basic and fundamental part” of any patient’s care. In spite of all of this, an experienced ward nurse and two psychiatrists (a consultant and a registrar) involved in Dan’s care seemed to minimise the practical importance of the required process and documentation , the latter both suggesting they would not routinely consult it.
” 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 delivery of regular and effective named nurse 1:1 sessions
Wider context from the report “2. Inadequate system of allocating a named nurse to patients and recording the same
I am concerned that, notwithstanding the existence of a clear, appropriate policy requiring the same, the current system of allocating a named nurse and ensuring patients receive regular and effective 1:1 sessions with them are inadequate . I am also concerned that no record is kept of the named nurse appointed to each patient, thus (as in this case) hindering any investigation where issue around the role and actions of that person arises.
The General Manager of Adult Mental Health at the Trust helpfully and frankly acknowledged that the evidence heard at inquest raised questions about the adequacy of the existing system, of which he was not previously aware of. It remains unclear whether Daniel was appointed a Named Nurse who failed to perform that role effectively, or whether there was a failure to appoint such a nurse at all. The General Manager’s view was that under the existing system, it is possible that a named nurse was appointed without their knowledge. While the Ward Manager gave evidence that she would have no confidence Daniel would have known who his named nurse was, even if one was appointed. The inquest heard evidence that named nurse sessions with Daniel during previous admissions had been important opportunities for engagement with staff and had elicited a substantial amount of information pertinent to his risk and treatment. The General Manager assured me that he has already requested an urgent review of the system, but he was unable to provide any further information upon conclusion of the inquest as to what further action, if any, is proposed.
” 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 staff skills and knowledge for encouraging engagement with patients
Wider context from the report “3. Inadequate skills/knowledge/training on how to encourage patients to engage
I am concerned that clinical, nursing and/or support staff may not currently have sufficient skills or knowledge in dealing with patients who appear unable or unwilling to engage with staff and/or treatment .
A psychiatrist not involved in Dan’s care gave evidence about the advice he would have given to colleagues on how to seek to assist a patient who, like Dan, was unwilling or unable to engage with staff: first, identify the likely reasons for the patient’s lack of engagement; second, having regard to those reasons, develop plans and strategies to address the specific barriers identified.
I heard little evidence that either of these steps was followed by any of the staff involved in Dan’s care. One barrier was identified (his previous negative experiences on the ward and wish to be transferred to another ward or hospital) but seemingly forgotten after an initial transfer request to the Bed Management team, which was not then followed up. Even with the benefit of hindsight, the doctors, nurses and healthcare assistants involved in Dan’s care seemed unable to offer any insight into the reasons for his difficulties engaging beyond his diagnosis of EUPD or articulate any strategies or techniques that might have helped him overcome them .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update overdose guidance to include callers receiving a Category 5 disposition.
Verbatim wording from the response “Most recently, the overdose guidance was updated in November 2023 to include callers who reach a Category 5 disposition (hear and treat). This followed a review by the Emergency Call Prioritisation Advisory Group (ECPAG, NHS England) and the National Ambulance Service Medical Director’s Group (NASMeDG, Association of Ambulance Chief Executives) to ensure it remained clinically fit for purpose.” 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 Issue overdose and suicidal-intent guidance requiring further clinical intervention or automatic response upgrades and TOXBASE review for overdose incidents.
Verbatim wording from the response “NHS England issued guidance for Ambulance Services relating to overdoses and suicidal intent in April 2021. The guidance highlights the critical importance of clinical oversight and review and sets out that:” 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 Ingestion of a potentially fatal substance does not, by itself, justify assigning a Category 1 ambulance response.
Verbatim wording from the response “Ambulance Emergency Operation Centres (EOCs) use one of two approved triage tools to take 999 emergency calls – Medical Priority Dispatch System (MPDS) or NHS Pathways. At the time of the calls being made to East Midlands Ambulance Service NHS Trust (EMAS) in Dan’s case, EMAS were users of the protocols within the MPDS, for which there is a protocol. This protocol generates a specific ‘Determinant Code’ for overdose, following the initial assessment of the patient. This then allows the relevant Ambulance Emergency Operation Centre (EOC), in this case that of EMAS, to consider the Determinant Code and locally determine and apply a local response mode or ‘Category’. The response modes are underwritten by the UK Government Emergency Call Prioritisation Ambulance Group (ECPAG) and sent to NHS Ambulance Service Trusts in England for implementation.” 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 Listing every potentially fatal substance for dispatcher-led response assignment is impractical and risks dangerous over-triage because caller information may be unreliable.
Verbatim wording from the response “While ingestion of ████████ can lead to fatality, this can unfortunately be said of an array of substances, ranging from prescription medicines to over-the-counter household products and other agents available commercially or over the internet. The MPDS does specifically code some common overdose/poisoning agents, but this is for the provision of specific therapies and information for responders rather than for specific response assignment.¹ The listing of all possible fatal agents would likely lead” 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 overdose protocols, intentional-overdose coding and clinical oversight enable appropriate prioritisation regardless of the substance ingested.
Verbatim wording from the response “Ambulance Emergency Operation Centres (EOCs) use one of two approved triage tools to take 999 emergency calls – Medical Priority Dispatch System (MPDS) or NHS Pathways. At the time of the calls being made to East Midlands Ambulance Service NHS Trust (EMAS) in Dan’s case, EMAS were users of the protocols within the MPDS, for which there is a protocol. This protocol generates a specific ‘Determinant Code’ for overdose, following the initial assessment of the patient. This then allows the relevant Ambulance Emergency Operation Centre (EOC), in this case that of EMAS, to consider the Determinant Code and locally determine and apply a local response mode or ‘Category’. The response modes are underwritten by the UK Government Emergency Call Prioritisation Ambulance Group (ECPAG) and sent to NHS Ambulance Service Trusts in England for implementation.” 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 relevant ambulance Emergency Operation Centre, including EMAS in this case, determines and applies the local response category.
Verbatim wording from the response “Ambulance Emergency Operation Centres (EOCs) use one of two approved triage tools to take 999 emergency calls – Medical Priority Dispatch System (MPDS) or NHS Pathways. At the time of the calls being made to East Midlands Ambulance Service NHS Trust (EMAS) in Dan’s case, EMAS were users of the protocols within the MPDS, for which there is a protocol. This protocol generates a specific ‘Determinant Code’ for overdose, following the initial assessment of the patient. This then allows the relevant Ambulance Emergency Operation Centre (EOC), in this case that of EMAS, to consider the Determinant Code and locally determine and apply a local response mode or ‘Category’. The response modes are underwritten by the UK Government Emergency Call Prioritisation Ambulance Group (ECPAG) and sent to NHS Ambulance Service Trusts in England for implementation.” Source location Response from NHS England
Open published response
28 Feb 2024 Chloe Anne Tapp · Prevention of Future Deaths report Essex
View report summary
Concerns raised 15 Failure to implement identified actions addressing unsafe neurology practice View source Delays and unsafe processes in investigation reporting and results access View source Provision of medication tapering instructions based on incorrect doses View source Chronic staffing shortages across neurology doctors, nurses and administrative staff View source Failure to establish medication doses and apply appropriate conversion factors View source Unsafe backlogs for neurology first and follow-up appointments View source Failure to deliver medication tapering information through a valid and timely communication channel View source Failure to make timely referrals to adult neurology services View source Worsening unsafe condition of the neurology department View source Failure to provide visual assessment when clinically required View source Failure to respond to patient communications requiring medication clarification View source Insufficient national neurologist capacity relative to demand View source Failure to answer patient and carer communications in a timely manner View source Failure to record medication tapering regimes in clinical notes View source Unsafe practice in the neurology department View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Chloe Anne Tapp · 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
Chloe Anne Tapp, a 20-year-old with epilepsy and other medical conditions, suffered seizures and respiratory and cardiac arrest on 7 October 2021 and died in hospital on 8 October 2021. The principal concerns included delays transferring her to adult neurology, a telephone consultation despite her being non-verbal, an incorrect and inadequately documented medication tapering regime, and unanswered attempts to obtain clarification. Broader concerns were raised about staffing shortages, unsafe backlogs and difficulties responding to patients and carers within the neurology department.
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 implement identified actions addressing unsafe neurology practice
Wider context from the report “Notwithstanding Chloe’s death in 2021, the letter in July 2023 and follow-up in January 2024, many of the more significant actions identified remained as part of an Action Plan . Business cases were being drawn up for a number of areas (but not additional consultants) and these had not yet been approved, nor was it guaranteed that they would be .
” 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 Delays and unsafe processes in investigation reporting and results access
Wider context from the report “The consultant in question gave evidence of a very bleak picture of ongoing practice in the neurology department; a letter from all four consultants in that department had been sent to the Trust in July 2023, where patient care was described as ‘sub-optimal’, and numerous concerns were set out including:
o Chronic staff shortages in respect of doctors, nurses and administrative staff within the neurology department
o Substantial and unsafe backlogs for first and follow up appointments
o Inability to answer, in a timely manner, the volume of phone calls, phone messages and emails from patients/carers raising queries.
o The delays / ways in which investigations are carried out and reported , and the way in which clinical staff can access results .
” 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 Provision of medication tapering instructions based on incorrect doses
Wider context from the report “A handwritten note of a tapering regime based on incorrect doses was sent to Chloe.
” 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 Chronic staffing shortages across neurology doctors, nurses and administrative staff
Wider context from the report “The consultant in question gave evidence of a very bleak picture of ongoing practice in the neurology department; a letter from all four consultants in that department had been sent to the Trust in July 2023, where patient care was described as ‘sub-optimal’, and numerous concerns were set out including:
o Chronic staff shortages in respect of doctors, nurses and administrative staff within the neurology department
o Substantial and unsafe backlogs for first and follow up appointments
o Inability to answer, in a timely manner, the volume of phone calls, phone messages and emails from patients/carers raising queries.
o The delays / ways in which investigations are carried out and reported, and the way in which clinical staff can access results.
” 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 establish medication doses and apply appropriate conversion factors
Wider context from the report “An overworked consultant under considerable pressure, did not have time before or during the consultation to establish the dose that Chloe was taking and/or apply the appropriate conversion factor , for medications that can interact negatively at higher doses .
” 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 Unsafe backlogs for neurology first and follow-up appointments
Wider context from the report “The consultant in question gave evidence of a very bleak picture of ongoing practice in the neurology department; a letter from all four consultants in that department had been sent to the Trust in July 2023, where patient care was described as ‘sub-optimal’, and numerous concerns were set out including:
o Chronic staff shortages in respect of doctors, nurses and administrative staff within the neurology department
o Substantial and unsafe backlogs for first and follow up appointments
o Inability to answer, in a timely manner, the volume of phone calls, phone messages and emails from patients/carers raising queries.
o The delays / ways in which investigations are carried out and reported, and the way in which clinical staff can access results.
” 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 deliver medication tapering information through a valid and timely communication channel
Wider context from the report “The same regime was repeated in a letter to the Epilepsy Nurses, but this letter was not received until October 2021 (in paper form) as the initial email was sent to an address that no longer existed .
” 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 timely referrals to adult neurology services
Wider context from the report “Neurology departments are so overwhelmed and/or understaffed that a vulnerable young girl (particularly so during the Covid-19 pandemic), was not referred in a timely manner to adult neurology services and in fact, it transpired a referral had not been made at all . This appears to have been done for the first time in August 2021.
” 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 Worsening unsafe condition of the neurology department
Wider context from the report “The state of the department , compared to when Chloe died was described as ‘worse’ .
” 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 visual assessment when clinically required
Wider context from the report “An initial consultation with a complex non-verbal patient was arranged over the telephone , notwithstanding the concerns about a tremor which would have required visual assessment .
” 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 respond to patient communications requiring medication clarification
Wider context from the report “Phone calls and messages left with the neurology department went unanswered , at a time when clarity over the tapering regime was needed .
” 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 national neurologist capacity relative to demand
Wider context from the report “The independent consultant neurologist in giving evidence expressed that this was not an unfamiliar picture across a number of different Trusts and that there was a recognised shortage of neurologists and increase in demand for that speciality nationally .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to answer patient and carer communications in a timely manner
Wider context from the report “The consultant in question gave evidence of a very bleak picture of ongoing practice in the neurology department; a letter from all four consultants in that department had been sent to the Trust in July 2023, where patient care was described as ‘sub-optimal’, and numerous concerns were set out including:
o Chronic staff shortages in respect of doctors, nurses and administrative staff within the neurology department
o Substantial and unsafe backlogs for first and follow up appointments
o Inability to answer, in a timely manner, the volume of phone calls, phone messages and emails from patients/carers raising queries.
o The delays / ways in which investigations are carried out and reported, and the way in which clinical staff can access results.
” 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 medication tapering regimes in clinical notes
Wider context from the report “No note was made of the tapering regime for the medication change in Chloe’s notes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unsafe practice in the neurology department
Wider context from the report “A further letter was sent by Chloe’s consultant in January 2024 in lieu of her attending a meeting where progress was to be discussed. That letter highlighted that, not only did the concerns remain live , she believed that the department had now reached levels of ‘unsafe practice’ .
” 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 Deliver the Long Term Workforce Plan, expanding domestic education, training and recruitment while improving culture, leadership and staff wellbeing.
Verbatim wording from the response “NHS England is also working at a national level to deliver the Long Term Workforce Plan which was published in June 2023. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years.” 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 national neurology guidance and specifications supporting integrated care, including epilepsy services.
Verbatim wording from the response “NHS England’s Neurology Programme is in the process of developing guidance and specifications to support Systems and NHS Trusts to develop integrated care for neurology services, including epilepsy. However, this cannot directly impact issues arising from funding shortfalls in individual services or challenges with recruitment and retention of appropriately qualified medical and nursing staff in some parts of the country, as raised in your Report.” 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 and disseminate a national bundle of care for children and young people with epilepsy, including transition recommendations.
Verbatim wording from the response “Transition pathways from paediatric to adult services are a particular point of risk with variable processes across the country, with both paediatric and adult neurology services stretched. This is particularly a recognised issue for epilepsy. NHS England’s Paediatrics Programme recently published the national bundle of care for children and young people with epilepsy. Published in October 2023, and builds on existing guidance from the National Institute for Health and Care Excellence (NICE), it is aimed at clinicians by outlining specific recommendations for integrated care systems on the provision of care for children and young people with epilepsy particularly around transition.” 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 Conduct a GIRFT review visit to Mid and South Essex NHS Foundation Trust’s neurology department.
Verbatim wording from the response “Having considered your Report and the concerns raised, a GIRFT visit to Mid and South Essex NHS Foundation Trust has been arranged to review the specific situation within their Neurology department.” 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 National guidance cannot directly address funding shortfalls or recruitment and retention challenges in individual neurology services.
Verbatim wording from the response “NHS England’s Neurology Programme is in the process of developing guidance and specifications to support Systems and NHS Trusts to develop integrated care for neurology services, including epilepsy. However, this cannot directly impact issues arising from funding shortfalls in individual services or challenges with recruitment and retention of appropriately qualified medical and nursing staff in some parts of the country, as raised in your Report.” 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 Trusts are responsible for ensuring safe staffing levels during the day-to-day operation of their hospitals.
Verbatim wording from the response “These actions will aim to close anticipated staffing shortfalls in the NHS in the long term, however Trusts have a responsibility to ensure safe staffing levels in the current day to day operation of their hospitals. This is in line with Care Quality Commission (CQC) Regulation 18 which states that providers must deploy enough suitably qualified, competent, and experienced staff to enable them to meet all other regulatory requirements.” 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 Many concerns about Chloe’s care fall within the NHS Foundation Trust’s remit rather than NHS England’s national programme or policy remit.
Verbatim wording from the response “In your Report you raise concerns over pressures being placed on neurology departments and that there was a recognised shortage of neurologists amid an increase in demand. This response focuses on the concerns raised relevant to NHS England national programme or policy. Many of your concerns around the quality of care delivered to Chloe sit within the remit of Mid and South Essex NHS Foundation Trust, and I note that you have also addressed your Report to them.” Source location Response from NHS England
Open published response
21 Feb 2024 Mr Oliver Beswetherick · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 1 Lack of contact details for neighbouring psychiatric liaison and crisis mental health teams View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Oliver Beswetherick · 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
Mr Oliver Beswetherick, who had a history of depression, bulimia and bipolar affective disorder, was found dead after falling from his flat on 4 September 2020. The report raised concern that mental health crisis teams did not have contact details for psychiatric liaison services and crisis teams in neighbouring boroughs, hindering direct referrals and the sharing of case 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 Lack of contact details for neighbouring psychiatric liaison and crisis mental health teams
Wider context from the report “(1) It became evidence during the inquest that CMHT/ Crisis teams do not have contact details of:
(i) Psychiatric liaison nurse services in neighbouring (out of their locality) boroughs based in Accident & Emergency departments, or details of
(ii) CMHT/ crisis teams in neighbouring boroughs.
Such contact could provide for direct referral, contact and passing on of knowledge of cases between neighbouring organisations, especially when individuals have already been assessed and asked to attend for a face-to-face consultation. Otherwise, those individuals who seek help, may have to revisit the same process of being interviewed on multiple occasions with a sense of déjà vu and anxiety that they are not obtaining the urgent assistance and support that they require. That may lead to them not engaging when they had hitherto made every attempt to do so.
To provide those contact details would seem a relatively simple task, so teams could contact each other, and the local psychiatric liaison nurses based within the A&Es.
” 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 Existing NHS Service Finder and website directories provide professionals with current neighbouring mental health service contact details and referral information.
Verbatim wording from the response “Your Report raises the concern that Community Mental Health and Crisis Teams do not have the contact details of Psychiatric Liaison, Community Mental Health, and Crisis Teams within neighbouring boroughs.” Source location Response from NHS England
Open published response
Concerns raised 7 Continued shortages in psychiatric care provision View source Failure to provide evidence in accordance with the duty of candour View source Insufficient training of SPA call handlers in patient identification and information seeking View source Failure of psychiatric liaison clinicians to consider diagnoses made by other doctors View source Insufficient use of protective film over glass in areas where patients are at increased risk of smashing windows View source Insufficient psychiatric service response capacity out of hours for section 136 usage View source Failure to identify CNWL staff operating outside policy View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Roberto Bottello · 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
Roberto Bottello, who had been experiencing depression, anxiety, panic attacks and later an acute psychotic episode, was detained under section 136 of the Mental Health Act after police found him acutely disturbed. While in a hospital cubicle, he broke the window and fell 25 feet, suffering multiple injuries including a divided axillary vein and artery; his death was announced at 07:27 on 16 September 2020. Substantive concerns included the unsuitability and inadequate safety of the cubicle, communication and information-management failures, insufficient mental-health nursing provision, confusion over his identity, limited access to section 136 suites, and wider concerns about training and psychiatric-care resources.
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 Continued shortages in psychiatric care provision
Wider context from the report “10. That there are continued shortages in psychiatric care provision .
” 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 evidence in accordance with the duty of candour
Wider context from the report “1. That CNWL failed in its duty of candour in relation to provision of evidence in this 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 Insufficient training of SPA call handlers in patient identification and information seeking
Wider context from the report “3. That SPA call handlers were not sufficiently trained in how to identify patients by using computer searches and by not seeking information appropriately for example by using the international phonetic alphabet and using the word for the month in a person’s date of birth .
” 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 psychiatric liaison clinicians to consider diagnoses made by other doctors
Wider context from the report “6. That the psychiatric liaison nurses and psychiatric liaison doctors should have regard to and specifically consider diagnoses made by other doctors for example those who see such patients repeatedly in A&E as in this 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 Insufficient use of protective film over glass in areas where patients are at increased risk of smashing windows
Wider context from the report “9. That the use of film over glass in areas where patients are at increased risk of smashing windows should be more widespread in the NHSE estate .
” 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 psychiatric service response capacity out of hours for section 136 usage
Wider context from the report “7. That most section 136 usage is out of hours when there is less resource to respond from psychiatric services .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to identify CNWL staff operating outside policy
Wider context from the report “5. That CNWL were and may still be unaware that CNWL staff operate outside policy .
” 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 Fund training for approximately 15,000 additional psychological therapists and practitioners over the next three years.
Verbatim wording from the response “In addition to education and training for clinical psychologists and child and adolescent psychotherapists, over the next three years NHS England has committed funding of over £600 million to grow the wider psychological professions workforce through training approximately 15,000 more individuals to undertake psychological therapist and psychological practitioner roles. Training places for mental health nursing will also increase by 38%. The Long-Term Workforce Plan makes a commitment to keep the mental health workforce under review.” 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 and implement the Long-Term Workforce Plan to train, retain and reform the NHS workforce, including growth in psychiatric care staffing.
Verbatim wording from the response “Workforce and staffing levels continue to be a challenge across the NHS, and we know that this can present issues to Trusts. In June 2023, NHS England published the NHS Long Term Workforce Plan, setting out how it will train, retain and reform its workforce across the next fifteen years to ensure that we are improving access, providing safe and timely urgent and emergency care and continuing to reduce elective care backlogs. The Plan is underpinned by the biggest recruitment drive in NHS history and includes focus on growing the psychiatric care workforce.” 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 Increase mental health nursing training places by 38%.
Verbatim wording from the response “In addition to education and training for clinical psychologists and child and adolescent psychotherapists, over the next three years NHS England has committed funding of over £600 million to grow the wider psychological professions workforce through training approximately 15,000 more individuals to undertake psychological therapist and psychological practitioner roles. Training places for mental health nursing will also increase by 38%. The Long-Term Workforce Plan makes a commitment to keep the mental health workforce under review.” 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 Increase clinical psychology and child and adolescent psychotherapy training places, with more than 1,000 places annually through 2028/29.
Verbatim wording from the response “Psychological professionals, comprising psychologists, psychological therapists, and psychological practitioners, are making a rapidly growing contribution to the NHS across mental health and physical health services. Education and training places for clinical psychology and child and adolescent psychotherapy are estimated to need to grow by at least 20–33%, reaching 1,258–1,397 by 2033/34. Our ambition is to grow these training places by 26% by 2031/32. To support working towards this ambition, training places for clinical psychology and child and adolescent psychotherapy will be more than 1,000 each year up to 2028/29.” 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 Each NHS Trust is responsible for estate management, including deciding whether reinforced toughened glass should be fitted.
Verbatim wording from the response “Estate management is the responsibility of each individual NHS Trust. I note that a Serious Incident Investigation was undertaken by the Trust in this matter and recommendations were made to consider reconfiguring the space to provide a more appropriate place of safety for mental health patients. We are advised that the Trust will be reviewing their windows to ascertain whether reinforced toughened glass can be fitted.” Source location Response from NHS England
Open published response
8 Feb 2024 Ethel Doreen Reed · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 5 Failure of the electronic patient record system to identify authors of changes to finalised discharge letters View source Risk of cross infection from misallocated patients’ personal effects View source Lack of continuity of nursing staff on winter-pressure wards View source Lack of visible ward leadership and a clear escalation pathway View source Paucity of personal care on the ward 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
Ethel Doreen Reed · 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
Ethel Doreen Reed fell at home, sustaining rib fractures that caused a pneumothorax and chest infection, and later developed pneumonia and Covid-19 while in hospital. She was discharged to a community rehabilitation centre while described as not medically fit for discharge and died there on 2 March 2023. The report raises concerns about staffing, continuity of care, personal care, leadership and escalation arrangements on a winter-pressure ward, as well as an electronic record system issue affecting identification of authors of discharge-letter changes.
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 the electronic patient record system to identify authors of changes to finalised discharge letters
Wider context from the report “(2) An issue with the Lorenzo electronic patient record keeping system has been identified in respect of the system not auto populating the identification of the author of any changes made in the immediate discharge letter (IDL) after it has been finalised . This could lead to miscommunication of critical issues and difficulties in establishing who made what decisions which could lead to delays in treatment in the next post discharge setting which in turn could lead to future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Risk of cross infection from misallocated patients’ personal effects
Wider context from the report “(1) H130 is on the 13th floor of Hull Royal Infirmary. It has an East and a West wing and spans the full floor. It was opened in response to winter pressures. At that time, in January 2023, Hull Royal Infirmary was placed under significant pressure in terms of admissions and staffing. The ward been open only a matter of some two weeks by the time Mrs Reed was transferred to that ward. Despite being medically fit for discharge upon arrival on that ward Mrs Reed’s condition worsened and family raised concerns as best they could but they reported that the ward was chaotic and that staff would tell them they had only just found out they were working on the ward before their shift started and there was no consistency of nursing staff on the ward.
Mrs Reed was dehydrated and family report that there was a paucity of personal care afforded on that ward. There was a risk of cross infection as patients’ personal effects such as toiletries were not with the right patients and had to be located by family. There was no established cohort of permanent staff on the ward at that time and no signposting to the ward sister or matron and therefore no way of patients, their friends, or their families being able to have a clear escalation pathway to ventilate concerns. Although HUTH now have an established team and leadership chain on Ward H130 there is a real concern that wards opened in response to winter pressures in the future in any busy hospital may give rise to the same peripatetic staffing regime, that is to say, agency staff and no fixed team in place and a lack of visible leadership. This could lead to the deterioration of patients not being recognised if there is no continuity of care by the same team of nursing staff.
” 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 continuity of nursing staff on winter-pressure wards
Wider context from the report “(1) H130 is on the 13th floor of Hull Royal Infirmary. It has an East and a West wing and spans the full floor. It was opened in response to winter pressures. At that time, in January 2023, Hull Royal Infirmary was placed under significant pressure in terms of admissions and staffing. The ward been open only a matter of some two weeks by the time Mrs Reed was transferred to that ward. Despite being medically fit for discharge upon arrival on that ward Mrs Reed’s condition worsened and family raised concerns as best they could but they reported that the ward was chaotic and that staff would tell them they had only just found out they were working on the ward before their shift started and there was no consistency of nursing staff on the ward .
Mrs Reed was dehydrated and family report that there was a paucity of personal care afforded on that ward. There was a risk of cross infection as patients’ personal effects such as toiletries were not with the right patients and had to be located by family. There was no established cohort of permanent staff on the ward at that time and no signposting to the ward sister or matron and therefore no way of patients, their friends, or their families being able to have a clear escalation pathway to ventilate concerns. Although HUTH now have an established team and leadership chain on Ward H130 there is a real concern that wards opened in response to winter pressures in the future in any busy hospital may give rise to the same peripatetic staffing regime, that is to say, agency staff and no fixed team in place and a lack of visible leadership. This could lead to the deterioration of patients not being recognised if there is no continuity of care by the same team of nursing staff.
” 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 visible ward leadership and a clear escalation pathway
Wider context from the report “(1) H130 is on the 13th floor of Hull Royal Infirmary. It has an East and a West wing and spans the full floor. It was opened in response to winter pressures. At that time, in January 2023, Hull Royal Infirmary was placed under significant pressure in terms of admissions and staffing. The ward been open only a matter of some two weeks by the time Mrs Reed was transferred to that ward. Despite being medically fit for discharge upon arrival on that ward Mrs Reed’s condition worsened and family raised concerns as best they could but they reported that the ward was chaotic and that staff would tell them they had only just found out they were working on the ward before their shift started and there was no consistency of nursing staff on the ward.
Mrs Reed was dehydrated and family report that there was a paucity of personal care afforded on that ward. There was a risk of cross infection as patients’ personal effects such as toiletries were not with the right patients and had to be located by family. There was no established cohort of permanent staff on the ward at that time and no signposting to the ward sister or matron and therefore no way of patients, their friends, or their families being able to have a clear escalation pathway to ventilate concerns . Although HUTH now have an established team and leadership chain on Ward H130 there is a real concern that wards opened in response to winter pressures in the future in any busy hospital may give rise to the same peripatetic staffing regime, that is to say, agency staff and no fixed team in place and a lack of visible leadership . This could lead to the deterioration of patients not being recognised if there is no continuity of care by the same team of nursing staff.
” 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 Paucity of personal care on the ward
Wider context from the report “(1) H130 is on the 13th floor of Hull Royal Infirmary. It has an East and a West wing and spans the full floor. It was opened in response to winter pressures. At that time, in January 2023, Hull Royal Infirmary was placed under significant pressure in terms of admissions and staffing. The ward been open only a matter of some two weeks by the time Mrs Reed was transferred to that ward. Despite being medically fit for discharge upon arrival on that ward Mrs Reed’s condition worsened and family raised concerns as best they could but they reported that the ward was chaotic and that staff would tell them they had only just found out they were working on the ward before their shift started and there was no consistency of nursing staff on the ward.
Mrs Reed was dehydrated and family report that there was a paucity of personal care afforded on that ward. There was a risk of cross infection as patients’ personal effects such as toiletries were not with the right patients and had to be located by family. There was no established cohort of permanent staff on the ward at that time and no signposting to the ward sister or matron and therefore no way of patients, their friends, or their families being able to have a clear escalation pathway to ventilate concerns. Although HUTH now have an established team and leadership chain on Ward H130 there is a real concern that wards opened in response to winter pressures in the future in any busy hospital may give rise to the same peripatetic staffing regime, that is to say, agency staff and no fixed team in place and a lack of visible leadership. This could lead to the deterioration of patients not being recognised if there is no continuity of care by the same team of nursing staff.
” 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 Responsibility for the Lorenzo system relationship sits directly with trusts and the supplier because NHS England has no contract.
Verbatim wording from the response “Your Report also raised a concern around the Lorenzo electronic patient record keeping system not auto-populating the identification of the author of any changes made in the immediate discharge letter after it has been finalised. NHS England no longer has a contract with Dedalus (Lorenzo system) and therefore the relationship sits directly with the Trust(s) and supplier.” 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 Staffing at individual NHS trusts is their responsibility, while national workforce support continues.
Verbatim wording from the response “While staffing is the responsibility of individual Trusts, growing the healthcare workforce is one of NHS England’s chief priorities and we were pleased to achieve the government target of having 50,000 more nurses working in the NHS by November last year than in 2019. Nurse, Allied Healthcare Professionals, and wider health and care vacancies remain a pressing concern which we are addressing through the delivery of the NHS Long Term Workforce Plan, offering flexible routes into the professions including apprenticeships and working with employers to support retention of the current workforce.” Source location Response from NHS England
Open published response
Concerns raised 1 Unavailability of suitable psychiatric hospital bed spaces in a timely way View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Abdullah Popalzai · 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
Abdullah Popalzai was a remand prisoner at HMP Pentonville who was found hanging in his cell on 29 November 2019, and his death was confirmed by paramedics. He had acute psychosis and required transfer to a psychiatric unit, but no suitable bed was available for a prolonged period. The principal concern was that acutely psychotic prisoners refusing treatment were being left untreated and at risk of deterioration because suitable psychiatric hospital beds were not becoming available in a timely way.
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 Unavailability of suitable psychiatric hospital bed spaces in a timely way
Wider context from the report “1) Prisoners who are acutely psychotic and refusing treatment that requires transfer to hospital under the Mental Health Act are being left untreated and at risk of further deterioration due to a shortage of suitable psychiatric hospital bed spaces becoming available in a timely way .
” 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 Address concerns and lessons identified in the HMIP review of delays transferring mentally unwell prisoners.
Verbatim wording from the response “His Majesty’s Inspectorate of Prisons (HMIP) recently published the report The long wait: A thematic review of delays in the transfer of mentally unwell prisoners which outlines similar issues. NHS England is also addressing the areas of concern and lessons learnt within this report.” 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 Increase timely access to psychiatric hospital beds and provide earlier identification, treatment and support for people in custody who need mental healthcare.
Verbatim wording from the response “NHS England is committed to ensuring access to timely, responsive, and least restrictive mental health care and is already working to address this in this area by focusing on increasing access to hospital beds pre-sentence, rather than prison being used as a place of safety.” Source location Response from NHS England
Open published response
2 Feb 2024 Samuel Thomas Jordan · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 1 Lack of access to temporary GP practice records through the NHS Spine View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Samuel Thomas Jordan · 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
Samuel Thomas Jordan, aged 25, was imprisoned at HMP Exeter and was found hanging in a single-occupancy cell after an incident with his cell mate on 26 March 2020. The inquest concluded that he died by suicide while suffering from mental illness. The jury identified the lack of access to records from a temporary GP practice, including information about his mental health and current medication, as a contributory factor in his death.
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 access to temporary GP practice records through the NHS Spine
Wider context from the report “During the four months before his imprisonment, Samuel Jordan had been receiving treatment for severe anxiety while registered as a temporary patient with a medical practice in Launceston, Cornwall. Samuel had come to Cornwall from his home in Whitchurch, Hampshire where he was registered with another GP practice. On entering HMP Exeter, the prison Healthcare obtained a summary of Samuel’s GP records from Hampshire via the NHS spine. The records from the Launceston practice were not sent to the prison since the NHS spine only operates to transmit records from the permanent GP practice and not a practice consulted on a temporary basis. As a result, Exeter Prison Healthcare was unaware of Samuel’s mental health issues immediately before coming to Prison and was unaware of a current medication prescription lack of which the jury found contributed to Samuel’s death.
The inquest heard that prisoners coming to prison frequently were nomadic and frequently had registered with GP practices on a temporary basis and records from such practices not coming to the notice of prison healthcare as such records are not accessible through the NHS spine . Lack of access through the NHS Spine to the records of the practice where Samuel was registered as a temporary patient was, the jury found, a contributory factor in Samuel’s death.
” 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 Improve information sharing between the detained estate and wider NHS by enabling access to Spine-connected services, including PDS, eRS and GP2GP Transfer.
Verbatim wording from the response “NHS England has been working to improve the processes around information sharing between the detained estate and the wider NHS. This includes enabling access to a range of Spine connected services including Personal Demographics Service (PDS), Electronic Referral Service (eRS) and GP2GP Transfer. As a result of these changes, some patients transferring into the detained estate will have a GP2GP transfer whereby the patient’s electronic GP record is sent from their previously registered GP Practice to the new GP Practice that they register with within the detained estate. Further details are available via the links 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 GP2GP electronic transfer of community GP records into and out of healthcare systems across the adult male and children’s secure estate.
Verbatim wording from the response “Patients within the adult male and children and young people’s secure estate (adult male prisons, young offender institutions and secure training centres) have the opportunity to register with healthcare at their place of detention. This means a GP2GP transfer can now take place, electronically transferring the patient’s community GP record into the clinical system in place across the secure estate, and then back out to the community when the patient registers with a GP on release. The ability for a GP2GP transfer of a community GP record into the prison healthcare system was rolled out to the male prison estate between February and July 2022, so this option was not available at the time of Samuel’s death, but I hope provides assurance around current practice.” 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 temporary-registration and detained-estate information-sharing processes are considered sufficient, subject to consent and direct contact where necessary.
Verbatim wording from the response “In summary, there are existing processes around the management of temporary resident patients. These support GP Practices to take over the management of patients by registering them permanently at the new practice where this is appropriate. Where care continues to be provided on a temporary basis, there are existing information flows to send information about the care episode back to the patients’ registered GP Practice via the GMS3 form, where the patient has consented, and for this information to then be integrated into the patients’ registered GP record so that” Source location Response from NHS England
Open published response
Concerns raised 2 Lack of an appropriate structure to educate and manage people diagnosed with allergies and anaphylaxis View source Failure to provide regular review of allergy, anaphylaxis risk and the benefits of automatic adrenaline injectors View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James Stuart Atkinson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Stuart Atkinson, who had a known peanut allergy and asthma, died of anaphylaxis after eating a Chicken Tikka Masala pizza containing peanuts from Dadyal Takeaway Restaurant on 10 July 2020. The report identified concerns about the lack of allergen information from the takeaway, the absence of regular allergy reviews, and the failure to locate his Epi-pen during the reaction.
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 an appropriate structure to educate and manage people diagnosed with allergies and anaphylaxis
Wider context from the report “The evidence in this case unequivocally established that James was not under regular review for his allergy, risk of anaphylaxis and the benefits of automatic adrenaline injectors.
The report of ████████ (attached) identifies the need for wider consideration of a systematic approach to improving anaphylaxis awareness and management .
The risk of future deaths in the context of allergy/anaphylaxis remains in the absence of an appropriate structure to educate, review and manage those who are diagnosed allergies .
” 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 regular review of allergy, anaphylaxis risk and the benefits of automatic adrenaline injectors
Wider context from the report “The evidence in this case unequivocally established that James was not under regular review for his allergy, risk of anaphylaxis and the benefits of automatic adrenaline injectors .
The report of ████████ (attached) identifies the need for wider consideration of a systematic approach to improving anaphylaxis awareness and management.
The risk of future deaths in the context of allergy/anaphylaxis remains in the absence of an appropriate structure to educate, review and manage those who are diagnosed allergies.
” 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 update the Specialist Allergy Service Specification, including stronger transition, self-care, information and personal management plan requirements.
Verbatim wording from the response “NHS England has a Clinical Reference Group (CRG) that provides clinical advice and leadership for both Specialised Immunology and Specialised Allergy services. The membership includes clinicians, commissioners, public health experts and Patient and Public Voice members. They use their combined knowledge and expertise to advise NHS England on the optimal arrangements for the commissioning of specialised services. This includes developing national standards for services delivering specialised care to patients with allergies in the form of national service specifications and policies. The CRG commenced a review of the current published Specialist Allergy Service Specification in May 2023, which is expected to be complete by Summer 2024.” Source location Response from NHS England
Open published response
Concerns raised 3 Crowded and noisy treatment areas ill-suited to proper patient treatment View source Insufficient clinician awareness and ability to apply NICE guidelines for adrenal insufficiency View source Failure to apply NICE steroid-treatment guidelines for adrenal insufficiency during intercurrent illness View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Leslie PEGG · 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
Michael Leslie Pegg, who lived with congenital adrenal insufficiency and epilepsy, was admitted to Worcestershire Royal Hospital after two significant seizures and died there on 15 January 2023 following deterioration and pneumonia. The report raised concerns that steroid treatment fell far short of relevant NICE guidelines, that staff awareness and application of the guidelines were insufficient, and that crowded treatment areas created difficulties in providing appropriate 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 Crowded and noisy treatment areas ill-suited to proper patient treatment
Wider context from the report “3) For a substantial part of his time at Worcestershire Royal Hospital, Mr. Pegg was being treated in a bed in a corridor in the Emergency Department, and then in the Majors Overflow area, both busy, crowded and noisy areas ill-suited to the proper treatment of patients . In his evidence to the inquest about trying to ensure that the Trust’s staff are aware of these Guidelines, Dr Raven told the inquest:
“As long as we still have crowded settings, it is difficult to provide assurances that these guidelines will be followed , for example because we have a high turnover of locum clinicians and agency nursing staff.”
It is particularly concerning to hear that patients’ wellbeing may be put at risk because a hospital Trust may not be able properly to ensure that the staff it employs are aware of, and able to apply NICE Guidelines.
It is perhaps unfair to put responsibility for rectifying this situation solely at the door of the Worcestershire Acute Hospitals NHS Trust, which is why this report is also being sent to NHS England and Health Education England.
” 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 clinician awareness and ability to apply NICE guidelines for adrenal insufficiency
Wider context from the report “2) Although in this case, I was unable to conclude that the above omissions in steroid treatment probably caused or contributed to Mr. Pegg’s death, it was nonetheless concerning to hear that none of those treating him had sufficient awareness of the NICE Guidelines as to be able to apply them properly in his case . Unless action is taken to ensure clinicians employed by the Trust are aware of, and able to apply these Guidelines , there remains a risk that another patient with adrenal insufficiency may die in similar circumstances ;
” 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 NICE steroid-treatment guidelines for adrenal insufficiency during intercurrent illness
Wider context from the report “1) Over the two days that Mr. Pegg was at Worcestershire Royal Hospital, those treating him failed to apply the NICE guidelines which relate to the treatment of those with adrenal insufficiency conditions who are being treated for intercurrent illness . ████████, who conducted the Trust’s serious incident investigation into these events, told the inquest:
“There was a policy in place for administering steroids, as per the 2020 NICE guidelines – this advises:
(a) double dosing of oral steroids in cases of intercurrent illness until 48 hours after recovery (also known as Sick Day rule 1);
(b) if [the patient has ] significant trauma, prolonged vomiting or diarrhoea, then 100mg IV hydrocortisone [ should be administered ];
(c) if suspected adrenal crisis, 100mg IV hydrocortisone immediately.”
In fact, the steroid treatment provided to Mr. Pegg during this admission fell far short of those Guidelines , in that:
(a) He only received one double dose of his oral hydrocortisone medication , which he was usually required to take twice a day;
(b) He received no doses at all ( double or standard ) of his oral prednisolone medication , which he was usually required to take once a day;
(c) Although he did eventually receive a 100mg dose of IV hydrocortisone on 14.1.23, this should have been given much earlier that day when his condition seriously deteriorated .
” 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 guidance for preventing and managing adrenal insufficiency emergencies in adults.
Verbatim wording from the response “NHS England has also worked closely with the Society for Endocrinology and the Royal College of Physicians on the issue of under-recognition and treatment of adrenal insufficiency or crisis. This culminated in the publication of ‘Guidance for the prevention and emergency management of adult patients with adrenal insufficiency’ in July 2020, which outlines the causes of adrenal insufficiency, groups at risk of an adrenal crisis, emergency management and management for surgical procedures. As a result of work in this area, a new NHS Steroid Emergency Card was developed, to be carried by patients at risk of adrenal crisis and ensure the prompt delivery of steroids to those patients presenting within an emergency or acute medicine 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 Develop the NHS Steroid Emergency Card for patients at risk of adrenal crisis.
Verbatim wording from the response “NHS England has also worked closely with the Society for Endocrinology and the Royal College of Physicians on the issue of under-recognition and treatment of adrenal insufficiency or crisis. This culminated in the publication of ‘Guidance for the prevention and emergency management of adult patients with adrenal insufficiency’ in July 2020, which outlines the causes of adrenal insufficiency, groups at risk of an adrenal crisis, emergency management and management for surgical procedures. As a result of work in this area, a new NHS Steroid Emergency Card was developed, to be carried by patients at risk of adrenal crisis and ensure the prompt delivery of steroids to those patients presenting within an emergency or acute medicine setting.” 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 Trust is responsible for addressing local emergency department crowding, staffing, overflow-area and acuity concerns.
Verbatim wording from the response “NHS England would refer you to the Trust on what actions are being taken locally to address your concerns. We have been sighted on their Serious Investigation Report and Action Plan and note that they have taken learnings around Emergency Department crowding and improving end-of-life care for patients and are reviewing staffing levels in the Overflow Area and Acuity.” Source location Response from NHS England
Open published response
15 Jan 2024 Rhys Lennon Hill · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 9 Lack of clarity on VTE prophylaxis for patients who are both bariatric and neurosurgical View source Unclear responsibility and system for reconciling community and hospital medications View source Failure to record escalation of omitted critical medicines in the notes View source Limited nursing-team understanding of when to instigate the hospital passport system View source Incomplete clinical and nursing documentation View source Unclear governance of safe discharge decisions from the neurosurgical ward View source Lack of a clear escalation process for omitted critical medicines View source Failure to follow and understand the VTE policy for discharge risk reduction View source Failure to share key patient information between clinicians and the nursing team 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
Rhys Lennon Hill · 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
Rhys Lennon Hill underwent spinal surgery and was discharged from Royal Preston Hospital on 30 January 2023. He collapsed at home on 9 February 2023 and attempts to resuscitate him were unsuccessful; a post-mortem examination found that he died from a pulmonary embolus due to a deep vein thrombosis. The principal concerns included failure to escalate his refusal of Dalteparin or assess the associated risk, failure to provide required VTE information at discharge, and wider problems with communication, documentation, medication reconciliation, and discharge processes.
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 clarity on VTE prophylaxis for patients who are both bariatric and neurosurgical
Wider context from the report “8. The VTE policy of the trust is based on the NICE guidance. The inquest identified that there is a difference in approach on the use of prophylaxis for a surgical bariatric patient and a neuro surgical patient. Where there is a bariatric patient who is a neuro surgical patient there does not appear to be any clarity on how the challenges should be approached to reduce the risk of VTE as far as possible .
” 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 Unclear responsibility and system for reconciling community and hospital medications
Wider context from the report “5. The evidence was that the system and responsibility between the hospital pharmacy and clinicians for reconciling medications given in the community with those given in the hospital to ensure all necessary medications were given was unclear . As a consequence, Rhys did not receive his ADHD medication;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to record escalation of omitted critical medicines in the notes
Wider context from the report “4. Despite a critical medicine being not given to Rhys there appeared to be no clear policy on how that would be escalated to a senior nurse/ treating clinician and how that escalation would be captured in the notes ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Limited nursing-team understanding of when to instigate the hospital passport system
Wider context from the report “6. There appeared to be limited understanding amongst the nursing team of when a hospital “passport” system should be instigated for someone who was admitted with a “passport”;
” 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 Incomplete clinical and nursing documentation
Wider context from the report “2. Documentation (clinical and nursing) was incomplete and did not detail key/important information about Rhys. This included ward round notes containing limited information which meant it was difficult to know what matters had been considered as part of discharge planning and what information was known to the clinicians;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unclear governance of safe discharge decisions from the neurosurgical ward
Wider context from the report “7. The system for deciding when a discharge form the neuro surgical ward was safe was unclear . The evidence appeared to suggest that the Physiotherapy team took responsibility for it if they assessed mobility at a suitable level. It was unclear how that was overseen and fitted with the responsibility of the treating clinician ;
” 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 escalation process for omitted critical medicines
Wider context from the report “4. Despite a critical medicine being not given to Rhys there appeared to be no clear policy on how that would be escalated to a senior nurse/ treating clinician and how that escalation would be captured in the notes;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to follow and understand the VTE policy for discharge risk reduction
Wider context from the report “3. The VTE policy was not fully followed and there was evidence that there was limited understanding by staff of precisely what the trust policy required in relation to reducing the risk at discharge of VTE;
” 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 share key patient information between clinicians and the nursing team
Wider context from the report “1. The inquest heard evidence that communication between clinicians and the nursing team on the neurosurgical ward was not effective . The teams appeared to operate in silos and key information about patients did not appear to have been shared between the teams ;
” 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 Concerns about differing prophylaxis approaches should be referred to NICE, which produces the relevant clinical guidelines.
Verbatim wording from the response “Concern number eight in your report raises concerns that there is a difference in approach on the use of prophylaxis for a surgical bariatric patient and a neurosurgical patient. You raised the concern that where there is a bariatric patient who has also undergone neurosurgery there is a lack of clarity on how to reduce the chances of venous thromboembolism (VTE) occurring. As your Report notes, the National Institute for Health and Care Excellence (NICE) produce the relevant clinical guidelines [NG89] for reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism and the Quality Standard for Venous thromboembolism in adults [QS2011]. You may also therefore wish to refer your concerns to NICE.” 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 Lancashire Teaching Hospitals NHS Foundation Trust is the appropriate organisation to respond to concerns one to seven.
Verbatim wording from the response “This response focuses on the issues raised in your Report within the remit of NHS England national policy and programmes. Concern numbers one to seven in your Report fall under the remit of Lancashire Teaching Hospitals NHS Foundation Trust. I note that you have also addressed your Report to the Trust, who are the appropriate organisation to respond. NHS England has requested to be sighted on this and will carefully consider their response to the coroner. My regional Quality colleagues within the North West have been engaging with Lancashire and South Cumbria Integrated Care Board (ICB) to seek assurance for the local concerns raised.” Source location Response from NHS England
Open published response
Concerns raised 5 Inadequacy of the action plan for addressing ambulance response concerns View source Failure of ambulance transfer triage to prioritise urgent clinician-requested transfers View source Lack of clarity in the categorisation process for urgent inter-hospital transfers View source Inadequate means for delivering centralised exigent care through regional centres View source Unavailability of ambulances for timely urgent transfers and emergency call attendances 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
Dennis John William KING · 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
Dennis John William KING suffered a myocardial infarction after experiencing chest pain on 9 December 2022 and died on 13 December 2022 following recognised complications of emergency treatment. The report raised concerns about delays in ambulance responses and inter-hospital transfers, confusion over transfer categorisation, and the adequacy of arrangements for urgent care at regional specialist centres.
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 Inadequacy of the action plan for addressing ambulance response concerns
Wider context from the report “a. Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.
b. Confusion as between ambulance and hospital staff and a lack of clarity in the purpose of and process for the categorisation of transfers (particularly in urgent situations) between NHS hospitals.
c. The suitability of the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver such an approach are inadequate.
d. Adequacy of the action plan provided to the court in addressing the concern at (a) above and that of ambulance attendances to 999 and 111 calls; the plan is generalised, lacking detail and any means of measurement of progress.
Evidence received at Inquest identified waits for ambulance attendance of between 5-6 hours on the evening of 9th/10th December 2022. This, in circumstances where there call relating to Mr. KING had been categorised as a category 2 response. In Mr. KING’s case he was exhibiting symptoms of having suffered/was suffering a heart attack.
In Mr. KING’s case he had arrived at hospital been triaged, assessed and arrangements for urgent lifesaving care made by competent emergency clinicians in conjunction with experts from the regional cardiac unit. This included the requirement for an urgent transfer to the regional cardiac centre. A request for an emergency transfer from West Suffolk Hospital to The Royal Papworth Hospital was subject to further computer algorithm-based triage by the ambulance service. This resulted in a several hour delay to Mr. KING’s transfer, notwithstanding the protests from competent clinical staff in the Accident and Emergency Department at West Suffolk Hospital.
The circumstances of this case raise concerns about the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver the approach are inadequate.
East of England Ambulance Service provided evidence to the Inquest, including a Report concerning its response. This plan is generalised, lacking detail and any means of measurement of progress and is inadequate in addressing the concerns raised at the Inquest.
” 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 ambulance transfer triage to prioritise urgent clinician-requested transfers
Wider context from the report “a. Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.
b. Confusion as between ambulance and hospital staff and a lack of clarity in the purpose of and process for the categorisation of transfers (particularly in urgent situations) between NHS hospitals.
c. The suitability of the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver such an approach are inadequate.
d. Adequacy of the action plan provided to the court in addressing the concern at (a) above and that of ambulance attendances to 999 and 111 calls; the plan is generalised, lacking detail and any means of measurement of progress.
Evidence received at Inquest identified waits for ambulance attendance of between 5-6 hours on the evening of 9th/10th December 2022. This, in circumstances where there call relating to Mr. KING had been categorised as a category 2 response. In Mr. KING’s case he was exhibiting symptoms of having suffered/was suffering a heart attack.
In Mr. KING’s case he had arrived at hospital been triaged, assessed and arrangements for urgent lifesaving care made by competent emergency clinicians in conjunction with experts from the regional cardiac unit. This included the requirement for an urgent transfer to the regional cardiac centre. A request for an emergency transfer from West Suffolk Hospital to The Royal Papworth Hospital was subject to further computer algorithm-based triage by the ambulance service. This resulted in a several hour delay to Mr. KING’s transfer, notwithstanding the protests from competent clinical staff in the Accident and Emergency Department at West Suffolk Hospital.
The circumstances of this case raise concerns about the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver the approach are inadequate.
East of England Ambulance Service provided evidence to the Inquest, including a Report concerning its response. This plan is generalised, lacking detail and any means of measurement of progress and is inadequate in addressing the concerns raised at the Inquest.
” 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 clarity in the categorisation process for urgent inter-hospital transfers
Wider context from the report “a. Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.
b. Confusion as between ambulance and hospital staff and a lack of clarity in the purpose of and process for the categorisation of transfers (particularly in urgent situations) between NHS hospitals.
c. The suitability of the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver such an approach are inadequate.
d. Adequacy of the action plan provided to the court in addressing the concern at (a) above and that of ambulance attendances to 999 and 111 calls; the plan is generalised, lacking detail and any means of measurement of progress.
Evidence received at Inquest identified waits for ambulance attendance of between 5-6 hours on the evening of 9th/10th December 2022. This, in circumstances where there call relating to Mr. KING had been categorised as a category 2 response. In Mr. KING’s case he was exhibiting symptoms of having suffered/was suffering a heart attack.
In Mr. KING’s case he had arrived at hospital been triaged, assessed and arrangements for urgent lifesaving care made by competent emergency clinicians in conjunction with experts from the regional cardiac unit. This included the requirement for an urgent transfer to the regional cardiac centre. A request for an emergency transfer from West Suffolk Hospital to The Royal Papworth Hospital was subject to further computer algorithm-based triage by the ambulance service. This resulted in a several hour delay to Mr. KING’s transfer, notwithstanding the protests from competent clinical staff in the Accident and Emergency Department at West Suffolk Hospital.
The circumstances of this case raise concerns about the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver the approach are inadequate.
East of England Ambulance Service provided evidence to the Inquest, including a Report concerning its response. This plan is generalised, lacking detail and any means of measurement of progress and is inadequate in addressing the concerns raised at the Inquest.
” 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 means for delivering centralised exigent care through regional centres
Wider context from the report “a. Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.
b. Confusion as between ambulance and hospital staff and a lack of clarity in the purpose of and process for the categorisation of transfers (particularly in urgent situations) between NHS hospitals.
c. The suitability of the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver such an approach are inadequate.
d. Adequacy of the action plan provided to the court in addressing the concern at (a) above and that of ambulance attendances to 999 and 111 calls; the plan is generalised, lacking detail and any means of measurement of progress.
Evidence received at Inquest identified waits for ambulance attendance of between 5-6 hours on the evening of 9th/10th December 2022. This, in circumstances where there call relating to Mr. KING had been categorised as a category 2 response. In Mr. KING’s case he was exhibiting symptoms of having suffered/was suffering a heart attack.
In Mr. KING’s case he had arrived at hospital been triaged, assessed and arrangements for urgent lifesaving care made by competent emergency clinicians in conjunction with experts from the regional cardiac unit. This included the requirement for an urgent transfer to the regional cardiac centre. A request for an emergency transfer from West Suffolk Hospital to The Royal Papworth Hospital was subject to further computer algorithm-based triage by the ambulance service. This resulted in a several hour delay to Mr. KING’s transfer, notwithstanding the protests from competent clinical staff in the Accident and Emergency Department at West Suffolk Hospital.
The circumstances of this case raise concerns about the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver the approach are inadequate.
East of England Ambulance Service provided evidence to the Inquest, including a Report concerning its response. This plan is generalised, lacking detail and any means of measurement of progress and is inadequate in addressing the concerns raised at the Inquest.
” 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 ambulances for timely urgent transfers and emergency call attendances
Wider context from the report “a. Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.
b. Confusion as between ambulance and hospital staff and a lack of clarity in the purpose of and process for the categorisation of transfers (particularly in urgent situations) between NHS hospitals.
c. The suitability of the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver such an approach are inadequate.
d. Adequacy of the action plan provided to the court in addressing the concern at (a) above and that of ambulance attendances to 999 and 111 calls; the plan is generalised, lacking detail and any means of measurement of progress.
Evidence received at Inquest identified waits for ambulance attendance of between 5-6 hours on the evening of 9th/10th December 2022. This, in circumstances where there call relating to Mr. KING had been categorised as a category 2 response. In Mr. KING’s case he was exhibiting symptoms of having suffered/was suffering a heart attack.
In Mr. KING’s case he had arrived at hospital been triaged, assessed and arrangements for urgent lifesaving care made by competent emergency clinicians in conjunction with experts from the regional cardiac unit. This included the requirement for an urgent transfer to the regional cardiac centre. A request for an emergency transfer from West Suffolk Hospital to The Royal Papworth Hospital was subject to further computer algorithm-based triage by the ambulance service. This resulted in a several hour delay to Mr. KING’s transfer, notwithstanding the protests from competent clinical staff in the Accident and Emergency Department at West Suffolk Hospital.
The circumstances of this case raise concerns about the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver the approach are inadequate.
East of England Ambulance Service provided evidence to the Inquest, including a Report concerning its response. This plan is generalised, lacking detail and any means of measurement of progress and is inadequate in addressing the concerns raised at the Inquest.
” 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 Speed up hospital discharges to support ambulance availability and urgent care flow.
Verbatim wording from the response “The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care services, including improving ambulance response times (specifically for Category 2 patients), increasing ambulance capacity through growing the workforce, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.” Source location Response from NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain and update the national framework for inter-facility ambulance transfers.
Verbatim wording from the response “The National framework for inter-facility transfers was published by NHS England in July 2019 and updated in March 2021. The framework is intended for patients who require transfer by ambulance between facilities due to an increase in either their medical or nursing care need. The framework states that patients going directly to theatre for primary percutaneous coronary intervention should receive an IFT Level 2 (IFT2) Category 2 response and that the clinical staff responsible for the patient” Source location Response from NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase ambulance capacity by growing the workforce.
Verbatim wording from the response “The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care services, including improving ambulance response times (specifically for Category 2 patients), increasing ambulance capacity through growing the workforce, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.” Source location Response from NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve ambulance performance and response times across England.
Verbatim wording from the response “NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic, including transfers between NHS hospitals. Given that patient safety risks for both NHS hospital transfers and 999 patient calls from the community can be reduced by faster ambulance response times, NHS England have continued to focus on improving ambulance performance overall for 2023/24, supported by the Delivery Plan for Recovering Urgent and Emergency Care Services.” Source location Response from NHS Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commenting on EEAST’s action plan adequacy is outside the respondent’s remit.
Verbatim wording from the response “It is not within NHS England’s remit to comment on the adequacy of the action plan provided to the court by EEAST and we would refer you to the Trust on this issue. We understand that their action plan is under review and once updated will be sent to you.” Source location Response from NHS Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation EEAST is responsible for addressing the adequacy of its action plan and updating the court.
Verbatim wording from the response “It is not within NHS England’s remit to comment on the adequacy of the action plan provided to the court by EEAST and we would refer you to the Trust on this issue. We understand that their action plan is under review and once updated will be sent to you.” Source location Response from NHS Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Centralised PPCI care is clinically justified because specialist centres provide superior outcomes and continuous expert cover.
Verbatim wording from the response “The national PPCI Programme was established following the National Infarct Angioplasty Project, completed in 2008, which showed a reduction in hospital mortality (5.2% v 7.1%) and 18 month mortality (9.9% v 14.8%) for patients treated with PPCI as opposed to thrombolysis.¹ PPCI was judged to be superior to thrombolysis if the infarct artery could be opened within 150 minutes of the call for help which was applicable across 95% of the UK population.” Source location Response from NHS Trust
Open published response
12 Jan 2024 Iona Grace Buckingham · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 1 Unavailability of immediate paediatric chest ultrasound assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Iona Grace Buckingham · 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
Iona Grace Buckingham was admitted to Northampton General Hospital with bronchiolitis and later developed pneumonia, pleural effusion and worsening respiratory distress. She died on 4 December 2022 during an accidental extubation and cardiac arrest, despite attempts at resuscitation. The principal concern was that a very unwell child requiring a chest ultrasound may face a substantial delay because paediatric radiology services were not routinely available outside limited hours, potentially for up to 48 hours over a weekend.
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 Unavailability of immediate paediatric chest ultrasound assessment
Wider context from the report “The recommendation made by the investigation panel was that children with pneumonia who are not improving after forty-eight hours of treatment or deteriorate at a later point should get “an immediate x-ray and chest ultrasound”. However, the evidence I heard suggests this is not possible .
I heard from the Clinical Director that as a district general hospital, Northampton General Hospital does not have access to a paediatric radiologist outside of 9am-5pm on Mondays and Fridays when such a specialist is either on duty or on-call. I heard evidence that in Iona’s case, a Consultant in ITU and Anaesthesia was able to perform an ultrasound scan at around 2pm on 4th December 2022 however this is not a facility that would routinely be available to the Trust and was not, in any event, part of that clinician’s core duties.
I am concerned that a very unwell child who may require a chest ultrasound may not receive one ‘immediately’ and in fact may have to wait for a considerable period of time . For example, if the need arose over a weekend, that child may not receive an ultrasound scan for up to 48 hours .
” 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 Visit all 22 imaging networks during 2024 and review paediatric imaging and reporting provision.
Verbatim wording from the response “NHS England’s National Imaging Strategy, published in November 2019, set out a proposal to create collaborative imaging networks across England which is now in the process of being implemented. One of the stated purposes of imaging networks is to improve equity of access to specialist services which would include paediatric radiology. Collaboration between paediatric radiologists in different hospitals already exists, for example in the provision of reporting services for imaging studies conducted in cases of Suspected Physical Abuse. The GIRFT programme will be visiting all 22 imaging networks during the course of 2024 and the provision of paediatric imaging and reporting services will be on the list of topics to be reviewed.” 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 Trusts to increase radiology reporting capacity through additional reporting radiographers, radiologist trainees, international recruitment and workforce planning tools.
Verbatim wording from the response “There is a national shortage of radiologists of all specialisms. Sir Mike Richards’ independent report “Diagnostics recovery and renewal” published in October 2020 identified a need for 2000 additional consultant radiologists. Workforce data is collected by the Royal College of Radiologists (RCR) and published in an annual census report. The most recent report demonstrates a 29% shortfall in consultant radiologists across the UK. Regional analysis suggests that this shortfall is up to 35% in the East Midlands. This is not due to a lack of interested applicants but to a historic shortage of funded training places. NHS England are supporting Trusts to increase reporting capacity by increasing the number of reporting radiographers and radiologist” 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 Implement collaborative imaging networks across England to improve equitable access to specialist services, including paediatric radiology.
Verbatim wording from the response “NHS England’s National Imaging Strategy, published in November 2019, set out a proposal to create collaborative imaging networks across England which is now in the process of being implemented. One of the stated purposes of imaging networks is to improve equity of access to specialist services which would include paediatric radiology. Collaboration between paediatric radiologists in different hospitals already exists, for example in the provision of reporting services for imaging studies conducted in cases of Suspected Physical Abuse. The GIRFT programme will be visiting all 22 imaging networks during the course of 2024 and the provision of paediatric imaging and reporting services will be on the list of topics to be reviewed.” 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 Comprehensive 24/7 paediatric radiology cover is not currently possible at district hospitals because of the national radiologist workforce shortage.
Verbatim wording from the response “Against this backdrop, 24/7 provision of specialist paediatric radiology services is currently only available in specialist children’s hospitals and other tertiary centres. It is rare for a district hospital to have more than one or two radiologists with an interest in paediatric imaging and comprehensive cover is therefore not currently possible.” 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 Hospitals need not establish a formal thoracic-ultrasound rota; seeking timely assistance from a tertiary centre is considered sufficient.
Verbatim wording from the response “With reference to thoracic ultrasound in children for the purpose of identifying a pleural fluid collection such as empyema, this is a technique performed not only by specialist paediatric radiologists but also by some general radiologists, some advanced practice sonographers and by some paediatric intensivists with appropriate training. NHS England would not expect hospitals to have a formal rota for the provision of this service, but to be able to seek help from a tertiary centre on the occasions on which an ultrasound was needed and not available locally in a timely fashion.” Source location Response from NHS England
Open published response
Concerns raised 2 Failure to limit medication dispensing in line with overdose-risk controls View source Lack of accident and emergency staff access to medication records and dispensing rationale View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sarah Julie MITCHELL · 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
Sarah Julie MITCHELL, who had a history of chronic back pain, medication dependence, and previous overdoses, was found deceased at her residence on 22 September 2022. The post-mortem found multiple drug toxicity from prescribed medication. The principal concerns were that she received 28 days’ worth of medication in less than 48 hours despite known overdose and hoarding risks, and that emergency department staff had no process for accessing relevant medication records and dispensing 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 Failure to limit medication dispensing in line with overdose-risk controls
Wider context from the report “The provision to Ms. MITCHELL of 28 days’ worth of prescribed medication in less than a 48-hour period (14 days’ worth of medication dispensed on each occasion she was discharged hospital on the 3rd and 4th of August 2022). This occurred at a time when, due to concerns about Ms. MITCHELL hoarding medication and taking an overdose, she was receiving weekly medication prescriptions from her GP to control this risk .
The evidence heard at Inquest indicated that there was no process in place whereby accident and emergency staff could access Ms. MITCHELL’s medical records detailing the medication she was receiving and the rationale behind the dispensing regime in place.
” 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 accident and emergency staff access to medication records and dispensing rationale
Wider context from the report “The provision to Ms. MITCHELL of 28 days’ worth of prescribed medication in less than a 48-hour period (14 days’ worth of medication dispensed on each occasion she was discharged hospital on the 3rd and 4th of August 2022). This occurred at a time when, due to concerns about Ms. MITCHELL hoarding medication and taking an overdose, she was receiving weekly medication prescriptions from her GP to control this risk.
The evidence heard at Inquest indicated that there was no process in place whereby accident and emergency staff could access Ms. MITCHELL’s medical records detailing the medication she was receiving and the rationale behind the dispensing regime in place .
” 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 transferring users from the legacy Summary Care Record application to the National Care Records Service to improve access to national patient information.
Verbatim wording from the response “For background, it is worth mentioning that, in the past, the Summary Care Record application (SCRa) was the main method to access SCRs for the existing NHS user base. However, NHS England have been involved in a programme of work to transfer SCR users from the legacy SCRa service to the new National Care Records Service (NCRS) service. This work was accelerated during 2023 and is projected to conclude during Q2 2024. NCRS is the successor to SCRa and by design removes a large amount of the reported barriers to adoption within many care settings. The National Care Records Service (NCRS) provides a quick, secure way to access national patient information to improve clinical decision making and healthcare outcomes, it is free to use and includes additional features and services beyond the legacy SCRa product.” 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 Norfolk and Waveney Integrated Care Board is responsible for delivering local Shared Care Records relevant to local information sharing.
Verbatim wording from the response “Healthcare organisations use a combination of locally / regionally provided and nationally provided information sharing systems to support patient care. A contribution from the Shared Care Records programme would be helpful in this case to understand what information is provided in the area where the deceased received care through any local Shared Care Record or other local sharing agreements. You may wish to refer to Norfolk and Waveney Integrated Care Board (ICB) on this matter as ICBs are responsible for the delivery of Shared Care Records. This response focuses on nationally provided services.” 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 James Paget University Hospitals NHS Trust should provide information about the deceased’s care, including prescribing policies and the concerns raised.
Verbatim wording from the response “NHS England would refer you to James Paget University Hospitals NHS Trust for further information on Sarah’s care and your concerns, including their prescribing policies and we note that you have also addressed your Report to them. We understand that the Trust has contacted the coroner to clarify some of the issues referenced within your Report. We have been asked to be sighted on their response and will consider this carefully once we are in receipt.” Source location Response from NHS England
Open published response
Concerns raised 1 Lack of guidelines for anaesthetic and/or Intensive Care management of a flanged tracheostomy tube View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Bryan Moore · 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 Bryan Moore sustained burns to 32% of his body in an industrial electrical accident and later underwent tracheostomy surgery during treatment. His tracheostomy became dislodged while he was being turned, causing hypoxic cardiac arrest and a non-survivable hypoxic brain injury; he died after care was withdrawn. The substantive concern identified was the absence of guidelines for the anaesthetic and/or Intensive Care management of a flanged tracheostomy tube.
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 guidelines for anaesthetic and/or Intensive Care management of a flanged tracheostomy tube
Wider context from the report “1. Guidelines for the anaesthetic and/or Intensive Care management of a flanged tracheostomy tube
” 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 Commissioners and providers are responsible for developing and implementing local policies and guidance within their context.
Verbatim wording from the response “Commissioners and providers have a responsibility to ensure local policies and guidance are appropriately developed and implemented within their local context and regarding national guidance/guidelines. NHS England has engaged with Queen Victoria Hospital NHS Foundation Trust on the concerns from your Report and understand that a new local protocol they have developed has also been shared with the coroner.” 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 National resources and guidance already address the management and safety of flanged tracheostomy tubes.
Verbatim wording from the response “The National Tracheostomy Safety Project (NTSP) exists to provide a wide range of resources, materials and e-learning to support healthcare professionals with responsibility for providing care for patients with tracheostomies, for both general and emergency care. The website includes guidance on the different types and features of tracheostomy tubes, including flange tubes (NTSP Manual 2013 (tracheostomy.org.uk)), red flags for tracheostomy emergencies, which includes displacement, as well as day-to-day management and checks.” 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 Association of Anaesthetists and Royal College of Anaesthetists are better placed to respond on national guidance for flanged tracheostomy tubes.
Verbatim wording from the response “NHS England notes that you have also addressed your concerns to the Association of Anaesthetists Great Britain and Ireland and the Royal College of Anaesthetists. These organisations are better placed to respond to your concerns over national guidance for flanged tracheostomy tubes.” Source location Response from NHS England
Open published response
Concerns raised 3 Absence of redundancies or safeguards for early detection of missed communications View source Absence of effective arrangements for sharing important clinical information between private and public healthcare providers View source Failure to provide effective supervision of operators handling calls View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Meghan Irene CHRISMAS · 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
Meghan Irene CHRISMAS attempted suicide by hanging on 18 October 2021 and, after resuscitation, died two days later on 20 October 2021 from a hypoxic brain injury. The report raised concerns about the delayed handling and supervision of communications in the Hampshire Police Force Control Room and the absence of an adequate structure for sharing important clinical information between NHS and private healthcare providers.
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 Absence of redundancies or safeguards for early detection of missed communications
Wider context from the report “b. The handling of the incident involving Mrs. CHRISMAS in Hampshire Constabulary’s Force Control Room which resulted in a hour delay in determining that an important communication (being a request for assistance) had not been received by a neighbouring force. This raises concerns as to the effectiveness in the supervision of operators handling the calls and the presence of redundancies or safeguards to detect such circumstances sooner to avoid repetition .
” 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 Absence of effective arrangements for sharing important clinical information between private and public healthcare providers
Wider context from the report “a. Passage of information between NHS and private healthcare providers. At a time where pressures on the NHS exist, particularly for mental health services, it is of concern that measures which could alleviate this pressure (where someone sources private care) do not exist. There is little or no policy, guidance or other effective arrangements to share important clinical information about patients between private and public healthcare sectors.
” 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 effective supervision of operators handling calls
Wider context from the report “b. The handling of the incident involving Mrs. CHRISMAS in Hampshire Constabulary’s Force Control Room which resulted in a hour delay in determining that an important communication (being a request for assistance) had not been received by a neighbouring force. This raises concerns as to the effectiveness in the supervision of operators handling the calls and the presence of redundancies or safeguards to detect such circumstances sooner to avoid repetition.
” 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 Enhance patient-information sharing with commissioned VCSE and independent/private healthcare providers.
Verbatim wording from the response “NHS England is currently working to enhance the sharing of patient information to and from Voluntary, Charity and Social Enterprise (VCSE) and other independent/private sector providers who are commissioned by NHS organisations.” 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 Transfer Summary Care Record users from the legacy SCRa service to the National Care Records Service.
Verbatim wording from the response “It is worth mentioning that, in the past, the Summary Care Record application (SCRa) was the main method to access SCRs for the existing NHS user base and the private sector PoCs. However, NHS England have been involved in a programme of work to transfer SCR users from the legacy SCRa service to the new National Care Records Service (NCRS) service. This work has accelerated during 2023 and is projected to conclude during Q2 2024.” 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 proof-of-concept work to expand Summary Care Record access across private hospitals and independent healthcare services.
Verbatim wording from the response “The SCR Team at NHS England have done significant work with a number of private sector organisations, including a range of private hospitals and privately funded healthcare services as part of Proof of Concepts (PoCs), into settings where SCRs have previously been unavailable. e.g. private GP Services. This work will continue throughout 2024. Clearly, it is difficult to define precisely what is included within “private hospitals and privately funded healthcare services”. However, all “private hospitals and independent healthcare services” that have approached NHS England to date seeking access to SCR have either been onboarded into the existing proof of concepts or there have been discussions with the requesters regarding initial setup and their use for access to SCR.” 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 Report proof-of-concept learning to the Expert Advisory Committee, including benefits and potential unintended consequences.
Verbatim wording from the response “Learnings from these PoCs will be reported back to the Expert Advisory Committee to better understand any benefits realised but also any potential unintended consequences. The SCR Team will work with the Expert Advisory Committee to seek full rollout approval in this sector and consider the scope of this approval and any specific exclusions, constraints, or caveats.” 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 Expert Advisory Committee to seek approval for full private-sector rollout and consider its scope, exclusions, constraints, and caveats.
Verbatim wording from the response “Learnings from these PoCs will be reported back to the Expert Advisory Committee to better understand any benefits realised but also any potential unintended consequences. The SCR Team will work with the Expert Advisory Committee to seek full rollout approval in this sector and consider the scope of this approval and any specific exclusions, constraints, or caveats.” 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, developed according to 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 (ICB). Each ICB’s shared care records 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
Concerns raised 3 Failure to ensure Cardiology team awareness and access to the emergency GP telephone number View source Failure to complete referrals needed for UHCW Multi-Disciplinary Team discussion View source Failure of Medical Consultants and staff to access the UHCW switchboard View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrew Douglas Guillaume · 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
Andrew Douglas Guillaume was admitted to Warwick Hospital on 5 June 2023 with shortness of breath and a cough, and was later assessed as likely having severe aortic stenosis requiring urgent referral. He deteriorated, was admitted to the Cardiothoracic Critical Care unit at UHCW on 19 June 2023, and died on 20 June 2023; concerns included difficulties contacting the UHCW switchboard, lack of awareness of an emergency contact number, and the absence of a completed referral preventing discussion at a multi-disciplinary meeting.
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 ensure Cardiology team awareness and access to the emergency GP telephone number
Wider context from the report “(2) A previous incident in which a similar concern had been raised, had led to provision of an emergency GP phone number, that can be used by the clinical teams at SWFT, which is manned 24 hours a day and is prioritised over other calls. The Cardiology team had not been aware of this, nor did they have the telephone number .
” 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 complete referrals needed for UHCW Multi-Disciplinary Team discussion
Wider context from the report “(3) Mr Guillaume was not discussed at the Multi-Disciplinary Team meeting with UHCW on 9 June 2023 , as the referral had not been completed .
(4) Had the referral been completed, the team at UHCW could have prioritised the patient’s transfer.
” 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 Medical Consultants and staff to access the UHCW switchboard
Wider context from the report “(1) The inability of Medical Consultants and staff to get through to the switchboard at UHCW on two occasions .
” 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 The concerns predominantly fall within the relevant NHS trusts’ remit, including UHCW, so they should be addressed to those trusts.
Verbatim wording from the response “The matters of concern raised in your Report predominantly fall under the remit of the relevant Trusts, South Warwickshire University NHS Foundation Trust (SWFT) and University Hospitals Coventry and Warwickshire NHS Trust (UHCW). I note that you have addressed your Report to SWFT, but you may also wish to address your concerns to UHCW.” Source location Response from NHS England
Open published response
Concerns raised 8 Inaccessibility of primary care records to secondary mental health services View source Delays in considering SCARF information View source Failure to communicate relevant SCARF information to family View source Failure of the out-of-hours SCARF process to provide timely effective information transfer View source Failure to produce a clear holistic care and crisis contingency plan View source Lack of a unified record-keeping system for sharing patient information View source Breakdowns in communication between inpatient staff and the CMHT View source Failure to gather relevant collateral history while respecting patient confidentiality View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Barbara Ann WOODMAN · 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
Barbara Ann WOODMAN was found deceased at her residence on 31 March 2021 after police attended following concerns for her welfare. The post-mortem determined that she died from Paracetamol, Codeine and Amlodipine toxicity, having also consumed alcohol. Concerns included missed opportunities to obtain collateral information, the handling of a risk form, care planning and record-keeping, communication between inpatient and community teams, and information-sharing systems.
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 Inaccessibility of primary care records to secondary mental health services
Wider context from the report “ a. ████████ evidence is that on several occasions during Ms. Woodman’s inpatient admission to Spenser Ward he was in communication with her and of which treating clinicians were aware. On at least one of those occasions ████████ spoke with Spenser Ward staff. I noted that Ms. Woodman had not given consent for staff to contact ████████ concerning her treatment. Notwithstanding this, I found that there were missed opportunities to gather important collateral history from ████████; Ms. Woodman’s partner and who knew her well in the lead up to her admission.
It would seem that staff speaking with ████████ on these occasions failed to think laterally or innovatively as to how to collect important, relevant collateral history whilst still respecting Ms. Woodman’s wish that her condition not be discussed with ████████.
The ability of mental health clinicians to gain a complete picture of Ms. Woodman’s medical history was hampered by the fact that the information management systems holding these records at her GP practice was not accessible to secondary mental health services . This resulted in gaps in information available to mental health clinicians which was not necessarily filled by measures taken by secondary mental health services to gather collateral information from the family and Ms. Woodman herself.
” 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 Delays in considering SCARF information
Wider context from the report “b. The handling of the Single Combined Assessment of Risk Form (SCARF) within the Community Mental Health Team (CMHT) on 29th of March 2021. The SCARF was categorised Amber and had been received by SABP from the Police via Surrey County Council Adult Social Services. It concerned a patient on the CMHT’s books. Several witnesses gave evidence that best practice would involve the family of Ms. Woodman being contacted when the SCARF was received and considered. This did not occur. The failure to consider the SCARF in a more timely manner or refer the details to Ms. Woodman’s family is of concern; both in relation to timeliness of consideration and actions on receipt of the SCARF.
” 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 communicate relevant SCARF information to family
Wider context from the report “b. The handling of the Single Combined Assessment of Risk Form (SCARF) within the Community Mental Health Team (CMHT) on 29th of March 2021. The SCARF was categorised Amber and had been received by SABP from the Police via Surrey County Council Adult Social Services. It concerned a patient on the CMHT’s books. Several witnesses gave evidence that best practice would involve the family of Ms. Woodman being contacted when the SCARF was received and considered. This did not occur . The failure to consider the SCARF in a more timely manner or refer the details to Ms. Woodman’s family is of concern; both in relation to timeliness of consideration and actions on receipt of the SCARF.
” 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 the out-of-hours SCARF process to provide timely effective information transfer
Wider context from the report “d. Multiple witnesses observed that there is frequent tension between inpatient staff and the CMHT in the context of decisions relating to the discharge of inpatients. I note the explanations provided as to why such tension exists given the role of each team. However, in the context of Ms. Woodman’s care, these tensions led to gaps and breakdowns in communication between inpatient and CMHT with respect to diagnosis and formulation of both the care plan and CCMP.
There is a lack of a unified record keeping system which allows the effective sharing of patient information between different components of the NHS, including primary and secondary care providers. This results in circumstances where important, relevant information for the treatment of patients is not available to treating clinicians.
The use of the SCARF process during out of hours to provide timely and effective passage of information in relation to concerns for vulnerable persons in the community .
” 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 produce a clear holistic care and crisis contingency plan
Wider context from the report “c. The care planning and recording of care plans within Ms. Woodman’s notes raises a further area of concern. Questions exist as to the adequacy of the manner in which Ms. Woodman’s care plan was recorded. It required anyone wishing to understand the care plan for Ms. Woodman to consult her SystmOne medical record and read the detailed note recorded following the Discharge CPA meeting on the 25th of March 2021, extrapolating from this to deduce the broad care plan. There was, it would seem, no single document that drew together multiple inputs from either MDT meetings (where risk had been considered), or aspects of care and crisis contingency planning (such that this had been considered). The result was a failure to present a holistic view of how Ms. Woodman’s care and risk would be managed in the community . Although not causative of the death and I noted ████████’s very clear expert evidence that had a Crisis and Contingency Management Plan (CCMP) been in place it would have been unlikely to have averted the death, the failure to produce such a clear plan in accordance with Trust policies is a concern .
” 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 unified record-keeping system for sharing patient information
Wider context from the report “d. Multiple witnesses observed that there is frequent tension between inpatient staff and the CMHT in the context of decisions relating to the discharge of inpatients. I note the explanations provided as to why such tension exists given the role of each team. However, in the context of Ms. Woodman’s care, these tensions led to gaps and breakdowns in communication between inpatient and CMHT with respect to diagnosis and formulation of both the care plan and CCMP.
There is a lack of a unified record keeping system which allows the effective sharing of patient information between different components of the NHS , including primary and secondary care providers. This results in circumstances where important, relevant information for the treatment of patients is not available to treating clinicians .
The use of the SCARF process during out of hours to provide timely and effective passage of information in relation to concerns for vulnerable persons in the community.
” 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 Breakdowns in communication between inpatient staff and the CMHT
Wider context from the report “d. Multiple witnesses observed that there is frequent tension between inpatient staff and the CMHT in the context of decisions relating to the discharge of inpatients. I note the explanations provided as to why such tension exists given the role of each team. However, in the context of Ms. Woodman’s care, these tensions led to gaps and breakdowns in communication between inpatient and CMHT with respect to diagnosis and formulation of both the care plan and CCMP .
There is a lack of a unified record keeping system which allows the effective sharing of patient information between different components of the NHS, including primary and secondary care providers. This results in circumstances where important, relevant information for the treatment of patients is not available to treating clinicians.
The use of the SCARF process during out of hours to provide timely and effective passage of information in relation to concerns for vulnerable persons in the community.
” 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 gather relevant collateral history while respecting patient confidentiality
Wider context from the report “ a. ████████ evidence is that on several occasions during Ms. Woodman’s inpatient admission to Spenser Ward he was in communication with her and of which treating clinicians were aware. On at least one of those occasions ████████ spoke with Spenser Ward staff. I noted that Ms. Woodman had not given consent for staff to contact ████████ concerning her treatment. Notwithstanding this, I found that there were missed opportunities to gather important collateral history from ████████; Ms. Woodman’s partner and who knew her well in the lead up to her admission.
It would seem that staff speaking with ████████ on these occasions failed to think laterally or innovatively as to how to collect important, relevant collateral history whilst still respecting Ms. Woodman’s wish that her condition not be discussed with ████████ .
The ability of mental health clinicians to gain a complete picture of Ms. Woodman’s medical history was hampered by the fact that the information management systems holding these records at her GP practice was not accessible to secondary mental health services. This resulted in gaps in information available to mental health clinicians which was not necessarily filled by measures taken by secondary mental health services to gather collateral information from the family and Ms. Woodman herself.
” 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 Achieve national read-only interoperability between Shared Care Records across England.
Verbatim wording from the response “There is now a target to achieve national interoperability (read only) between all Shared Care Records in England by March 2025. This project will ensure that any authorised health and care professional can have safe, secure and ready access to the person-based information they need to deliver high quality individual (direct) 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 Responsibility for the out-of-hours SCARF process rests with Surrey Police, County Council and Surrey & Borders Partnership Trust.
Verbatim wording from the response “NHS England would refer you to Surrey Police, County Council and Surrey & Borders Partnership Trust (SABP) on your second concern relating to the use of the SCARF process during out of hours. NHS England has been sighted on and notes the response sent to the coroner by SABP and the County Council, detailing their mental health crisis support services.” Source location Response from NHS England
Open published response
21 Dec 2023 Carrianne Franks · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Failure of clinical and public health guidelines to identify healthcare professionals as a group at heightened risk of TB exposure View source Overly restrictive definition of close contact for notifying NHS staff of TB exposure risk View source Failure to broaden warn-and-inform parameters for highly transmissible TB cases and all staff exposed on the unit View source Exclusion of agency workers and seconded nurses from occupational-health contact tracing or warn-and-inform letters View source Insufficient education of NHS staff about TB symptoms and disclosure of possible exposure to assessing clinicians 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
Carrianne Franks · 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
Carrianne Franks, a Royal Air Force nurse working on placement at an NHS hospital, was exposed to smear-positive tuberculosis in November 2020 and died from tuberculosis on 27 August 2021. She was not classed as a close contact and was not informed of the exposure, which delayed diagnosis and treatment. The principal concerns were that healthcare professionals may not be recognised as a heightened-risk group, contact-tracing thresholds may be too restrictive, and staff education and notification arrangements may be insufficient, particularly for agency and seconded workers.
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 clinical and public health guidelines to identify healthcare professionals as a group at heightened risk of TB exposure
Wider context from the report “1. I am concerned that the current clinical and public health guidelines do not identify Healthcare professionals as a group at heightened risk of TB exposure .
2. I am concerned that the current definition of ‘close contact’, thus triggering a contact trace or warn and inform letter, sets the bar too high for notifying NHS staff of the risk of exposure to TB.
3. I am concerned that there are insufficient education measures in place to inform NHS staff of the TB symptoms to looks out for, and the need to inform any assessing clinician of their possible exposure to the condition in order to facilitate early diagnostic testing.
Carrianne was exposed to a very aggressive form of TB from what seemed to be a rather transient exposure to the index patient during her occupation as a Nurse. Of course, not each and every contact with a patient will be logged within the medical records, especially in relation to an ambulatory patient such as the index patient in this case, and so it is possible that Carrianne had greater exposure to the patient while on the ward than interrogation of the medical records would suggest. But at its height, she had only been at work on the unit at the same time as the index patient over 23 and 24 November.
The index patient was cared for in a side room with infection prevention measures in place but Carrianne may well have been unaware that the infectious disease in question was TB as she was not the “named nurse” for this patient and lots of patients had increased infection prevention measures in place during the pandemic. Indeed, Carrianne had denied any known TB exposure when asked by doctors during her respiratory illness.
Carrianne’s case highlights the increased transmissibility of smear positive TB in the context of limited exposure to the index patient. I heard evidence from an expert who told me of cases of medical professionals contracting the condition despite no known direct contact with the patient but having spent time in a corridor containing an air vent leading from the infected patient’s room.
The warn and inform parameters did not alter (as in broaden) to reflect the fact that the index case was smear positive and highly transmissible, and the patient was known to be ambulatory on the ward. I cannot see a good reason for restricting the warn and inform letter process, rather than applying the same broadly to all staff who worked on the unit at the relevant time.
Carrianne’s case highlights the importance of warning all staff of TB cases on their wards, so that if they do become symptomatic in the coming months, and it may be many months later, they will be equipped with the necessary information to share with their treating clinicians.
I heard evidence that the NHS hospital’s Occupational Health team will issue contact tracing or warn and inform letters to staff, but this may not include Agency workers, and, in this case, Nurses seconded from the RAF. This is a missed opportunity to ensure that the relevant OH team or GP is aware of the potential exposure to add to the clinical picture should the patient develop atypical respiratory symptoms.
I understand that your agency has input into the UK’s TB Action Plan, and I hope that the above concerns can be considered in your drive to reduce the incidence of TB nationally, but also specifically with regard to healthcare professionals to ensure they are given the greatest possible protection from TB related harm and death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Overly restrictive definition of close contact for notifying NHS staff of TB exposure risk
Wider context from the report “1. I am concerned that the current clinical and public health guidelines do not identify Healthcare professionals as a group at heightened risk of TB exposure.
2. I am concerned that the current definition of ‘close contact’, thus triggering a contact trace or warn and inform letter, sets the bar too high for notifying NHS staff of the risk of exposure to TB .
3. I am concerned that there are insufficient education measures in place to inform NHS staff of the TB symptoms to looks out for, and the need to inform any assessing clinician of their possible exposure to the condition in order to facilitate early diagnostic testing.
Carrianne was exposed to a very aggressive form of TB from what seemed to be a rather transient exposure to the index patient during her occupation as a Nurse. Of course, not each and every contact with a patient will be logged within the medical records, especially in relation to an ambulatory patient such as the index patient in this case, and so it is possible that Carrianne had greater exposure to the patient while on the ward than interrogation of the medical records would suggest. But at its height, she had only been at work on the unit at the same time as the index patient over 23 and 24 November.
The index patient was cared for in a side room with infection prevention measures in place but Carrianne may well have been unaware that the infectious disease in question was TB as she was not the “named nurse” for this patient and lots of patients had increased infection prevention measures in place during the pandemic. Indeed, Carrianne had denied any known TB exposure when asked by doctors during her respiratory illness.
Carrianne’s case highlights the increased transmissibility of smear positive TB in the context of limited exposure to the index patient. I heard evidence from an expert who told me of cases of medical professionals contracting the condition despite no known direct contact with the patient but having spent time in a corridor containing an air vent leading from the infected patient’s room.
The warn and inform parameters did not alter (as in broaden) to reflect the fact that the index case was smear positive and highly transmissible, and the patient was known to be ambulatory on the ward. I cannot see a good reason for restricting the warn and inform letter process, rather than applying the same broadly to all staff who worked on the unit at the relevant time.
Carrianne’s case highlights the importance of warning all staff of TB cases on their wards, so that if they do become symptomatic in the coming months, and it may be many months later, they will be equipped with the necessary information to share with their treating clinicians.
I heard evidence that the NHS hospital’s Occupational Health team will issue contact tracing or warn and inform letters to staff, but this may not include Agency workers, and, in this case, Nurses seconded from the RAF. This is a missed opportunity to ensure that the relevant OH team or GP is aware of the potential exposure to add to the clinical picture should the patient develop atypical respiratory symptoms.
I understand that your agency has input into the UK’s TB Action Plan, and I hope that the above concerns can be considered in your drive to reduce the incidence of TB nationally, but also specifically with regard to healthcare professionals to ensure they are given the greatest possible protection from TB related harm and death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to broaden warn-and-inform parameters for highly transmissible TB cases and all staff exposed on the unit
Wider context from the report “1. I am concerned that the current clinical and public health guidelines do not identify Healthcare professionals as a group at heightened risk of TB exposure.
2. I am concerned that the current definition of ‘close contact’, thus triggering a contact trace or warn and inform letter, sets the bar too high for notifying NHS staff of the risk of exposure to TB.
3. I am concerned that there are insufficient education measures in place to inform NHS staff of the TB symptoms to looks out for, and the need to inform any assessing clinician of their possible exposure to the condition in order to facilitate early diagnostic testing.
Carrianne was exposed to a very aggressive form of TB from what seemed to be a rather transient exposure to the index patient during her occupation as a Nurse. Of course, not each and every contact with a patient will be logged within the medical records, especially in relation to an ambulatory patient such as the index patient in this case, and so it is possible that Carrianne had greater exposure to the patient while on the ward than interrogation of the medical records would suggest. But at its height, she had only been at work on the unit at the same time as the index patient over 23 and 24 November.
The index patient was cared for in a side room with infection prevention measures in place but Carrianne may well have been unaware that the infectious disease in question was TB as she was not the “named nurse” for this patient and lots of patients had increased infection prevention measures in place during the pandemic. Indeed, Carrianne had denied any known TB exposure when asked by doctors during her respiratory illness.
Carrianne’s case highlights the increased transmissibility of smear positive TB in the context of limited exposure to the index patient. I heard evidence from an expert who told me of cases of medical professionals contracting the condition despite no known direct contact with the patient but having spent time in a corridor containing an air vent leading from the infected patient’s room.
The warn and inform parameters did not alter (as in broaden) to reflect the fact that the index case was smear positive and highly transmissible, and the patient was known to be ambulatory on the ward. I cannot see a good reason for restricting the warn and inform letter process , rather than applying the same broadly to all staff who worked on the unit at the relevant time .
Carrianne’s case highlights the importance of warning all staff of TB cases on their wards, so that if they do become symptomatic in the coming months, and it may be many months later, they will be equipped with the necessary information to share with their treating clinicians.
I heard evidence that the NHS hospital’s Occupational Health team will issue contact tracing or warn and inform letters to staff, but this may not include Agency workers, and, in this case, Nurses seconded from the RAF. This is a missed opportunity to ensure that the relevant OH team or GP is aware of the potential exposure to add to the clinical picture should the patient develop atypical respiratory symptoms.
I understand that your agency has input into the UK’s TB Action Plan, and I hope that the above concerns can be considered in your drive to reduce the incidence of TB nationally, but also specifically with regard to healthcare professionals to ensure they are given the greatest possible protection from TB related harm and death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Exclusion of agency workers and seconded nurses from occupational-health contact tracing or warn-and-inform letters
Wider context from the report “1. I am concerned that the current clinical and public health guidelines do not identify Healthcare professionals as a group at heightened risk of TB exposure.
2. I am concerned that the current definition of ‘close contact’, thus triggering a contact trace or warn and inform letter, sets the bar too high for notifying NHS staff of the risk of exposure to TB.
3. I am concerned that there are insufficient education measures in place to inform NHS staff of the TB symptoms to looks out for, and the need to inform any assessing clinician of their possible exposure to the condition in order to facilitate early diagnostic testing.
Carrianne was exposed to a very aggressive form of TB from what seemed to be a rather transient exposure to the index patient during her occupation as a Nurse. Of course, not each and every contact with a patient will be logged within the medical records, especially in relation to an ambulatory patient such as the index patient in this case, and so it is possible that Carrianne had greater exposure to the patient while on the ward than interrogation of the medical records would suggest. But at its height, she had only been at work on the unit at the same time as the index patient over 23 and 24 November.
The index patient was cared for in a side room with infection prevention measures in place but Carrianne may well have been unaware that the infectious disease in question was TB as she was not the “named nurse” for this patient and lots of patients had increased infection prevention measures in place during the pandemic. Indeed, Carrianne had denied any known TB exposure when asked by doctors during her respiratory illness.
Carrianne’s case highlights the increased transmissibility of smear positive TB in the context of limited exposure to the index patient. I heard evidence from an expert who told me of cases of medical professionals contracting the condition despite no known direct contact with the patient but having spent time in a corridor containing an air vent leading from the infected patient’s room.
The warn and inform parameters did not alter (as in broaden) to reflect the fact that the index case was smear positive and highly transmissible, and the patient was known to be ambulatory on the ward. I cannot see a good reason for restricting the warn and inform letter process, rather than applying the same broadly to all staff who worked on the unit at the relevant time.
Carrianne’s case highlights the importance of warning all staff of TB cases on their wards, so that if they do become symptomatic in the coming months, and it may be many months later, they will be equipped with the necessary information to share with their treating clinicians.
I heard evidence that the NHS hospital’s Occupational Health team will issue contact tracing or warn and inform letters to staff, but this may not include Agency workers, and, in this case, Nurses seconded from the RAF . This is a missed opportunity to ensure that the relevant OH team or GP is aware of the potential exposure to add to the clinical picture should the patient develop atypical respiratory symptoms.
I understand that your agency has input into the UK’s TB Action Plan, and I hope that the above concerns can be considered in your drive to reduce the incidence of TB nationally, but also specifically with regard to healthcare professionals to ensure they are given the greatest possible protection from TB related harm and death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient education of NHS staff about TB symptoms and disclosure of possible exposure to assessing clinicians
Wider context from the report “1. I am concerned that the current clinical and public health guidelines do not identify Healthcare professionals as a group at heightened risk of TB exposure.
2. I am concerned that the current definition of ‘close contact’, thus triggering a contact trace or warn and inform letter, sets the bar too high for notifying NHS staff of the risk of exposure to TB.
3. I am concerned that there are insufficient education measures in place to inform NHS staff of the TB symptoms to looks out for, and the need to inform any assessing clinician of their possible exposure to the condition in order to facilitate early diagnostic testing .
Carrianne was exposed to a very aggressive form of TB from what seemed to be a rather transient exposure to the index patient during her occupation as a Nurse. Of course, not each and every contact with a patient will be logged within the medical records, especially in relation to an ambulatory patient such as the index patient in this case, and so it is possible that Carrianne had greater exposure to the patient while on the ward than interrogation of the medical records would suggest. But at its height, she had only been at work on the unit at the same time as the index patient over 23 and 24 November.
The index patient was cared for in a side room with infection prevention measures in place but Carrianne may well have been unaware that the infectious disease in question was TB as she was not the “named nurse” for this patient and lots of patients had increased infection prevention measures in place during the pandemic. Indeed, Carrianne had denied any known TB exposure when asked by doctors during her respiratory illness.
Carrianne’s case highlights the increased transmissibility of smear positive TB in the context of limited exposure to the index patient. I heard evidence from an expert who told me of cases of medical professionals contracting the condition despite no known direct contact with the patient but having spent time in a corridor containing an air vent leading from the infected patient’s room.
The warn and inform parameters did not alter (as in broaden) to reflect the fact that the index case was smear positive and highly transmissible, and the patient was known to be ambulatory on the ward. I cannot see a good reason for restricting the warn and inform letter process, rather than applying the same broadly to all staff who worked on the unit at the relevant time.
Carrianne’s case highlights the importance of warning all staff of TB cases on their wards, so that if they do become symptomatic in the coming months, and it may be many months later, they will be equipped with the necessary information to share with their treating clinicians.
I heard evidence that the NHS hospital’s Occupational Health team will issue contact tracing or warn and inform letters to staff, but this may not include Agency workers, and, in this case, Nurses seconded from the RAF. This is a missed opportunity to ensure that the relevant OH team or GP is aware of the potential exposure to add to the clinical picture should the patient develop atypical respiratory symptoms.
I understand that your agency has input into the UK’s TB Action Plan, and I hope that the above concerns can be considered in your drive to reduce the incidence of TB nationally, but also specifically with regard to healthcare professionals to ensure they are given the greatest possible protection from TB related harm and death.
” 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 TB awareness and education by publishing posters, leaflets, cards, animation videos and an electronic TB e-learning resource for healthcare professionals.
Verbatim wording from the response “World TB Day is an annual event held on the 24 March. This date is used to raise awareness of TB with many TB services holding education sessions and running stalls in their hospital and/or public areas. Information is provided by UKHSA for use by local 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 Develop and implement national contact-tracing guidance or toolkits, including evidence-based occupational-health TB screening guidance.
Verbatim wording from the response “• Development and implementation of national contact tracing guidance and /or toolkits for HPTs, TB services and occupational health services including national, evidence-based guidance on occupational health screening for TB.” 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 Issue a TB service specification covering service communication with Occupational Health departments and evidence-based contact tracing.
Verbatim wording from the response “NHS England has also issued a TB service specification. It is not mandatory, so ICBs and Trusts can use it to reflect local commissioning and service delivery arrangements. The document references informing all appropriate services including Occupational Health departments re the transfer and discharge of patients. This specification includes a section on evidence-based contact tracing.” 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 NICE to update contact-tracing guidance, strengthening prevention, detection and treatment for higher-risk groups including healthcare workers.
Verbatim wording from the response “Clinical guidelines are provided by the National Institute for Health and Care Excellence (NICE). Their guidelines on TB can be found here: Recommendations | Tuberculosis | Guidance | NICE) and NHS bodies are under the same duties to have regard to the guidance, as they are with other NICE guidance. The NICE guidance, which was last updated in 2019, defines ‘close contact’. Healthcare staff are not specifically referred to in the section on contact tracing in healthcare settings. Any change to the guidance sits with NICE, however the action plan referenced above includes an action and deliverable to work with NICE on updates to their guidance. UKHSA have approached NICE regarding updating the guidance and are meeting with them shortly.” 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 Available evidence does not establish that UK healthcare workers face increased occupational TB risk compared with other workers.
Verbatim wording from the response “In 2016, Public Health England (the predecessor organisation of UKHSA) published a detailed analysis on TB in healthcare workers. This reported that there was ‘no increased risk of TB in healthcare workers compared with non-healthcare workers after stratifying by country of birth for all but two countries of birth, combined with the very small number of cases with a molecular and epidemiological link consistent with nosocomial transmission, suggests that TB diagnosed in healthcare workers in the UK is generally not acquired as a result of UK occupational exposure’. It also highlighted that only 10 nosocomial (in healthcare) acquired cases of TB occurred in healthcare workers between 2010 and 2012 – approximately three cases per year in over one million healthcare workers.” 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 NICE is responsible for changing the clinical TB guidance, although UKHSA and NHS England can work with NICE on updates.
Verbatim wording from the response “Clinical guidelines are provided by the National Institute for Health and Care Excellence (NICE). Their guidelines on TB can be found here: Recommendations | Tuberculosis | Guidance | NICE) and NHS bodies are under the same duties to have regard to the guidance, as they are with other NICE guidance. The NICE guidance, which was last updated in 2019, defines ‘close contact’. Healthcare staff are not specifically referred to in the section on contact tracing in healthcare settings. Any change to the guidance sits with NICE, however the action plan referenced above includes an action and deliverable to work with NICE on updates to their guidance. UKHSA have approached NICE regarding updating the guidance and are meeting with them shortly.” Source location Response from NHS England
Open published response
20 Dec 2023 James CAMPION · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 3 Insufficient ambulance service capacity during periods of high demand View source Delays in ambulance dispatch View source Delays in triaging emergency calls involving threats of overdose 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
James CAMPION · 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
James Campion, aged 57, died after consuming mirtazapine and alcohol following contact with the Psychiatric Crisis Team about taking an overdose. An ambulance was not allocated until six hours after the initial call, and he was found deceased at home when the crew arrived. The principal concerns were delays in mental health assessment, call triage and ambulance dispatch, alongside inadequate family contact information and limited family involvement.
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 ambulance service capacity during periods of high demand
Wider context from the report “The delay in triaging the call made by Mr Campion threatening to take an overdose resulted in him taking the overdose. The delay in the ambulance dispatch prevented Mr Campion receiving medical treatment and further psychiatric assistance. The outcome for Mr Campion has been adversely impacted due to the demand on the ambulance service . At the time of the 999 call on 21st July 2022 NWAS were operating at Level 4 of the Plan (PSP) experiencing high demand, acute pressures and high numbers of waiting calls. The options for the emergency services were extremely limited and an ambulance was deployed at the earliest opportunity. Consideration be given to how to support the Ambulance and Mental Health Services in fulfilling the NHS long-term plan for Mental Health, in particular Mental Health Practitioners in Ambulance control rooms.
” 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 Delays in ambulance dispatch
Wider context from the report “The delay in triaging the call made by Mr Campion threatening to take an overdose resulted in him taking the overdose. The delay in the ambulance dispatch prevented Mr Campion receiving medical treatment and further psychiatric assistance. The outcome for Mr Campion has been adversely impacted due to the demand on the ambulance service . At the time of the 999 call on 21st July 2022 NWAS were operating at Level 4 of the Plan (PSP) experiencing high demand, acute pressures and high numbers of waiting calls. The options for the emergency services were extremely limited and an ambulance was deployed at the earliest opportunity. Consideration be given to how to support the Ambulance and Mental Health Services in fulfilling the NHS long-term plan for Mental Health, in particular Mental Health Practitioners in Ambulance control rooms.
” 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 Delays in triaging emergency calls involving threats of overdose
Wider context from the report “The delay in triaging the call made by Mr Campion threatening to take an overdose resulted in him taking the overdose. The delay in the ambulance dispatch prevented Mr Campion receiving medical treatment and further psychiatric assistance. The outcome for Mr Campion has been adversely impacted due to the demand on the ambulance service . At the time of the 999 call on 21st July 2022 NWAS were operating at Level 4 of the Plan (PSP) experiencing high demand, acute pressures and high numbers of waiting calls. The options for the emergency services were extremely limited and an ambulance was deployed at the earliest opportunity. Consideration be given to how to support the Ambulance and Mental Health Services in fulfilling the NHS long-term plan for Mental Health, in particular Mental Health Practitioners in Ambulance control rooms.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations