Concerns raised 14 Lack of a written procedure for making a 999 emergency call View source Lack of a national system for managing and sharing Health and Safety information across company sites View source Lack of guidance for urgent referral of children to hospital or tertiary care View source Lack of a written procedure for obtaining first aid help quickly View source Failure to provide adequately for visitors' first aid needs across sites View source Insufficient availability of AEDs in key site areas View source Lack of national guidance for consistent referral of children for tonsillectomy and similar treatment View source Failure to provide direct ENT referral or follow-up assessment after a child chokes View source Insufficiently robust incident investigation and reporting system View source Delays in reassessment and referral of urgent cases due to inadequate cover View source Inadequate systems for reviewing local information sharing View source Unavailability of an external phone line for emergencies View source Failure to communicate specialist referral priorities to local hospitals View source Absence of choking-related red flags in tonsillectomy guidance View source See 11 more concerns
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 Joseph MANNING · 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 Joseph Manning, aged two, choked on a piece of sausage at Butlins, Bognor Regis, on 6 June 2018, suffered a cardiac arrest and hypoxic ischaemic brain injury, and died in hospital on 20 June 2018. The concerns included delays and weaknesses in healthcare referral, follow-up and information-sharing systems, and shortcomings in the management of health and safety, incident reporting, first-aid provision and emergency procedures at Bourne Leisure sites.
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 written procedure for making a 999 emergency call
Wider context from the report “e) Witnesses confirmed that there was no written standard operating procedure setting out how staff can get first aid help quickly as well as when and how to make a 999-emergency call especially if a trained first aider is not immediately available.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a national system for managing and sharing Health and Safety information across company sites
Wider context from the report “a) From speaking to a number of witnesses in this case, I was deeply concerned that there was no national system for managing Health & Safety issues across company sites . Staff agreed it would help to share information and learning on a reciprocal basis across all sites .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for urgent referral of children to hospital or tertiary care
Wider context from the report “a) I heard expert evidence that GPs and general hospital doctors would benefit from national guidance to ensure that greater consistency is achieved when referring children for tonsillectomy and similar treatment. In addition, both GP and hospital doctors gave evidence that raised a concern regarding:
i. whether additional guidance may be appropriate to help doctors decide which cases need an urgent referral to hospital or tertiary care ; and
ii. a system of red flags – for example including choking in the ENT UK Commissioning Guide for Tonsillectomy (2016). Experts and witnesses confirmed that choking is not mentioned in the current Guide.
” 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 written procedure for obtaining first aid help quickly
Wider context from the report “e) Witnesses confirmed that there was no written standard operating procedure setting out how staff can get first aid help quickly as well as when and how to make a 999-emergency call especially if a trained first aider is not immediately available .
” 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 adequately for visitors' first aid needs across sites
Wider context from the report “c) I am concerned that the Health & Safety Executive’s strong recommendation in the First Aid Regulations to consider the first aid of visitors and what will be offered in terms of provision across each site was not sufficiently reflected in company practices .
” 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 availability of AEDs in key site areas
Wider context from the report “d) I was concerned to hear evidence that many months after this tragic incident during Tots Week, installation of an external phone line and sufficient AEDs in key areas such as restaurants and swimming pool areas had not been completed .
” 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 national guidance for consistent referral of children for tonsillectomy and similar treatment
Wider context from the report “a) I heard expert evidence that GPs and general hospital doctors would benefit from national guidance to ensure that greater consistency is achieved when referring children for tonsillectomy and similar treatment . In addition, both GP and hospital doctors gave evidence that raised a concern regarding:
i. whether additional guidance may be appropriate to help doctors decide which cases need an urgent referral to hospital or tertiary care; and
ii. a system of red flags – for example including choking in the ENT UK Commissioning Guide for Tonsillectomy (2016). Experts and witnesses confirmed that choking is not mentioned in the current Guide.
” 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 direct ENT referral or follow-up assessment after a child chokes
Wider context from the report “b) I also heard evidence from experts that when a child chokes as James did in May 2017, the risk of a life-threatening event is high. I was concerned to hear that A&E paediatricians could either refer directly to ENT specialists or arrange a follow-up visit to assess the likelihood of a repeat choking episode but in this case the child’s mother was referred back to the GP .
” 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 Insufficiently robust incident investigation and reporting system
Wider context from the report “b) After hearing extensive evidence, I was deeply concerned about whether there was a sufficiently robust incident investigation and reporting system in place so that lessons could be learned then shared with 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 Delays in reassessment and referral of urgent cases due to inadequate cover
Wider context from the report “c) I heard evidence that at some points in James’s medical care there were delays in being reassessed especially following the sleep study . The delay in being reassessed and referred to tertiary care was contributed to by medical staff being off leave. Doctors will inevitably have leave yet I am still concerned that systems in place at that time were not sufficiently robust to ensure suitable cover was in place to progress urgent cases .
” 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 systems for reviewing local information sharing
Wider context from the report “f) At several points during the inquest, questions were asked of medical witnesses about how best practice is shared between local NHS Trusts and GP surgeries. I am concerned that systems to review how information is shared locally may need to be reconsidered .
” 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 an external phone line for emergencies
Wider context from the report “d) I was concerned to hear evidence that many months after this tragic incident during Tots Week, installation of an external phone line and sufficient AEDs in key areas such as restaurants and swimming pool areas had not been completed .
” 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 specialist referral priorities to local hospitals
Wider context from the report “d) I also heard evidence to suggest that locally devised priorities agreed in specialist or tertiary centres (in this case the Royal Sussex County Hospital, Brighton) had not been communicated to local hospitals and shared so that doctors making a referral can consider the best place to refer a case taking into consideration relative waiting times .
” 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 choking-related red flags in tonsillectomy guidance
Wider context from the report “a) I heard expert evidence that GPs and general hospital doctors would benefit from national guidance to ensure that greater consistency is achieved when referring children for tonsillectomy and similar treatment. In addition, both GP and hospital doctors gave evidence that raised a concern regarding:
i. whether additional guidance may be appropriate to help doctors decide which cases need an urgent referral to hospital or tertiary care; and
ii. a system of red flags – for example including choking in the ENT UK Commissioning Guide for Tonsillectomy (2016). Experts and witnesses confirmed that choking is not mentioned in the current Guide .
” Open source report
9 Jun 2022 Shirley Alice Moloney · Prevention of Future Deaths report East London
View report summary
Concerns raised 10 Lack of establishments suitably designed for dual physical and mental health needs View source Failure to identify mental health concerns towards the end of life View source Insufficient resourcing of older age psychiatric teams View source Failure to provide community mental health services to older patients View source Absence of adequately trained staff to address mental health in residential home settings View source Lack of easy access to older age psychiatry teams for care homes and nursing homes View source Lack of older adult psychiatry resource for elderly patients View source Poorly defined access to care and support for psychological distress towards the end of life View source Insufficient availability of mental health nurses in care homes and nursing homes View source Delays in re-accessing older age community psychiatry teams after discharge View source See 7 more concerns
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
Shirley Alice Moloney · 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
Shirley Alice Moloney, who had longstanding paranoid schizophrenia and severe frailty, was found unresponsive at her care home on 10 December 2020 after suffering three vomits the previous day. The report states that it was likely she died from aspiration pneumonia and that the death was from natural causes. Concerns included the deterioration of her mental health and the lack of community mental health team care in the last nine months of her life, alongside wider concerns about access to older adult psychiatry for care-home residents.
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 establishments suitably designed for dual physical and mental health needs
Wider context from the report “(ii) The inquest heard that older age psychiatric teams are very poorly resourced, nationally. This is compounded by an absence of adequately trained staff, to address mental health in residential home settings. The inquest also heard that there is a lack of establishments suitably designed for dual physical/mental health needs .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to identify mental health concerns towards the end of life
Wider context from the report “(iv) The inquest heard that mental health concerns can often be overlooked towards the end of life . Structures for accessing care for physical symptoms towards the end of life are well developed. Accessing care and support for psychological distress is not so well defined. Care homes and nursing homes tend to have mainly general nurses, as opposed to mental health nurses. They also have easy access to GPs and geriatricians. There is a perceived lack of easy access to older age psychiatry teams, by care homes and nursing homes.
” 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 resourcing of older age psychiatric teams
Wider context from the report “(ii) The inquest heard that older age psychiatric teams are very poorly resourced, nationally . This is compounded by an absence of adequately trained staff, to address mental health in residential home settings. The inquest also heard that there is a lack of establishments suitably designed for dual physical/mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide community mental health services to older patients
Wider context from the report “(i) Mrs Moloney suffered from paranoid schizophrenia. There was evidence of her mental state deteriorating in the months leading up to her death. Her mental health deterioration is likely to have impacted upon her physical health deterioration, but she was not under the care of community mental health services in the last nine months of her 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 Absence of adequately trained staff to address mental health in residential home settings
Wider context from the report “(ii) The inquest heard that older age psychiatric teams are very poorly resourced, nationally. This is compounded by an absence of adequately trained staff, to address mental health in residential home settings . The inquest also heard that there is a lack of establishments suitably designed for dual physical/mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of easy access to older age psychiatry teams for care homes and nursing homes
Wider context from the report “(iv) The inquest heard that mental health concerns can often be overlooked towards the end of life. Structures for accessing care for physical symptoms towards the end of life are well developed. Accessing care and support for psychological distress is not so well defined. Care homes and nursing homes tend to have mainly general nurses, as opposed to mental health nurses. They also have easy access to GPs and geriatricians. There is a perceived lack of easy access to older age psychiatry teams, by care homes and nursing homes .
” 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 older adult psychiatry resource for elderly patients
Wider context from the report “(v) As mental health and physical health are so closely inter-linked, the lack of older adult psychiatry resource for elderly patients , gives rise to a risk of 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 Poorly defined access to care and support for psychological distress towards the end of life
Wider context from the report “(iv) The inquest heard that mental health concerns can often be overlooked towards the end of life. Structures for accessing care for physical symptoms towards the end of life are well developed. Accessing care and support for psychological distress is not so well defined . Care homes and nursing homes tend to have mainly general nurses, as opposed to mental health nurses. They also have easy access to GPs and geriatricians. There is a perceived lack of easy access to older age psychiatry teams, by care homes and nursing homes.
” 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 availability of mental health nurses in care homes and nursing homes
Wider context from the report “(iv) The inquest heard that mental health concerns can often be overlooked towards the end of life. Structures for accessing care for physical symptoms towards the end of life are well developed. Accessing care and support for psychological distress is not so well defined. Care homes and nursing homes tend to have mainly general nurses, as opposed to mental health nurses . They also have easy access to GPs and geriatricians. There is a perceived lack of easy access to older age psychiatry teams, by care homes and nursing homes.
” 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 re-accessing older age community psychiatry teams after discharge
Wider context from the report “(iii) Once discharged from an older age community psychiatry team, it can take a very long time to access the teams again . These delays can act as a deterrent to GPs in referring patients to community mental health teams.
” Open source report
7 Jun 2022 Mena Tekloe Marim Teferi · Prevention of Future Deaths report West London
View report summary
Concerns raised 1 Insufficient capacity and resources to meet mental health service demand 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
Mena Tekloe Marim Teferi · 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
Mena Tekloe Marim Teferi died by suicide at home on 10 October 2021, after being referred to a mental health service but not seen or contacted before her death. The service was described as critically under-resourced, with demand substantially exceeding capacity and resulting in failures to meet service obligations.
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 capacity and resources to meet mental health service demand
Wider context from the report “The mental health services went through a transformation process during the Covid pandemic. It became apparent that the anticipated level of direct referrals to the service from primary care was many times in excess of those predicted. The expectation was 6 per day, at the peak this rose to 30 and has currently reduced to 13-14 daily, so remains over 100% above the anticipated level.
The inquest was advised that the service was failing to meet the service demands due to insufficient capacity . The decision was made to enter this onto the Trust’s risk register, and this remains the situation. The critical features remain a high demand for services and a lack of resources .
This court has been told on many occasions that there is an intention for “parity” of mental health services with physical health services, but this is not apparent and the service is unable to meet its obligations now or going forward . This is greater than a “long waiting list” issue and is not a situation that can be explained exclusively by the covid pandemic. A more significant risk to individuals requiring mental health services has now arisen than existed before the transformation programme; it creates a real concern that lives will be lost as a consequence, and no solution was offered to the court during the inquest. The service is set up to deal with less than half of the referrals that it receives, leading to inevitable failings that currently cannot be rectified .
” Open source report
Concerns raised 3 Unavailability of communication interpretation and advocacy support for callers with learning disabilities View source Lack of a procedure or specific protocol for callers with learning disabilities View source Failure of NHS Pathways triage to take account of callers with learning disabilities 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
Daniel Robert Ludlam · 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 Robert Ludlam died at the scene on 30 December 2019 after an obstructed hiatus hernia caused gastrointestinal haemorrhage and hypovolemic shock. Concerns included that NHS Pathways triage did not specifically account for callers with learning disabilities, and that the absence of a suitable procedure could lead to incorrect triage or delays in sending paramedic support, particularly where no carer was available to assist communication.
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 communication interpretation and advocacy support for callers with learning disabilities
Wider context from the report “(1) The NHS Pathways triage system for the calls that were made did not appear to take specific account of the patient who had a learning disability. Daniel could not communicate accurately his symptoms, and specifically would give the responses that he felt the call handler wanted to hear. He could not understand the questions being asked during the NHS Pathways triage.
(2) There appears to be no procedure or specific protocol in place to deal with a caller with learning disabilities, save for an early exit from the triage Pathway to request a clinician review. I am concerned that in similar future cases, either the information being given will not result in the correct triage category being reached, or any exit from the pathway to seek clinician input may result in a delay in sending out a paramedic crew.
(3) The carer assisting Daniel had to interpret the questions from the call handler in a way that Daniel could easily understand and then relay the responses back. In the future a call may come in from someone with learning disabilities who does not have a carer present to assist with the interpretation of the questions and to advocate on their behalf. Without there being a policy in place to deal with callers who cannot easily communicate or understand the questions, there is a risk of future death which could occur.
” 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 procedure or specific protocol for callers with learning disabilities
Wider context from the report “(1) The NHS Pathways triage system for the calls that were made did not appear to take specific account of the patient who had a learning disability. Daniel could not communicate accurately his symptoms, and specifically would give the responses that he felt the call handler wanted to hear. He could not understand the questions being asked during the NHS Pathways triage.
(2) There appears to be no procedure or specific protocol in place to deal with a caller with learning disabilities , save for an early exit from the triage Pathway to request a clinician review. I am concerned that in similar future cases, either the information being given will not result in the correct triage category being reached, or any exit from the pathway to seek clinician input may result in a delay in sending out a paramedic crew .
(3) The carer assisting Daniel had to interpret the questions from the call handler in a way that Daniel could easily understand and then relay the responses back. In the future a call may come in from someone with learning disabilities who does not have a carer present to assist with the interpretation of the questions and to advocate on their behalf. Without there being a policy in place to deal with callers who cannot easily communicate or understand the questions, there is a risk of future death which could occur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of NHS Pathways triage to take account of callers with learning disabilities
Wider context from the report “(1) The NHS Pathways triage system for the calls that were made did not appear to take specific account of the patient who had a learning disability . Daniel could not communicate accurately his symptoms, and specifically would give the responses that he felt the call handler wanted to hear. He could not understand the questions being asked during the NHS Pathways triage.
(2) There appears to be no procedure or specific protocol in place to deal with a caller with learning disabilities, save for an early exit from the triage Pathway to request a clinician review. I am concerned that in similar future cases, either the information being given will not result in the correct triage category being reached, or any exit from the pathway to seek clinician input may result in a delay in sending out a paramedic crew.
(3) The carer assisting Daniel had to interpret the questions from the call handler in a way that Daniel could easily understand and then relay the responses back. In the future a call may come in from someone with learning disabilities who does not have a carer present to assist with the interpretation of the questions and to advocate on their behalf. Without there being a policy in place to deal with callers who cannot easily communicate or understand the questions, there is a risk of future death which could occur.
” Open source report
1 Jun 2022 Angela Maguire · Prevention of Future Deaths report West London
View report summary
Concerns raised 1 Lack of a shared regional system for cross-site sharing of radiology images View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Angela Maguire · 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
Angela Maguire deteriorated after being referred for investigation of suspected malignancy and died in Kingston Hospital on 8 April 2021 following an upper gastrointestinal bleed. The report identified the lack of a shared regional system for accessing radiology images, which meant Kingston Hospital could not access previous images from Queen Mary's Hospital; this resulted in missed opportunities for diagnosis and palliative care, although it did not affect the outcome in this case.
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 shared regional system for cross-site sharing of radiology images
Wider context from the report “The clinicians assisting with the inquest advised the court that there was no system to share radiology across the Region . In West London, patients are frequently transferred from hospitals to access particular specialisms of care, such as cancer care. In this case, the previous images taken at Queen Mary's Hospital, London, could not be accessed across a common link by Kingston Hospital, Surrey and therefore the opportunity was missed to see and compare previous images. While this did not have an impact on the outcome in this case, it could have very significant consequences and lead to missed diagnoses and potentially fatal outcomes of untreated disease processes. In this case the opportunity to offer palliative care and ease the relatives of end of life treatment was lost. The lack of a shared portal also creates further work for clinicians who have to contact the previous hospitals to access this information.
There are many shared systems in place in the NHS for cross-site sharing of images and reports, and it was not clear from those assisting the court at this inquest why similar systems are not currently in place for this Region and not anticipated for “several more years”.
” 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 Imaging Networks to mature shared access to imaging histories, reports and images across organisations.
Verbatim wording from the response “The NHS Long Term Plan committed to establishing Imaging Networks across England by 2023. Currently, the 22 Imaging Networks across England are being supported to increase their maturity, with a specific focus on the sharing of imaging history, reports and the images themselves.” 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 Imaging Networks are responsible for assessing their maturity and implementing network-level imaging-sharing plans.
Verbatim wording from the response “Each Imaging Network is responsible for assessing their own maturity against a maturity matrix, with the aim of having 70% at a “Maturing” level by the end of the financial year 2024/5. By reaching a “Maturing” level, this means that the Networks will be “jointly working across the Network with the implementation of a network level plan underway”.” Source location Response from NHS England
Open published response
Concerns raised 2 Delays in private ambulance attendance to transport patients after MHA assessments View source Failure to provide timely access to second (s.12) doctors out of office hours for MHA assessments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Dean Ryan CROSSMAN · 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
On 18 June 2019, Dean Ryan Crossman was found hanging after contact with emergency and crisis mental health services following suicidal behaviour the previous evening. The report identifies ongoing concerns about out-of-hours access to second doctors for Mental Health Act assessments and delays in securing private ambulance attendance.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in private ambulance attendance to transport patients after MHA assessments
Wider context from the report “1. Evidence was given at the inquest that at the time of Dean’s passing, there were issues accessing second (s.12) doctors out of office hours for the purpose of carrying out a MHA assessment, resulting in delays to MHA assessments being carried out. The EDT explained that since Dean’s passing, a “s.12 Solutions” App has been introduced, and although this had made a significant improvement, issues still exist trying to access a second doctor out of hours, as the EDT is still wholly reliant on second doctors making themselves available after midnight (with no fixed rota).
2. Evidence was given at the inquest that at the time of Dean’s passing, there were issues securing the timely attendance of the private ambulance service (ERS Medical) to transport patients after a MHA assessment had taken place , potentially resulting in an increased risk to both the AMHP and the patient for MHA assessments in the community. The EDT advised that since Dean’s passing, despite spot purchasing of private ambulances being introduced, issues still exist trying to get the private ambulance to attend a MHA assessment in a timely manner .
3. Evidence was given at the inquest that both of the above matters of concern are on-going national issues .
” 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 timely access to second (s.12) doctors out of office hours for MHA assessments
Wider context from the report “1. Evidence was given at the inquest that at the time of Dean’s passing, there were issues accessing second (s.12) doctors out of office hours for the purpose of carrying out a MHA assessment, resulting in delays to MHA assessments being carried out . The EDT explained that since Dean’s passing, a “s.12 Solutions” App has been introduced, and although this had made a significant improvement, issues still exist trying to access a second doctor out of hours, as the EDT is still wholly reliant on second doctors making themselves available after midnight (with no fixed rota) .
2. Evidence was given at the inquest that at the time of Dean’s passing, there were issues securing the timely attendance of the private ambulance service (ERS Medical) to transport patients after a MHA assessment had taken place, potentially resulting in an increased risk to both the AMHP and the patient for MHA assessments in the community. The EDT advised that since Dean’s passing, despite spot purchasing of private ambulances being introduced, issues still exist trying to get the private ambulance to attend a MHA assessment in a timely manner.
3. Evidence was given at the inquest that both of the above matters of concern are on-going national issues .
” 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 local availability of section 12 doctors through regional teams and identify further national mitigation for out-of-hours access.
Verbatim wording from the response “Integrated care systems (ICSs) are partnerships that bring together NHS organisations, local authorities and others to take collective responsibility for planning services, improving health and reducing inequalities across geographical areas. Each local system has responsibility to ensure that the section 12 rota for their area is adequately managed, to ensure 24/7 availability of s.12 doctors. NHS England recognise that, while doctors may indicate their availability for certain times and days on local rotas, this does not obligate them to accept a request to attend and undertake a MHA assessment. The National NHS England Mental Health Team will review this issue via our regional NHSE teams to understand if there are any local areas where this is a particular concern, and if there is anything further that can be done nationally to help mitigate the issues.” 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 Integrated care systems are responsible for managing local section 12 doctor rotas and ensuring 24/7 availability.
Verbatim wording from the response “Integrated care systems (ICSs) are partnerships that bring together NHS organisations, local authorities and others to take collective responsibility for planning services, improving health and reducing inequalities across geographical areas. Each local system has responsibility to ensure that the section 12 rota for their area is adequately managed, to ensure 24/7 availability of s.12 doctors. NHS England recognise that, while doctors may indicate their availability for certain times and days on local rotas, this does not obligate them to accept a request to attend and undertake a MHA assessment. The National NHS England Mental Health Team will review this issue via our regional NHSE teams to understand if there are any local areas where this is a particular concern, and if there is anything further that can be done nationally to help mitigate the issues.” 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 Integrated care boards are responsible for commissioning timely transportation after Mental Health Act assessments.
Verbatim wording from the response “This is particularly important after a MHA assessment has taken place, and is the responsibility of Integrated Care Boards (ICBs) who commission services for their footprint. Integrated Care Boards replaced Clinical Commissioning Groups (CCGs) as the statutory NHS organisation which is responsible for developing a plan for meeting the health needs of the population, managing the NHS budget and arranging for the provision of health services in a geographical area.” Source location Response from NHS England
Open published response
Concerns raised 12 Failure to ensure review of correspondence from TalkPlus View source Lack of guidance on thresholds for referral to secondary mental health services View source Failure to undertake mental health assessment and identify need for further or secondary mental health support View source Failure to document warnings about Mirtazepine side-effects and increased suicidal ideation risk View source Failure to confirm electronic letters are read and acted upon View source Prescribing of Mirtazepine without sufficient mental health prescribing competence View source Lack of ongoing mental health training for GPs View source Failure to offer face-to-face consultation or arrange follow-up View source Failure to ask about or document suicidal ideation and self-harm View source Failure to investigate and review deaths for learning and implementation of necessary changes View source Lack of prescribing policy for Mirtazapine, antidepressants and anxiolytics View source Failure to seek permission to involve partners and family in ongoing care View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Matthew John Evans · 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
Matthew John Evans was a 47-year-old man who developed insomnia, anxiety and depression during the third COVID-19 lockdown and died on 16 June 2021 after ending his life. The principal concerns related to the GP’s lack of mental-health assessment, suicide-risk assessment, follow-up and consideration of referral; the general practice’s prescribing, communication and clinical-governance arrangements; and TalkPlus’s lack of clear guidance on referral to secondary mental-health services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure review of correspondence from TalkPlus
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on thresholds for referral to secondary mental health services
Wider context from the report “3. The actions of TalkPlus
There does not appear to be robust guidance or a policy as to the threshold necessary to refer a patient to secondary mental health services in Matthew’s circumstances where his mental health had deteriorated as the sessions progressed and he had began to indicate suicidal ideation and self-harm on a background of no previous mental health difficulties.
” 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 undertake mental health assessment and identify need for further or secondary mental health support
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going care.
” 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 document warnings about Mirtazepine side-effects and increased suicidal ideation risk
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going care.
” 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 confirm electronic letters are read and acted upon
Wider context from the report “2. The actions of the General Practice
No policy was provided to assist GP’s with prescribing of Mirtazapine and antidepressants and anxiolytics in general practice. There is no confirmation electronic letters have been signed as read and acted upon by the relevant GP. No evidence was provided with regard to ongoing training in mental health for GP’s. Matthew’s death was not investigated or reviewed by the GP practice with the consequence no learning points have been considered or, if necessary, changes implemented, giving rise to concern over the lack of robust clinical governance procedure within the practice.
” 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 Prescribing of Mirtazepine without sufficient mental health prescribing competence
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going care.
” 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 ongoing mental health training for GPs
Wider context from the report “2. The actions of the General Practice
No policy was provided to assist GP’s with prescribing of Mirtazapine and antidepressants and anxiolytics in general practice. There is no confirmation electronic letters have been signed as read and acted upon by the relevant GP. No evidence was provided with regard to ongoing training in mental health for GP’s. Matthew’s death was not investigated or reviewed by the GP practice with the consequence no learning points have been considered or, if necessary, changes implemented, giving rise to concern over the lack of robust clinical governance procedure within the practice.
” 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 offer face-to-face consultation or arrange follow-up
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going care.
” 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 ask about or document suicidal ideation and self-harm
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going care.
” 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 investigate and review deaths for learning and implementation of necessary changes
Wider context from the report “2. The actions of the General Practice
No policy was provided to assist GP’s with prescribing of Mirtazapine and antidepressants and anxiolytics in general practice. There is no confirmation electronic letters have been signed as read and acted upon by the relevant GP. No evidence was provided with regard to ongoing training in mental health for GP’s. Matthew’s death was not investigated or reviewed by the GP practice with the consequence no learning points have been considered or, if necessary, changes implemented, giving rise to concern over the lack of robust clinical governance procedure within the practice.
” 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 prescribing policy for Mirtazapine, antidepressants and anxiolytics
Wider context from the report “2. The actions of the General Practice
No policy was provided to assist GP’s with prescribing of Mirtazapine and antidepressants and anxiolytics in general practice. There is no confirmation electronic letters have been signed as read and acted upon by the relevant GP. No evidence was provided with regard to ongoing training in mental health for GP’s. Matthew’s death was not investigated or reviewed by the GP practice with the consequence no learning points have been considered or, if necessary, changes implemented, giving rise to concern over the lack of robust clinical governance procedure within the practice.
” 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 seek permission to involve partners and family in ongoing care
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going care.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide the report to Regional Mortality Boards for dissemination to all Integrated Care Boards to support learning from the event.
Verbatim wording from the response “This report will be provided to the Regional Mortality Boards so that they may share it with all ICBs to ensure that they are able to learn from this event.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS commissioners are responsible for assuring provider serious-incident investigations, overseeing action plans, and closing incidents.
Verbatim wording from the response “c) Matthew’s death was not investigated or reviewed by the GP practice with the consequence no learning points have been considered or, if necessary, changes implemented, giving rise to concern over the lack of robust clinical governance procedure within the 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 Remote consultations during the COVID-19 pandemic were consistent with NHS England guidance, although face-to-face appointments were required from May 2021.
Verbatim wording from the response “c) The GP did not offer a face-to-face consultation” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing NICE, Clinical Knowledge Summaries, BNF, GP training and continuing professional development sufficiently support depression assessment and prescribing without a separate policy.
Verbatim wording from the response “a) No policy was provided to assist GP’s with prescribing of Mirtazapine and antidepressants and anxiolytics in general practice” Source location Response from NHS England
Open published response
16 May 2022 Mr Thomas Antony Smith · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 2 Failure to ensure escorting staff receive and review patient-specific risk information before s.17 leave View source Lack of staff knowledge and training about substance-related dangers and presentations in detained mental health settings View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Thomas Antony Smith · 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 Thomas Antony Smith died in a drugs-related death after serious failings in his care on Coral Ward during the night of 29–30 December 2020. The principal concerns were inadequate staff knowledge about the dangers and presentation of drugs, insufficient observation and escalation after a positive drugs test and signs of deterioration, and weaknesses in the system for assessing risks associated with Section 17 leave.
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 escorting staff receive and review patient-specific risk information before s.17 leave
Wider context from the report “2) The system for assessing risks associated with s.17 leave
I was told that, when a staff member is escorting a service user out of the ward, there is an expectation for that staff member to be aware of the location, general mental state and wellbeing of the service user; and that a ‘mental state assessment’ should be carried out on the ward prior to leave taking place, as a further safeguard once s.17 leave had been granted.
However, the evidence of the healthcare assistant who took Mr Smith out on leave, on the occasion (29 December 2020) that the jury concluded it was possible that he was able to buy the ████████ the misuse of which caused his death, was that:
(i) He would not necessarily read a patient’s RiO (electronic continuous) notes before taking a patient out on leave;
(ii) He had not read Mr Smith’s care plan before taking him on leave;
(iii) There had been no handover from other staff to him of Mr Smith’s presentation on 28 December 2020 presentation (when he was suspected of being ‘under the influence’ of a substance); and
(iv) Although he had read the form authorising Mr Smith’s leave (i.e. the s.17 form), that form – a statutory document – does not contain information about particular risks posed to a patient by or when out on s.17 leave.
As a result of the above, this particular healthcare assistant was unaware that:
(i) On 28 December 2020 Mr Smith had been suspected of being under the influence of drugs;
(ii) Mr Smith’s care plan of 20 December 2020 set out as a ‘risk issue’ the fact that “Thomas has a history of using illicit substances”; and
(iii) The care plan set out as an ‘intervention’ for Mr Smith: “Nursing staff to do random urine drug screening and breathalysing upon return to the ward.”
The healthcare assistant therefore appears to have been in a position of escorting a patient on leave without knowledge of a patient’s very recent potential drug-related presentation, or of a specified intervention aimed at reducing the risk posed to that patient by drugs as set out in his care plan.
There was, however, no suggestion in the evidence of any witness during Mr Smith’s inquest that the situation in which the escorting healthcare assistant found himself represented a failure to follow policy or expected procedure. In the event that this is correct there appears to be a wider issue – and this Report is therefore directed to NHS England and NHS Improvement.
” 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 staff knowledge and training about substance-related dangers and presentations in detained mental health settings
Wider context from the report “1) Knowledge of the dangers of ████████ in detained mental health patient settings
There was evidence of steps having been taken by the ELFT at a local level to remedy the apparent lack of knowledge amongst its staff regarding the dangers of ████████ and ████████ after Mr Smith’s death, including its own substance misuse training and inviting local substance misuse charities back onto its wards to work with its patients and staff as Covid restrictions lift.
There was, however, various evidence which suggested a lack of knowledge from ELFT staff around ████████ and it’s potentially fatal effects , including that several witnesses:
(i) Did not know what ████████ or ████████ could look like;
(ii) Were unaware of how a person under the influence of ████████ or ████████ might present; and
(iii) Had received no training on the dangers of ████████ or ████████
There was some evidence that this might be a wider issue of concern, both locally and nationally, than only with ELFT staff. In the event that is correct, this report is directed to NHS England and NHS Improvement.
” 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 Delivering education on the identified dangers is outside the commissioner’s remit.
Verbatim wording from the response “NHS England acknowledge and share your concerns regarding knowledge of ████████ both locally and nationally, although it is not within NHS England’s remit to deliver this education as a commissioner. Provider organisations are responsible for providing staff with the relevant training, to ensure that they are aware of issues pertinent to their patient population. In this particular case, ELFT will be responsible for training and refreshing their employees on ████████ in detained mental health patient settings, and this is addressed further below.” Source location Responses 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 Provider organisations, specifically ELFT, are responsible for training and refreshing staff on the identified dangers.
Verbatim wording from the response “NHS England acknowledge and share your concerns regarding knowledge of ████████ both locally and nationally, although it is not within NHS England’s remit to deliver this education as a commissioner. Provider organisations are responsible for providing staff with the relevant training, to ensure that they are aware of issues pertinent to their patient population. In this particular case, ELFT will be responsible for training and refreshing their employees on ████████ in detained mental health patient settings, and this is addressed further below.” Source location Responses from NHS England
Open published response
Concerns raised 13 Lack of guidance on placement of padded cot boards View source Delayed and incomplete serious incident investigations View source Failure to fully inform forensic pathology experts about relevant equipment involvement in a death View source Failure to accept and embed institutional learning from serious incidents View source Failure to preserve the scene and fully inform police and coronial investigators after a death View source Lack of regular direct visual supervision during the night View source Failure to inform the autopsy pathologist of the circumstances of a death View source Lack of openness, transparency and proper investigation of deaths View source Failure to provide yearly servicing of allocated cots View source Failure to provide accurate information to the CQC about a death View source Failure to undertake prompt internal enquiries after sudden unexpected deaths View source Failure to inform relevant statutory bodies of concerns after sudden unexpected deaths View source Failure to retain medical records after sudden unexpected deaths View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Connor Samuel Timothy Wellsted · 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
Connor Samuel Timothy Wellsted, a five-year-old boy with significant neuro-disabilities, was found deceased in his cot on 17 May 2017 during a residential neuro-rehabilitation stay. The investigation determined that he died following entrapment by a loose cot bumper causing airway obstruction. Concerns included inadequate cot maintenance and securing, lack of regular direct visual night-time supervision, and failures to preserve the scene, inform relevant bodies, and investigate the circumstances openly and transparently.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on placement of padded cot boards
Wider context from the report “1. The cot
The cot Connor’s was allocated was nine years old, used infrequently and had not had a yearly servicing for the previous five years. There was no guidance or clarity as to how the padded boards/cot bumper should have been placed around the wooden frame of the cot in circumstances whereby the foster parents did not wish the cot to be padded.
It is likely the padded board (1m long, 40 cm wide with a soft side and a rigid side) was inappropriately and inaccurately placed on the wooden frame of the cot and as its top edge was without Velcro it could not have been attached to the cot leaving it loose with the result that it dislodged entrapping Connor across his neck.
” 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 Delayed and incomplete serious incident investigations
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns. Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death.
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death.
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” 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 fully inform forensic pathology experts about relevant equipment involvement in a death
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns. Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death.
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death .
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” 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 accept and embed institutional learning from serious incidents
Wider context from the report “4. Senior management, Children’s Trust, Tadworth
The current senior management team have not acknowledged there was a lack of transparency and openness as to how Connor died, or that the Trust did not properly investigate his death or inform the relevant statutory bodies of the circumstances of his death giving rise to concern of an ongoing lack of insight that institutional learning around serious incidents has not been accepted by the Trust .
As a consequence, there is a need to introduce and develop robust clinical governance processes and systems to reassure the public and supervisory statutory bodies that they will be informed of any future adverse events and they will be investigated with openness, candour and transparency.
” 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 preserve the scene and fully inform police and coronial investigators after a death
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns. Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death.
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death.
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” 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 regular direct visual supervision during the night
Wider context from the report “2. Monitoring of Connor during the night:
Connor had no regular or direct visual supervision during the night (other than to open the door of his room to check if there was a smell) despite the request of his foster parent to check in circumstances whereby in other parts of the Trust regular visual inspection was the norm.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the autopsy pathologist of the circumstances of a death
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns. Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death.
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death.
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” 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 openness, transparency and proper investigation of deaths
Wider context from the report “4. Senior management, Children’s Trust, Tadworth
The current senior management team have not acknowledged there was a lack of transparency and openness as to how Connor died , or that the Trust did not properly investigate his death or inform the relevant statutory bodies of the circumstances of his death giving rise to concern of an ongoing lack of insight that institutional learning around serious incidents has not been accepted by the Trust.
As a consequence, there is a need to introduce and develop robust clinical governance processes and systems to reassure the public and supervisory statutory bodies that they will be informed of any future adverse events and they will be investigated with openness, candour and transparency.
” 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 yearly servicing of allocated cots
Wider context from the report “1. The cot
The cot Connor’s was allocated was nine years old, used infrequently and had not had a yearly servicing for the previous five years . There was no guidance or clarity as to how the padded boards/cot bumper should have been placed around the wooden frame of the cot in circumstances whereby the foster parents did not wish the cot to be padded.
It is likely the padded board (1m long, 40 cm wide with a soft side and a rigid side) was inappropriately and inaccurately placed on the wooden frame of the cot and as its top edge was without Velcro it could not have been attached to the cot leaving it loose with the result that it dislodged entrapping Connor across his neck.
” 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 accurate information to the CQC about a death
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns. Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death .
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death.
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” 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 undertake prompt internal enquiries after sudden unexpected deaths
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns . Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death.
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death.
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to inform relevant statutory bodies of concerns after sudden unexpected deaths
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns . Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death.
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death.
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” 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 retain medical records after sudden unexpected deaths
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns . Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death.
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death.
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish the Patient Safety Incident Response Framework to support effective investigation and learning from patient safety incidents.
Verbatim wording from the response “In terms of investigation, the NHS England Patient Safety Incident Response Framework in July 2022. The Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents, for the purpose of learning and improving patient safety. The PSIRF is a contractual requirement under the NHS Standard Contract, and as such is mandatory for services provided under that contract and will include Providers such as The Children’s Trust at Tadworth Court.” 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 Carry out a comprehensive review of the Report’s concerns at the Children’s Trust through South East regional representatives.
Verbatim wording from the response “I note that you also sent your Report to the Chief Executive and Medical Director of the Children’s Trust, Tadworth, and I have had sight of their response as referred to above. On 15 July 2022, representatives from the South East Region attended upon the Trust and carried out a comprehensive review of all of the points that you made in your Report. They concluded that there were no current quality concerns, however there was room for improvement. The outstanding actions for improvement will continue to be monitored by NHS England South East. I am assured that the Children’s Trust, Tadworth, have addressed all of the concerns 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 Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning across national and regional NHS structures.
Verbatim wording from the response “I would also like to provide further assurances on the national NHSE work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Connor, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.” Source location Response from NHS England
Open published response
×
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 Integrated Care Systems are responsible for providers in their areas and can check adherence to guidance intended to prevent future deaths.
Verbatim wording from the response “Further, your Report has been shared with the NHSE Regulation 28 Working Group, who in turn have shared the Report with their regions through their mortality working groups, whose membership includes Integrated Care Systems (ICSs). ICSs are partnerships of organisations that come together to plan and deliver joined up health and care services, and to improve the lives of people who live and work in their area. ICSs are responsible for providers within their area and are able to check that they are adhering to guidance which could prevent future deaths.” Source location Response from NHS England
Open published response
13 May 2022 RITA GIULIANNA NICOLA BRITTEN · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 1 Lack of clear national emergency and resuscitation guidance for choking emergencies where conventional abdominal thrusts are not possible or effective View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
RITA GIULIANNA NICOLA BRITTEN · 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
Rita Giuliana Nicola Britten, a detained patient, choked while trying to swallow pieces of fresh apple and later died in hospital after life support was withdrawn. The report records concerns about the lack of clear guidance and effective rescue techniques for choking incidents involving overweight, obese or bariatric individuals, including the possible use of inversion techniques and specialist equipment. The jury also recorded concerns about communication and handover, recording and access to key information, incomplete risk assessments, and inadequate first aid training.
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 clear national emergency and resuscitation guidance for choking emergencies where conventional abdominal thrusts are not possible or effective
Wider context from the report “The concern is of want of clear guidance on the steps to be taken to most effectively rescue the individual from the urgent and developing choking emergency when that individual does not conform to the competent adult to whom conventional abdominal thrusts are possible or might be effectively applied. In particular, this concern relates to but is not limited to the overweight/obese/bariatric individual (however that may be best described).
a) There should be clear national emergency /resuscitation guidelines for dealing effectively with choking incidents where the individual is overweight/obese or otherwise where “conventional abdominal thrusts” are not possible or are less able to be effectively applied. In Mrs Britten’s case a significant element of early rescue techniques was compromised. It is perceived this will be an increasing present and future risk in the UK population due to obesity.
b) There should be early review and assessment of papers that discuss the efficacy (or otherwise) in such circumstances of “inversion” of the affected choking individual said to be set out in:
Hubert Blaine et al in American Journal of Medicine ref, Am J Med 2010 Dec; 123 (12)
And
“Effect of body position on relieve of foreign body from the airway”, Artur Luczak AIMS Public Health 6(2): 154-159
And how this or similar technique(s) might have application in the Hospital/clinical setting in which this choking episode occurred.
c) There should be identified and assessed any specialist equipment to assist in these circumstances.
” 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 Resuscitation Council UK has addressed all concerns raised in the report.
Verbatim wording from the response “I note that you also sent your Report to the Resuscitation Council UK and I have had sight of their response. I am assured that Resuscitation Council UK have addressed all the concerns raised in your Report.” Source location Response from NHS England
Open published response
Concerns raised 2 Lack of mandatory inspection and approval checks on ligature alarm placement in newly built mental health units View source Lack of mandatory requirements for fitting ligature alarms to doors in newly built mental health units 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
Sergio DUNKLEY · 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
Sergio DUNKLEY was admitted voluntarily to a mental health ward on 24 July 2020 after threats to end his life. He was last seen alive shortly after midnight on 18 August 2020 and was found to have taken his own life before 1.30am. The report raised concerns about the lack of mandatory requirements for ligature alarms and for checking their placement in newly built mental health units, as well as failures to record observation changes and suicide-risk assessments adequately.
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 mandatory inspection and approval checks on ligature alarm placement in newly built mental health units
Wider context from the report “(3) That inspection and approval of newly built mental health units contains no mandatory requirement for the checking as to the placement of ligature alarms .
” 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 mandatory requirements for fitting ligature alarms to doors in newly built mental health units
Wider context from the report “(1) That there is no statutory requirement nor any current regulations which specifically require the doors within newly build mental health units to be fitted with ligature alarms .
(2) That whilst Health Building Note 03-01 as published by the Department of Health gives guidance that “ All fixtures and fittings should be ant ligature” the requirement to do so is not stated to be mandatory .
” Open source report
Concerns raised 1 Lack of a protocol governing the safeguarding of people awaiting Mental Health Act assessments who may be alone and at risk in the community 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
Cynthia Elizabeth Finlay · 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
Cynthia Elizabeth Finlay had depression, cognitive difficulties and impulsive personality traits. After an overdose and discharge from hospital, she was assessed by mental health professionals, but no adequate safeguarding plan was put in place while she was awaiting consideration of a Mental Health Act assessment. She was left alone and subsequently died by suicide; expert evidence identified that no protocol governed safeguarding people in this situation who might be alone and at risk in the community.
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 protocol governing the safeguarding of people awaiting Mental Health Act assessments who may be alone and at risk in the community
Wider context from the report “(1) Expert evidence was received from a Consultant Psychiatrist who indicated that there is no protocol in place which governs what steps should be taken to safeguard people who are awaiting Mental Health Act assessments and may be alone and at risk in the community whilst the assessment is set up .
” Open source report
9 May 2022 Raymond Griffiths · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 11 Restrictions on cardiac surgery training View source Restrictions in cardiac surgical capacity causing diversion to overstretched units View source Damage to public confidence in the cardiac surgery department, SGH and the NHS View source Collapse of cardiac surgery research View source Failure of the SJR process to identify lessons for patient safety improvement View source Restrictions on cardiac surgeons' operating rights reducing cardiac surgical capacity View source Damage to public confidence discouraging patients from presenting for care View source SJR process undermining staff morale, mental health and confidence View source Risk-averse surgical decision-making denying care to complex patients View source Loss of cardiac surgery staff View source SJR process failing to provide an appropriate audit of NHS work View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Raymond Griffiths · 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
Raymond Griffiths was admitted to St George’s Hospital for coronary artery bypass grafting on 21 May 2013, underwent surgery the following day, developed acute on chronic liver failure post-operatively, and died in intensive care three days later. The inquest concluded that his care was beyond reproach and that his liver failure could not reasonably have been predicted or prevented. The report raised concerns about restrictions on cardiac surgical capacity, diversion of emergency and other patients, damage to public confidence, and the adequacy of the SJR process, which were considered capable of increasing risks to future patients.
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 Restrictions on cardiac surgery training
Wider context from the report “8. That restrictions on training , collapse of research and staff leaving, further damages not only the cardiac surgery at SGH but also the wider cardiac surgery field, increasing the risk of death to patients by reducing their access to high quality care.
” 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 Restrictions in cardiac surgical capacity causing diversion to overstretched units
Wider context from the report “1. That restrictions in cardiac surgical capacity at SGH is causing patients to be diverted to other overstretched units, increasing their risk of 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 Damage to public confidence in the cardiac surgery department, SGH and the NHS
Wider context from the report “7. That the apparently unfounded damage to the reputation of the cardiac surgery department will take years to repair, increasing the risks of future deaths by damaging public confidence in SGH and the NHS .
” 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 Collapse of cardiac surgery research
Wider context from the report “8. That restrictions on training, collapse of research and staff leaving, further damages not only the cardiac surgery at SGH but also the wider cardiac surgery field, increasing the risk of death to patients by reducing their access to high quality care.
” 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 SJR process to identify lessons for patient safety improvement
Wider context from the report “4. That the evidentially inadequate and critical SJR process has failed to identify factors from which lessons could have been learnt and thus patient safety improved, and future deaths prevented.
” 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 Restrictions on cardiac surgeons' operating rights reducing cardiac surgical capacity
Wider context from the report “6. That the apparently unnecessary restrictions on operating rights of the cardiac surgeons is reducing the overall capacity for cardiac surgery and thus may increase the risk of death for patients awaiting such surgery, as they die on waiting lists.
” 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 Damage to public confidence discouraging patients from presenting for care
Wider context from the report “3. That public confidence has been so dented that patients requiring care have been discouraged from presenting to SGH thus increasing their risk of 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 SJR process undermining staff morale, mental health and confidence
Wider context from the report “5. That this SJR process has undermined the department unnecessarily , impacting on morale and the mental health and confidence of the cardiac surgeons and other clinicians and non-clinicians within SGH which may translate into a lower quality of care for patients.
” 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-averse surgical decision-making denying care to complex patients
Wider context from the report “9. The restrictions at SGH may make surgeons more risk adverse and thus deny care to the most complex patients and so increase the risk of 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 Loss of cardiac surgery staff
Wider context from the report “8. That restrictions on training, collapse of research and staff leaving , further damages not only the cardiac surgery at SGH but also the wider cardiac surgery field, increasing the risk of death to patients by reducing their access to high quality care.
” 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 SJR process failing to provide an appropriate audit of NHS work
Wider context from the report “10. That the SJR process as deployed in SGH is not fit for purpose , further undermining the public confidence in the NHS, which the public may perceive as the NHS being unable to appropriately audit its own work .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue supporting the Trust as the South London Cardiac Surgery Network evolves, including its collaborative approach to capacity and patient safety.
Verbatim wording from the response “Cardiac surgery has significantly evolved since the restrictions were put in place in August 2018. Indeed, as with most elective surgical specialties, the temporary pause during the initial impact of the Covid pandemic, provided an opportunity to reset and refocus surgical practice and procedures. We believe the support provided by the stakeholders to the Trust over the past few years has resulted in a more collaborative approach to cardiac surgery in South London. KCH, GSTT and the Trust meet regularly and are committed to work closer as part of the South London Cardiac Surgery Network benefiting patients, promoting patient choice and patient safety. This same network has also continued to regularly consider” 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 Trust to re-establish public confidence in cardiac care in South London through the Cardiac Collaborative.
Verbatim wording from the response “The Trust’s PFD response addresses the detail of referral patterns over the relevant period. NHSE and the Trust have been working to re-establish public confidence in cardiac care in South London, and the evolution of the Cardiac Collaborative reflects that.” 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 Commission and complete an independent mortality review of cardiac surgery at St George’s to investigate patient safety concerns.
Verbatim wording from the response “As you are aware from our letter to you dated 16 December 2020, and in accordance with statements within the public domain, the reason that NHS Improvement (now NHSE) commissioned the Independent Review was because of serious patient safety concerns that had been identified in cardiac surgery at the Trust by a number of different sources as mentioned above. There had also been significant public and media attention focused on patient safety concerns at the cardiac surgery unit at St George’s Hospital, and the Trust’s response details the cumulative concerns from that period. It was for the same reason that the Panel members, all experienced independent experts in their fields, agreed to give up their time to assist in this review process; a decision that was fully supported by their NHS employers given the importance of ensuring public safety and confidence in NHS services as a whole.” 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 Damage to public confidence had occurred before the Review was commissioned, so it was not caused by the Review.
Verbatim wording from the response “It is not clear whether this concern is directed at the Review, or more generally at the sequence of events over a period of years of concerns, investigations and public scrutiny of the Trust’s cardiac services. If this relates to the impact of the Review, our earlier comment on the timeline refers. It is clear that such damage had already occurred before NHS Improvement commissioned the Review or any opinions were expressed in the SJRs.” 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 SJR process was not inadequate or unfit for purpose and identified learning through expert review and recommendations.
Verbatim wording from the response “We do not agree that the SJR was inadequate as a process, nor that it failed to identify learning to improve patient safety. The objective evidential basis for this comment is unclear. The Review identified and acknowledged good practice; and it made 12 positive recommendations which were aimed at improving governance and patient safety (and therefore reducing the risk of patient deaths). The Trust’s PFD response acknowledges the assistance provided by the reasonable recommendations made by the Review, which the Trust has acted upon to drive improvements in service. We also understand that the surgeons, cardiologists and anaesthetists held individual discussions with Review panel members following the Review being completed, and they accepted the recommendations made by the Review panel.” 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 Health Education England decided to remove trainees from St George’s cardiac surgery service and owns the related training decision.
Verbatim wording from the response “It is stated in the PFD report that training has been severely constrained. For the avoidance of doubt, we understand from the Trust that the decision to remove trainees from St George’s cardiac surgery service was taken by Health Education England (HEE) on 11 September 2018 before the Review was commenced. The Trust’s PFD response provides further detail on HEE reasoning for their decision, and the subsequent reviews that they have undertaken, and data regarding the relative stability of staff numbers. These are not matters arising from the Review. The Trust’s response also evidences the mitigation in place to support continued high quality care despite the removal of trainees. In addition, the South London cardiac surgery network ensures appropriate access to high quality care for patients in need of that 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 The regional cardiac surgery network and alternative capable centres provide appropriate access when patients are diverted or complex care is unavailable locally.
Verbatim wording from the response “We defer to the Trust’s detailed response regarding the paucity of incidents arising from the diversion of patients linked to restriction of cardiac surgery capacity. As commissioners, we are unaware of any specific deaths arising from the clinical pathways arrangements for patients during the restrictions outlined earlier in this response. The Trust has described a single emergency care incident in which the restrictions were found to have been one of a number of factors that may have delayed care. We would welcome established facts and corresponding data and evidence from you, if this is the case, so that we or the Trust may investigate further.” 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 patient-safety and staff-wellbeing concerns are matters for St George’s University Hospital NHS Foundation Trust to address.
Verbatim wording from the response “We defer to the Trust’s response to the PFD to address this concern, as it reflects a local response to supporting the wellbeing of clinicians and Trust staff generally, and specifically in relation to maintaining patient safety. We are unaware of any objective evidence to suggest that the Review has caused a lower standard of care being provided to patients, and indeed the Trust’s subsequent CQC inspection, recent visit by HEE and good mortality outcomes detailed in the Trust’s PFD response all objectively evidence assurance of safe care. We would be grateful if you would provide any evidence of a lower quality of care being provided, in order that either NHSE or the Trust can investigate this further and offer support, if needed.” 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 cardiac surgery restrictions were necessary and proportionate responses to serious concerns, rather than apparently unnecessary measures increasing mortality risk.
Verbatim wording from the response “We have been unable to identify the evidence base for this concern. For the reasons outlined in significant detail in the Trust’s response, it was clear that the restrictions put in place were necessary and proportionate in response to serious concerns raised and investigated, prior to the commissioning of the Review referenced in the PFD report. These concerns arose from multiple different sources prior to the Review, and we believe that as a matter of public confidence, both commissioners and providers must respond to concerns and protect and promote patient safety.” 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 No tangible data supports claims that patients were discouraged from attending St George’s or faced increased mortality because of reduced public confidence.
Verbatim wording from the response “Any loss of confidence in services would be regrettable. However we would observe, as commissioners of services across London, that if patients requiring cardiac surgery do not wish to present to St George’s Hospital, there are other local centres within the cardiac surgery network which have eminently capable cardiac surgery units, to which patients can present or be referred. We are not aware of any tangible data to support the suggestion that “patients are discouraged” 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 There is no evidence that the Review or resulting actions caused patient harm, increased mortality, or lower-quality care.
Verbatim wording from the response “In terms of impact, we are not aware of any evidence to suggest that the Review, or any action taken in response to it, has resulted in any patient coming to harm, or indeed death (as stated in your paragraph 5 – see further below). The PFD response from the Trust provides further detail regarding the absence of any connection between the Review and additional safety issues flowing from actions taken by the Trust in response to the Review.” Source location Response from NHS England
Open published response
28 Apr 2022 Vilem Bock · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of clear national protocols to prevent language barriers to accessing care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Vilem Bock · 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
Vilem Bock was admitted to Tameside General Hospital with sepsis and suspected pulmonary embolism, but his CTPA was delayed because arrangements for an interpreter were not made. He developed a large retroperitoneal haematoma while receiving anticoagulation, subsequently developed sepsis, and died after further deterioration. The report raised concern about the lack of clear national protocols to prevent language barriers from obstructing access to care.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of clear national protocols to prevent language barriers to accessing care
Wider context from the report “1. The Trust in question has taken steps since the death of Mr Bock to improve the identification of the need for an interpreter to prevent language being a barrier to access to treatment. However, it was unclear from the evidence given that from a national perspective there were protocols in place to ensure that other Trusts would avoid a similar situation arising where language was a barrier to accessing care
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Encourage Trusts to review interpreter systems and processes to prevent similar access failures.
Verbatim wording from the response “I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors and other clinical and quality colleagues from across the regions. Trusts have been encouraged to review their systems and processes for interpreters to avoid a similar situation arising. This ensures that key learnings and insights around events, such as the sad death of Mr Bock, are shared across the NHS at both a national and regional level, and helps us to pay close attention to any emerging trends that may require further review and action.” Source location Response from NHS England
Open published response
×
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 NHS translation and interpretation framework arrangements provide Trusts with access to services addressing language barriers in care.
Verbatim wording from the response “Following the inquest, you raised concerns in your Report regarding whether, from a national perspective, there were protocols in place to ensure that other Trusts would avoid a similar situation arising where language was a barrier to accessing care.” Source location Response from NHS England
Open published response
Concerns raised 10 Lack of multidisciplinary clinical assessment and formulation addressing autism View source Gap in acute and crisis mental health support alongside commissioned autism care View source Lack of local specialist autism assessment and adapted psychological therapy View source Failure to understand autism-related trauma in risk assessment View source Failure to respond promptly to distress and remove discounted diagnostic references View source Failure of communication and shared information across autism and mental health teams View source Failure to make timely reasonable sensory and environmental adjustments View source Failure to provide a care coordinator and effective care plan View source Lack of person-centred autism-informed holistic care planning View source Failure to avoid attributing an undiagnosed personality disorder to an autistic patient View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Zoe Emma ZAREMBA · 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
Zoe Emma ZAREMBA, who had a history of repeated self-harm and suicide attempts, ingested an unknown quantity of a substance after going missing from home and was found unresponsive on 21 June 2020; her death was established as resulting from the ingestion. The report identified concerns about clinicians’ failure to understand and adapt care to her autism, the unsubstantiated attribution of Emotionally Unstable Personality Disorder, inadequate coordinated mental health support, and the absence of effective care planning and risk assessment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of multidisciplinary clinical assessment and formulation addressing autism
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism ;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Gap in acute and crisis mental health support alongside commissioned autism care
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of local specialist autism assessment and adapted psychological therapy
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy . Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to understand autism-related trauma in risk assessment
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe .
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to respond promptly to distress and remove discounted diagnostic references
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution . There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of communication and shared information across autism and mental health teams
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working , that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to make timely reasonable sensory and environmental adjustments
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all ;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a care coordinator and effective care plan
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of person-centred autism-informed holistic care planning
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender . As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to avoid attributing an undiagnosed personality disorder to an autistic patient
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”) .
3 That attribution was not formally diagnosed , and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” 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 Use project learning and research to inform guidance and support for improved autism diagnostic assessments.
Verbatim wording from the response “• £7 million for local areas to test ways to improve the quality of autism diagnostic pathways. This funding supported a wide range of projects that tested new ways to support people and their families through the autism diagnostic pathway (39 projects for children and young people and 25 projects for adults: a total of 64 one-off projects). The projects are still underway, and outcomes are expected to be reported to the programme later this year and into early 2023. We will use the learning from these projects along with any available research to inform guidance/support for local systems on how to improve the quality and access to autism diagnostic assessments including pre and post diagnostic support” 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 Fund projects improving sensory environments in mental health hospitals through environmental changes, staff training and patient-experience learning.
Verbatim wording from the response “• £4 million for a range of projects across the country to improve the sensory environment of mental health hospitals. There were 40 projects across the country aimed at environmental changes to accommodate sensory needs of autistic people in mental health inpatient settings. The projects delivered changes to the physical environment and/or training for staff on the sensory needs of autistic people and/or learning from the experiences of patients.” 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 Fund autism training for staff working in adult mental health inpatient settings.
Verbatim wording from the response “In the context of the NHS Long Term Plan, initiatives have been undertaken by NHS England that are of relevance to the issues raised following Zoe’s death. This includes one off funding made in 2021/2022 for future improvements, to include:” 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 projects testing improvements to autism diagnostic pathways.
Verbatim wording from the response “In the context of the NHS Long Term Plan, initiatives have been undertaken by NHS England that are of relevance to the issues raised following Zoe’s death. This includes one off funding made in 2021/2022 for future improvements, to include:” 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 a sensory-friendly resource pack for health trusts and Integrated Care Systems.
Verbatim wording from the response “The University of Reading were also been asked to develop a sensory assessment tool for use in mental health hospitals and we commissioned the National Development Team for Inclusion (NDTi) to develop Ten Sensory Friendly Ward Principles as part of the “It’s Not Rocket Science” work; see here for details. The Ten Principles are focused on the, often quite small, changes needed to ward environments to improve the sensory environment for autistic people. The principles were used to inform the development and delivery of the sensory projects programme in 2021/2022 so that projects had to demonstrate how the principles were used. We are currently developing a sensory friendly resource pack for health Trusts and Integrated Care Systems (ICSs).” Source location Response from NHS England
Open published response
7 Mar 2022 Josephine Celia BARKER · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 14 Early termination of 999 call triage before completion View source Failure to follow up a paramedic request for recategorisation with clinical discussion View source Failure to recognise drowsiness as a new symptom requiring re-triage View source Unavailability of clinicians for two-hour clinical review View source Failure to distinguish persistent vomiting from initial post-injury vomiting View source Absence of Clinical Safety Navigator management of Welfare Stack priority View source Absence of ongoing clinician input and clinical assessment during prolonged emergency call handling View source Failure to obtain available healthcare professional assessment early in call handling View source Failure to contextualise questions about worsening condition across callers View source Major trauma protocol failing to recognise potentially serious low-speed vehicle impact with head injury View source Failure to make callbacks after dropped calls and at the two-hour mark View source Failure to keep continuous CAD records updated with changing patient information View source Lack of policy guiding diversion of an allocated ambulance en route View source NHS Pathways tool failing to support triage of fluctuating or impaired consciousness View source See 11 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Josephine Celia BARKER · 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
Josephine Celia Barker suffered an unwitnessed fall and serious head injury in an Aldi car park on 15 February 2019. She waited over two hours for an ambulance after five 999 calls, and later died from her injuries on 3 March 2019. The principal concerns included inadequate triage and re-triage, failure to use clinical information from paramedics at the scene, lack of callbacks and clinical review, and the diversion of an allocated ambulance to a welfare briefing.
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 Early termination of 999 call triage before completion
Wider context from the report “1. The initial early exit of the first 999 call without full triage - this results in a category 3 response. There is no reason full triage could not have continued .
” 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 up a paramedic request for recategorisation with clinical discussion
Wider context from the report “12. The off-duty paramedic request re categorisation was not followed and the challenge to it did not lead to a clinical discussion .
” 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 recognise drowsiness as a new symptom requiring re-triage
Wider context from the report “9. When Jo was reported as drowsy, this was not considered as a new symptom and she was not re-triaged .
” 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 clinicians for two-hour clinical review
Wider context from the report “6. There should have been a clinical review at 2 hours . I have heard that there was not because there were not enough clinicians available .
” 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 distinguish persistent vomiting from initial post-injury vomiting
Wider context from the report “11. Jo’s vomiting was not the same symptom over time . Vomiting initially after a head injury is not the same as still vomiting after it two hours later .
” 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 Clinical Safety Navigator management of Welfare Stack priority
Wider context from the report “4. There was no Clinical Safety Navigator in place to manage the Welfare Stack . This is an alert that gives an indication to those viewing the list of cases waiting for an ambulance of the priority of the call within its category. Jo’s case had a number of features which would have led to it becoming a priority within its category and potentially being upgraded : the incident was outside and therefore less safe and comfortable than waiting in a home/workplace; the day was very cold and there was a risk of hypothermia particularly as Jo was lightly dressed in gym clothes and lying on the asphalt of the car park floor and as time passed she had been waiting a long time and finally her case breached its time limit.
” 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 ongoing clinician input and clinical assessment during prolonged emergency call handling
Wider context from the report “5. At no point did a clinician have any input into the calls after the initial question from the call handler of call 1 as to whether this was major trauma or not and therefore there was no clinical assessment by SECAMBS of Jo’s condition over the following two and a half hours : she was vomiting for over two hours after the fall, she had fluctuating consciousness and was rousable to shaking and not to voice. She had had a tonic-clonic seizure and had potentially been injured by being hit by a car. She was unable to open her eyes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain available healthcare professional assessment early in call handling
Wider context from the report “3. An off-duty paramedic was on scene throughout and had clinical experience which was not asked for until the final 999 call when the call handler was passed to him by the second off-duty paramedic (from HART) who had arrived on scene and made the call. There has been no reason given as to why the off-duty paramedic’s assessment was not asked for earlier and I was told that there is a policy in place with reference to Health Care Professionals which has since been updated but does
” 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 contextualise questions about worsening condition across callers
Wider context from the report “10. When speaking to different members of the public the questions about worsening condition were not contextualised so the caller is unable to be sure what information the call handler already has .
” 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 Major trauma protocol failing to recognise potentially serious low-speed vehicle impact with head injury
Wider context from the report “2. London Ambulance have a different major trauma protocol to SECAMBS and the fact that Jo had been potentially hit by a car – even moving slowly- and had a head injury would have been enough for the Major Trauma protocol for London Ambulance. SECAMBS major trauma protocol was not triggered because even if she had been hit by a car it was not moving fast enough to justify a major trauma category (cat 2) .
” 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 callbacks after dropped calls and at the two-hour mark
Wider context from the report “7. There were no callbacks made either to the caller whose call was dropped or to any of the callers at the 2 hour mark .
” 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 keep continuous CAD records updated with changing patient information
Wider context from the report “13. The continuous CAD was not kept updated with details of Jo’s condition or other useful information when each of the calls came in.
” 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 policy guiding diversion of an allocated ambulance en route
Wider context from the report “14. Call sign 239 was diverted to a welfare briefing after it had been allocated. There is no policy guiding making this decision after allocation has been made and the ambulance is en route .
” 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 NHS Pathways tool failing to support triage of fluctuating or impaired consciousness
Wider context from the report “8. There is a concern over the NHS Pathways tool’s ability to deal with fluctuating consciousness . This is because there is only an assessment on conscious or on unconscious so moving between the two states triggers the call handler to move into the conscious or unconscious pathway respectively but is not able to take into account fully that consciousness level is impaired or mixed . This is considered as a huge challenge to any call handler even a clinician as it then is not established if the patient is conscious or unconscious and it forces the call handler to restart triage with each change . I was told that this can
” 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 Incorporate feedback about fluctuating consciousness into the ongoing NHS Pathways review and governance cycle.
Verbatim wording from the response “NHS Pathways have not been advised that this principle is a challenging one for health advisors to date but will take this feedback into account in our ongoing review and governance cycle.” Source location Response from NHS Improvement
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 NHS Pathways early-exit options and clinical validation arrangements adequately manage complex or incompletely triaged calls.
Verbatim wording from the response “NHS Pathways has a function called ‘Early Exit’ which the health advisors can use for certain scenarios and reasons.” Source location Response from NHS Improvement
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 training and triage functions adequately address changing or fluctuating consciousness during calls.
Verbatim wording from the response “Health advisors are supported with training materials and undergo core learning. NHS Pathways provides a number of training materials which support health advisors relating to the identification of consciousness, unconsciousness or reduced consciousness. This includes a ‘Hot Topics on Levels of Consciousness and Checking Breathing and Consciousness’. Assessing consciousness is also heavily featured throughout the Pre-Module Learning for Core Module 1 (with a dedicated section on Levels of Consciousness, there is a video to support this). This material includes the following statement: “If you were presented with a patient who couldn’t be woken or was very difficult to wake (unconscious or semi-conscious), you would need to select” Source location Response from NHS Improvement
Open published response
22 Feb 2022 VAN THAI TUYEN · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Lack of a unified approach to address ongoing use of misplaced nasogastric tubes View source Continuing use of misplaced nasogastric tubes to administer liquids or medications 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
VAN THAI TUYEN · 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
Van Thai Tuyen was admitted to hospital for stroke treatment and, after a nasogastric tube was misplaced into his right lung, approximately 300ml of liquid feed was administered through it. He died from cavitating necrotising pneumonia. The principal concerns were the use of misplaced nasogastric tubes, the recurrence of such incidents, and the absence of a unified approach to preventing avoidable deaths from this problem.
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 unified approach to address ongoing use of misplaced nasogastric tubes
Wider context from the report “(1) Using a misplaced nasogastric tube is recognised as a ‘never event’, namely an event which is wholly preventable and should never happen.
(2) The court heard evidence at the inquest that an NHS improvement patient safety alert issued in 2016 identified that between 2011-2016 there had been 95 incidents of misplaced nasogastric tubes used to administer fluids or medication, 32 of which resulted in death.
(3) The court heard that there had been Barts NHS Trust had had at least 7 incidents relating to misplaced nasogastric tube since 2012.
(4) The court heard that the use of misplaced nasogastric tubes to administer liquids or medications continues to take place in Trusts across the country
(5) The court heard that there is no unified approach to address the on going issue of avoidable deaths caused by using misplaced nasogastric tubes .
” 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 use of misplaced nasogastric tubes to administer liquids or medications
Wider context from the report “(1) Using a misplaced nasogastric tube is recognised as a ‘never event’, namely an event which is wholly preventable and should never happen.
(2) The court heard evidence at the inquest that an NHS improvement patient safety alert issued in 2016 identified that between 2011-2016 there had been 95 incidents of misplaced nasogastric tubes used to administer fluids or medication, 32 of which resulted in death.
(3) The court heard that there had been Barts NHS Trust had had at least 7 incidents relating to misplaced nasogastric tube since 2012.
(4) The court heard that the use of misplaced nasogastric tubes to administer liquids or medications continues to take place in Trusts across the country
(5) The court heard that there is no unified approach to address the on going issue of avoidable deaths caused by using misplaced nasogastric tubes.
” Open source report
15 Feb 2022 Mr Jason Lennon · Prevention of Future Deaths report East London
View report summary
Concerns raised 8 Failure to effectively review medical records before assessment View source CRT staff performance falling below regulator standards View source Failure to adequately document important information arising from assessment View source Failure to monitor whether patients are on care pathways appropriate to their needs View source Failure of governance processes to complete serious incident investigation action plans View source Failure to evidence consideration of necessary referrals to a regulator View source Failure to communicate important clinical information between CRT staff and external stakeholders View source Failure to assess mental state, relapse and risk of harm View source See 5 more concerns
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
Mr Jason Lennon · 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
Jason Lennon, a 37-year-old man living in supported accommodation, died on 31 July 2019 after being found unresponsive while restrained in a prone position by security officers at the Excel Centre; resuscitation efforts later ceased in hospital. The concerns included failures in community mental health care, including inadequate monitoring, assessment, communication and documentation, and the extent and manner of the restraint used by security officers. The report also identified deficiencies in the Trust’s serious incident action plan and uncertainty about whether regulatory referral had been considered.
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 effectively review medical records before assessment
Wider context from the report “2. The CRT undertook a flawed review of Mr Lennon’s mental state on 29/7/19 which failed to assess that, Jason was in relapse and was a risk of harm to himself and others.
Factors which contributed to this failure included;
a. CRT staff did not effectively review medical records prior to assessing Jason,
b. The CRT did not communicate important clinical information between themselves and external stakeholders.
c. The CRT did not adequately document important information arising from the 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 CRT staff performance falling below regulator standards
Wider context from the report “4. Accepted individual failings by staff within the CRT fall below standards set by their regulator. There is no evidence before the court to assess whether ELFT have considered the necessity to make a referral to a regulator.
” 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 document important information arising from assessment
Wider context from the report “2. The CRT undertook a flawed review of Mr Lennon’s mental state on 29/7/19 which failed to assess that, Jason was in relapse and was a risk of harm to himself and others.
Factors which contributed to this failure included;
a. CRT staff did not effectively review medical records prior to assessing Jason,
b. The CRT did not communicate important clinical information between themselves and external stakeholders.
c. The CRT did not adequately document important information arising from the 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 monitor whether patients are on care pathways appropriate to their needs
Wider context from the report “1. Expert psychiatric evidence indicated that Mr Lennon was a suitable candidate for the Care Programme Approach mental health pathway and that the use of this pathway would have reduced the risk of an acute deterioration in his mental state. The CRT failed to effectively monitor whether Mr Lennon was on a care pathway appropriate to his needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of governance processes to complete serious incident investigation action plans
Wider context from the report “3. The Trust undertook a serious incident investigation report into the events leading to Mr Lennon’s death in November 2019 which made a series of recommendations for action. The action plan was found to have been incomplete by 6/2/22 due to errors attributable to the Trust’s governance team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to evidence consideration of necessary referrals to a regulator
Wider context from the report “4. Accepted individual failings by staff within the CRT fall below standards set by their regulator. There is no evidence before the court to assess whether ELFT have considered the necessity to make a referral to a regulator.
” 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 important clinical information between CRT staff and external stakeholders
Wider context from the report “2. The CRT undertook a flawed review of Mr Lennon’s mental state on 29/7/19 which failed to assess that, Jason was in relapse and was a risk of harm to himself and others.
Factors which contributed to this failure included;
a. CRT staff did not effectively review medical records prior to assessing Jason,
b. The CRT did not communicate important clinical information between themselves and external stakeholders.
c. The CRT did not adequately document important information arising from the 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 assess mental state, relapse and risk of harm
Wider context from the report “2. The CRT undertook a flawed review of Mr Lennon’s mental state on 29/7/19 which failed to assess that, Jason was in relapse and was a risk of harm to himself and others.
Factors which contributed to this failure included;
a. CRT staff did not effectively review medical records prior to assessing Jason,
b. The CRT did not communicate important clinical information between themselves and external stakeholders.
c. The CRT did not adequately document important information arising from the assessment.
” Open source report
Concerns raised 1 Failure to use clear and non-confusable communication and expression of numbers for medication dosages 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
John Paul SKINNER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Paul SKINNER was admitted to Watford Hospital on 15 May 2020 after suffering tonic clonic seizures and was given phenytoin. A verbal communication failure led to 15 mg/kg being heard as 50 mg/kg, resulting in an overdose; he arrested and died. The principal concern was that unclear communication of dosage could lead to foreseeable medication errors in hospitals.
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 use clear and non-confusable communication and expression of numbers for medication dosages
Wider context from the report “(1) The Junior doctor instructed to administer phenytoin did not know the required dosage and asked his more senior colleague for advice. The senior doctor's reply 15mk/kg was heard by the junior doctor as 50mg/kg resulting in administration of a significant overdose.
This is a readily foreseeable confusion which could apply in any hospital and could be avoided by use of clearer and less confusable
means of communication and expression of number
” Open source report
8 Feb 2022 Benjamin Lee Stroud · Prevention of Future Deaths report Essex
View report summary
Concerns raised 3 Reliance on a Care Coordinator to make clinical decisions about MDT referral View source Failure to document the rationale for non-referral to the MDT View source Failure to ensure all cases go before the MDT 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
Benjamin Lee Stroud · 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
Benjamin Lee Stroud died at his home on 19 March 2021 after an overdose involving multiple drugs, including tramadol and alprazolam, with empty medication blister packets and insulin pens found around him. The report raised concerns that his case was not referred to the multidisciplinary team despite escalating psychosis, that the Care Coordinator made the referral decision without a recorded rationale, and that this practice posed a risk of future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Reliance on a Care Coordinator to make clinical decisions about MDT referral
Wider context from the report “That in all cases must go before the MDT, the evidence in this inquest, made it clear that had Mr Stroud’s case had been discussed at an MDT then more help would have been made available to him, that he would have been seen by a psychiatrist and may have prevented his death.
On the evidence from EPUT and the PSIIR it was clear that the Care Coordinator makes the decisions as to whether to refer a case to the MDT , in this case, no entries were made around the rationale for none referral and no explanation was provided at the inquest. This is not the first time this issue has arisen at an Inquest and the reliance on a Care Coordinator to make a clinical decision and no written explanation provided on any clinical notes documented appears to be a way of working. If these practices continue there is a real risk of future deaths occurring.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to document the rationale for non-referral to the MDT
Wider context from the report “That in all cases must go before the MDT, the evidence in this inquest, made it clear that had Mr Stroud’s case had been discussed at an MDT then more help would have been made available to him, that he would have been seen by a psychiatrist and may have prevented his death.
On the evidence from EPUT and the PSIIR it was clear that the Care Coordinator makes the decisions as to whether to refer a case to the MDT, in this case, no entries were made around the rationale for none referral and no explanation was provided at the inquest. This is not the first time this issue has arisen at an Inquest and the reliance on a Care Coordinator to make a clinical decision and no written explanation provided on any clinical notes documented appears to be a way of working. If these practices continue there is a real risk of future deaths occurring.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure all cases go before the MDT
Wider context from the report “That in all cases must go before the MDT , the evidence in this inquest, made it clear that had Mr Stroud’s case had been discussed at an MDT then more help would have been made available to him, that he would have been seen by a psychiatrist and may have prevented his death .
On the evidence from EPUT and the PSIIR it was clear that the Care Coordinator makes the decisions as to whether to refer a case to the MDT, in this case, no entries were made around the rationale for none referral and no explanation was provided at the inquest. This is not the first time this issue has arisen at an Inquest and the reliance on a Care Coordinator to make a clinical decision and no written explanation provided on any clinical notes documented appears to be a way of working. If these practices continue there is a real risk of future deaths occurring.
” Open source report
Concerns raised 8 Inadequate communication with primary and secondary care providers View source Failure to formally update Care Plans and Risk Assessments thoroughly and timely View source Failure to recognise the need to escalate patient issues to multidisciplinary meetings or experienced supervisors View source Failure to maintain basic care records, including contacts and failed contacts View source Incomplete and inadequate recording of Care Coordinator supervision sessions View source Insufficient attention to the clinical significance of patient disengagement from services View source Inadequate formal training for Care Coordinators View source Lack of records of the nature, extent and duration of on-the-job or shadowing training View source See 5 more concerns
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
John David 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
John David Moore had a history of homelessness, mental health issues, substance misuse and previous suicide or serious self-harm incidents. He died by suicide on 10 June 2021 while homeless, after no recorded intervention from primary or secondary care since 2020. The report identified concerns about inadequate training and supervision of EPUT Care Coordinators, including shortcomings in record keeping, care planning, communication, recognition of disengagement and escalation of concerns.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication with primary and secondary care providers
Wider context from the report “(2) The evidence in this case, and in other recent inquests heard by me and fellow coroners in this jurisdiction, establishes the following common themes in respect to the inadequate performance of several EPUT Care Coordinators. In my settled view, these themes are (at least to a significant degree) a consequence of inadequate training for the role:
(i) failure to maintain basic record keeping generally and, particularly, with respect to the recording of contacts or, potentially importantly, failed contacts with the deceased in the weeks and months prior to a self-inflicted death;
(ii) a failure to formally up-date Care Plans and Risk Assessments in a thorough and/or timely fashion, or at all;
(iii) inadequate communication with other primary and secondary care providers ;
(iv) consistently, insufficient attention to the potential clinical significance of ‘disengagement’ with services by patients;
(v) failure to recognise the need to raise issues relating to a patient with the Multi-Disciplinary Team Meetings or in supervision with experienced supervisors.
” 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 formally update Care Plans and Risk Assessments thoroughly and timely
Wider context from the report “(2) The evidence in this case, and in other recent inquests heard by me and fellow coroners in this jurisdiction, establishes the following common themes in respect to the inadequate performance of several EPUT Care Coordinators. In my settled view, these themes are (at least to a significant degree) a consequence of inadequate training for the role:
(i) failure to maintain basic record keeping generally and, particularly, with respect to the recording of contacts or, potentially importantly, failed contacts with the deceased in the weeks and months prior to a self-inflicted death;
(ii) a failure to formally up-date Care Plans and Risk Assessments in a thorough and/or timely fashion, or at all ;
(iii) inadequate communication with other primary and secondary care providers;
(iv) consistently, insufficient attention to the potential clinical significance of ‘disengagement’ with services by patients;
(v) failure to recognise the need to raise issues relating to a patient with the Multi-Disciplinary Team Meetings or in supervision with experienced supervisors.
” 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 recognise the need to escalate patient issues to multidisciplinary meetings or experienced supervisors
Wider context from the report “(2) The evidence in this case, and in other recent inquests heard by me and fellow coroners in this jurisdiction, establishes the following common themes in respect to the inadequate performance of several EPUT Care Coordinators. In my settled view, these themes are (at least to a significant degree) a consequence of inadequate training for the role:
(i) failure to maintain basic record keeping generally and, particularly, with respect to the recording of contacts or, potentially importantly, failed contacts with the deceased in the weeks and months prior to a self-inflicted death;
(ii) a failure to formally up-date Care Plans and Risk Assessments in a thorough and/or timely fashion, or at all;
(iii) inadequate communication with other primary and secondary care providers;
(iv) consistently, insufficient attention to the potential clinical significance of ‘disengagement’ with services by patients;
(v) failure to recognise the need to raise issues relating to a patient with the Multi-Disciplinary Team Meetings or in supervision with experienced supervisors .
” 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 maintain basic care records, including contacts and failed contacts
Wider context from the report “(2) The evidence in this case, and in other recent inquests heard by me and fellow coroners in this jurisdiction, establishes the following common themes in respect to the inadequate performance of several EPUT Care Coordinators. In my settled view, these themes are (at least to a significant degree) a consequence of inadequate training for the role:
(i) failure to maintain basic record keeping generally and, particularly, with respect to the recording of contacts or, potentially importantly, failed contacts with the deceased in the weeks and months prior to a self-inflicted death;
(ii) a failure to formally up-date Care Plans and Risk Assessments in a thorough and/or timely fashion, or at all;
(iii) inadequate communication with other primary and secondary care providers;
(iv) consistently, insufficient attention to the potential clinical significance of ‘disengagement’ with services by patients;
(v) failure to recognise the need to raise issues relating to a patient with the Multi-Disciplinary Team Meetings or in supervision with experienced supervisors.
” 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 and inadequate recording of Care Coordinator supervision sessions
Wider context from the report “(3) The evidence received in the course of Mr Moore's inquest disclosed that the record keeping of supervision sessions , where a Care Coordinator might seek or be provided with further advice and support from a senior colleague, was incomplete and inadequate .
” 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 attention to the clinical significance of patient disengagement from services
Wider context from the report “(2) The evidence in this case, and in other recent inquests heard by me and fellow coroners in this jurisdiction, establishes the following common themes in respect to the inadequate performance of several EPUT Care Coordinators. In my settled view, these themes are (at least to a significant degree) a consequence of inadequate training for the role:
(i) failure to maintain basic record keeping generally and, particularly, with respect to the recording of contacts or, potentially importantly, failed contacts with the deceased in the weeks and months prior to a self-inflicted death;
(ii) a failure to formally up-date Care Plans and Risk Assessments in a thorough and/or timely fashion, or at all;
(iii) inadequate communication with other primary and secondary care providers;
(iv) consistently, insufficient attention to the potential clinical significance of ‘disengagement’ with services by patients ;
(v) failure to recognise the need to raise issues relating to a patient with the Multi-Disciplinary Team Meetings or in supervision with experienced supervisors.
” 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 formal training for Care Coordinators
Wider context from the report “(1) EPUT Care Coordinators receive inadequate training for the role . Care Coordinators carry significant responsibilities to coordinate the care provided to an often extremely vulnerable cohort of patients. This responsibility was significantly heightened in the context of the Covid-19 pandemic, and the accompanying periods of ‘lockdown’, when vulnerable and often isolated sufferers of mental health illness and disorders, including those with substance misuse issues, became increasingly isolated and thus increasingly vulnerable. Notwithstanding the imposition of this additional responsibility, the evidence in this and similar coronial investigations has established that Care Coordinators receive no formal training for the role and, at best, are introduced to it via the ‘shadowing’ of colleagues ‘on the job’ . At inquest evidence was provided by an experienced (Band 8a) EPUT Clinical Manager that the lack of formal training for the pivotal role of Care Coordinator within EPUT is one that reflects the same practice in NHS Trusts across the country.
” 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 records of the nature, extent and duration of on-the-job or shadowing training
Wider context from the report “(4) A lack of formal (or even informal) records of the nature, extent or duration of ad hoc ‘on the job’/shadowing’ training , apparently provided to new Care Coordinators.
” Open source report
16 Jan 2022 Luke Richard WILDEN · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 2 Inadequate transition arrangements for individuals with high functioning autism reaching adulthood View source National gap in transition services for individuals with high functioning autism View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Luke Richard WILDEN · 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
Luke Richard WILDEN was a vulnerable adult with high functioning autism and ADHD who, after turning 18, was not effectively transitioned from child to adult mental health services or provided with an appropriate social care package. He moved to independent living on 2 January 2020, experienced declining mental health and drug misuse, and was found deceased in his flat on 22 May 2020 after being discharged from psychiatric inpatient care. The principal concerns were inadequate transition arrangements within ELFT and a possible wider national gap in services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequate transition arrangements for individuals with high functioning autism reaching adulthood
Wider context from the report “Transition arrangements within ELFT for individuals with high functioning autism were inadequate when Luke turned 18 and, as a result, he was not transferred to the appropriate adult mental health team for continued treatment and to enable provision of an appropriate adult social care package, including suitable accommodation for him . Whilst I understand that changes have been made within ELFT in order to address this gap in services, I am concerned that these may still not be sufficient . Furthermore, I am concerned that this gap in services may also exist on a national level.
” 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 National gap in transition services for individuals with high functioning autism
Wider context from the report “Transition arrangements within ELFT for individuals with high functioning autism were inadequate when Luke turned 18 and, as a result, he was not transferred to the appropriate adult mental health team for continued treatment and to enable provision of an appropriate adult social care package, including suitable accommodation for him. Whilst I understand that changes have been made within ELFT in order to address this gap in services, I am concerned that these may still not be sufficient. Furthermore, I am concerned that this gap in services may also exist on a national level .
” 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 Prioritise transition within the Learning Disability and Autism Programme and work with partner agencies on an effective cross-system response to young people experiencing difficulty or crisis.
Verbatim wording from the response “It is for this reason that we have made transition one of the key priorities for the Learning Disability and Autism Programme and are working with partners in other agencies to ensure there is an effective cross system response to young people experiencing difficulty and crisis.” Source location 2022-0015-Response-from-NHS-Improvement_Published
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 Establish a comprehensive mental health support offer for people aged 0–25 in every area, without age-based thresholds and adapted to young adults’ needs.
Verbatim wording from the response “Improving transitions between Children and Young People’s Mental Health Services and Adult Mental Health Services is a key priority within NHSE/I’s LTP commitments regarding mental health. The LTP sets out a commitment that a comprehensive support offer for children and young people, between the ages of 0 to 25 years, would be in place in all areas of the country by March 2024. Critical to this ambition is improving support and care for young adults (18 to 25 years) with the expectation that by March 2024 no age-based threshold will be in place and that all services are adapted to meet the needs of young adults.” Source location 2022-0015-Response-from-NHS-Improvement_Published
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 Ensure NHS services make reasonable adjustments to better meet autistic people’s needs.
Verbatim wording from the response “NHSE/I are committed to improving care and support for autistic people. The LTP recognised the need to ensure all NHS services are reasonably adjusted to ensure they are better able to meet the needs of autistic people. We know that the transition to adult services does not always work well for children and young people and their families, acknowledging that this was the case here. It is so important that there are good multi-agency planning/actions, before young people turn 18, to ensure that they get the support they need as they move to adulthood services. It is even more important that there is effective support for young people, such as Luke, who experience multiple additional challenges.” Source location 2022-0015-Response-from-NHS-Improvement_Published
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 ELFT is responsible for responding directly regarding Luke’s transition arrangements to adult mental health services.
Verbatim wording from the response “Following the inquest, you raised concerns in your Report regarding the adequacy of transition arrangements within East London Foundation Trust (ELFT) for individuals with high functioning autism, stating that when Luke turned 18, he was not transferred to the appropriate adult mental health team for continued treatment and to enable provision of an appropriate adult social care package, including suitable accommodation for him. You raised a second concern that this gap in services may also exist on a national level.” Source location 2022-0015-Response-from-NHS-Improvement_Published
Open published response
14 Jan 2022 Jan Goodliffe · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2 Failure to use medically qualified clinicians in home assessments View source Failure to seek qualified medical advice on medication interactions 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
Jan Goodliffe · 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
Jan Goodliffe died on 15 June 2021 several days after taking his own life, following a recent suicide attempt and a history of mental health problems. The report raises concerns that social workers, rather than medically qualified clinicians, assessed him despite information about his suicide risk and recent restart of medication, and that opportunities to obtain qualified medical advice may have been missed.
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 use medically qualified clinicians in home assessments
Wider context from the report “That the Clinicians who attended to assess Mr Goodliffe where not medically qualified, they were social workers . They were presented with evidence around a serious attempt by Mr Goodliffe to take his own life that he had been doing by a family member. ████████ gave all this information at the assessment along with the recent reintroduction of the Bi Polar medication, and the facts of the previous reintroduction when starting this medication and the time taken for this medication to start to work. As they were unqualified medical practitioners, there were missed opportunities to seek qualified medical advice around the interactions of the medication and whether as a result of this contributed to his death.
I am concerned that suitably medically qualified clinicians are not being used in the home assessments and decisions are being made around issues that require medical expertise.
” 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 seek qualified medical advice on medication interactions
Wider context from the report “That the Clinicians who attended to assess Mr Goodliffe where not medically qualified, they were social workers. They were presented with evidence around a serious attempt by Mr Goodliffe to take his own life that he had been doing by a family member. ████████ gave all this information at the assessment along with the recent reintroduction of the Bi Polar medication, and the facts of the previous reintroduction when starting this medication and the time taken for this medication to start to work. As they were unqualified medical practitioners, there were missed opportunities to seek qualified medical advice around the interactions of the medication and whether as a result of this contributed to his death.
I am concerned that suitably medically qualified clinicians are not being used in the home assessments and decisions are being made around issues that require medical expertise .
” Open source report
Concerns raised 16 Under-reporting of eating disorder deaths to the coroner View source Lack of clear responsibility for monitoring and co-ordinating community eating disorder care View source Absence of an acute hospital liaison psychiatry service View source Poor and inaccurate compilation of clinical documentation View source Poor nursing care for patients with eating disorders View source Lack of dissemination and understanding of MARSIPAN guidance among medical professionals View source Lack of appropriate investigation and learning from eating disorder deaths View source Failures and delays in maintaining and re-referring patients on the Priory waiting list View source Unclear Priory referral and admission criteria for medically stable patients with low BMI View source Absence of an allocated consultant psychiatrist for CEDS in Bury and six other Manchester boroughs View source Failure to conduct incident reviews of referral failures View source Failure to closely monitor food intake and purging behaviours View source Absence of pathways for acute clinicians to access specialist eating disorder advice View source Lack of formally commissioned community monitoring provision for moderate- or high-risk eating disorder patients View source Exclusion of patients with BMI below 14 from the Community Eating Disorder Service View source Failure to maintain nutrition and fluid charts View source See 13 more concerns
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
Nichola Jane Lomax · 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
Nichola Jane Lomax had a long history of an eating disorder and attended hospital several times in 2020 with severe malnutrition and electrolyte imbalance. She died on 3 August 2020 after delays and failings involving hospital treatment, specialist referral, communication, monitoring, nutritional care and access to appropriate services. The report identified concerns about inadequate eating-dis disorder training, access to specialist advice, referral criteria, critical services, community monitoring, nursing care and investigation of deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Under-reporting of eating disorder deaths to the coroner
Wider context from the report “7) Lack of Recognition of the need to Investigate
For National Medical Examiner
It was of concern to the court that the only reason Nichola’s death was referred to HM Coroner was her initial medical cause of death had incorrectly included paracetamol toxicity. It was not until the court investigated this case, that there was any recognition by any of the agencies that there had been failings in the care of Nichola. If this death had not been reported to the Coroner, none of the above failings or the need for learning would have been identified. The court is extremely concerned that there is the real potential for under reporting of such cases and a lack of appropriate investigation to ensure learning is captured so as to prevent future deaths. This is important given the court heard eating disorders have the highest mortality rate of any mental disorder.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of clear responsibility for monitoring and co-ordinating community eating disorder care
Wider context from the report “3) Referral Criteria for the Priory and Community Eating Disorder Service
For GMMH, PRIORY, BURY CLINICAL COMMISSIONING, ICB
In Greater Manchester the Community Eating Disorder Service (CEDS) do not accept patients who have a BMI of less than 14. The court heard this is in part due to the structure and commissioning of the service. Adherence to this criteria had the following implications for Nichola’s care:
• As the only service who can refer to the Priory, CEDS became aware of Nichola. CEDS involvement created the impression that they were providing care to her. This created a confused picture as to who was co-ordinating her care .
• This meant that monitoring of Nichola was undertaken by the GP practice who were not specialists and had limited knowledge of eating disorders . It would have been more clinically appropriate for CEDS to have taken on this role and the court heard that in many other areas of the country the CEDS accept patients with BMIs lower than 14 and have responsibility for the monitoring and co-ordination of patients.
The Court heard evidence from a number of practitioners as to their understanding of the referral criteria for Nichola to be admitted to The Priory. The clear impression given by The Priory was that Nichola would not be accepted until 1) a bed became available but also 2) her BMI increased to somewhere around 12/13. The Court was told that the rationale for this is that a patient with a BMI below 13 is at high risk of refeeding according to MARSIPAN and more likely to require an acute hospital admission.
This impression meant that hospital clinicians and the GP understood that Nichola would not be accepted by the Priory until her weight had increased. However the court heard that the Priory can take someone with a BMI of less than 13 if medically stable and the benefits of specialist care outweigh the risks of refeeding. Given the impression created by the Priory no attempt was made to obtain an emergency bed for Nichola who was medically stable for some time after the 11th June.
” 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 an acute hospital liaison psychiatry service
Wider context from the report “4) Lack of Critical Services
For BURY CCG / ICB / GMHSCP
The Court heard evidence that despite FGH having a 24/7 Emergency Department, adherence had not been paid to NICE guidance which recommends the establishment of an Acute Liaison Psychiatry service. In this case the court heard that such a service would have provided continuity of care and psychiatric input. The only available psychiatry input at Fairfield hospital for the acute staff is either within the A&E department where there are psychiatric nurses or using the on-call psychiatrist, this post being on call for all psychiatry matters within the whole of Bury. There is no specific liaison psychiatric service for the Acute Hospital .
The evidence was that there is no Consultant Psychiatrist allocated to the CEDS in Bury or the 6 other boroughs of Manchester. However even though the CEDS is provided by the same mental health trust, it is only one of Manchester that does have an allocated Consultant Psychiatrist.
” 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 Poor and inaccurate compilation of clinical documentation
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care. There were no nutrition / fluid charts on her first admission in June. There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting information .
” 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 Poor nursing care for patients with eating disorders
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care . There were no nutrition / fluid charts on her first admission in June. There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting information.
” 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 dissemination and understanding of MARSIPAN guidance among medical professionals
Wider context from the report “1) Inadequate Training of doctors and other medical professionals re eating disorders
For National / NCA / Royal College of Psychiatrists
Over 30 members of the medical profession saw Nichola during her three admissions to FGH in 2020. Of those, only one had knowledge of MARSIPAN and his understanding of MARSIPAN was extremely limited. This is not a question of lack of familiarity by professionals, it reflects a complete absence of any understanding that MARSPAN exists and indeed how to implement it in respect of the emergency treatment of an anorexic patient .
Previous Regulation 28 reports suggests this remains an ongoing concern nationally and MARSIPAN is not being disseminated to practitioners on the ground .
Whilst MARSIPAN can be accessed via a link in the NICE guidance on Eating Disorders. My concern is that Acute Trusts may not have sufficient regard to Guidance issued by Royal College of Psychiatry which is relevant to the medical care which they provide.
” 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 appropriate investigation and learning from eating disorder deaths
Wider context from the report “7) Lack of Recognition of the need to Investigate
For National Medical Examiner
It was of concern to the court that the only reason Nichola’s death was referred to HM Coroner was her initial medical cause of death had incorrectly included paracetamol toxicity. It was not until the court investigated this case, that there was any recognition by any of the agencies that there had been failings in the care of Nichola. If this death had not been reported to the Coroner, none of the above failings or the need for learning would have been identified. The court is extremely concerned that there is the real potential for under reporting of such cases and a lack of appropriate investigation to ensure learning is captured so as to prevent future deaths . This is important given the court heard eating disorders have the highest mortality rate of any mental disorder.
” 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 Failures and delays in maintaining and re-referring patients on the Priory waiting list
Wider context from the report “7) Delay in Re-Referral
For GMMH/PRIORY
Due to a misunderstanding following the telephone discussion between the Priory and FGH on 11th June Nichola was clearly removed from the Priory waiting list . This led to confusion for the GP practice who did not know why she had been removed. There was then a delay by the CEDS in re-referring Nichola which meant only one bed being available. This should not have occurred and more worryingly had not been noted as there had been no incident review of this case by either the Priory or the CEDS.
” 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 Priory referral and admission criteria for medically stable patients with low BMI
Wider context from the report “3) Referral Criteria for the Priory and Community Eating Disorder Service
For GMMH, PRIORY, BURY CLINICAL COMMISSIONING, ICB
In Greater Manchester the Community Eating Disorder Service (CEDS) do not accept patients who have a BMI of less than 14. The court heard this is in part due to the structure and commissioning of the service. Adherence to this criteria had the following implications for Nichola’s care:
• As the only service who can refer to the Priory, CEDS became aware of Nichola. CEDS involvement created the impression that they were providing care to her. This created a confused picture as to who was co-ordinating her care.
• This meant that monitoring of Nichola was undertaken by the GP practice who were not specialists and had limited knowledge of eating disorders. It would have been more clinically appropriate for CEDS to have taken on this role and the court heard that in many other areas of the country the CEDS accept patients with BMIs lower than 14 and have responsibility for the monitoring and co-ordination of patients.
The Court heard evidence from a number of practitioners as to their understanding of the referral criteria for Nichola to be admitted to The Priory. The clear impression given by The Priory was that Nichola would not be accepted until 1) a bed became available but also 2) her BMI increased to somewhere around 12/13 . The Court was told that the rationale for this is that a patient with a BMI below 13 is at high risk of refeeding according to MARSIPAN and more likely to require an acute hospital admission.
This impression meant that hospital clinicians and the GP understood that Nichola would not be accepted by the Priory until her weight had increased. However the court heard that the Priory can take someone with a BMI of less than 13 if medically stable and the benefits of specialist care outweigh the risks of refeeding . Given the impression created by the Priory no attempt was made to obtain an emergency bed for Nichola who was medically stable for some time after the 11th June.
” 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 an allocated consultant psychiatrist for CEDS in Bury and six other Manchester boroughs
Wider context from the report “4) Lack of Critical Services
For BURY CCG / ICB / GMHSCP
The Court heard evidence that despite FGH having a 24/7 Emergency Department, adherence had not been paid to NICE guidance which recommends the establishment of an Acute Liaison Psychiatry service. In this case the court heard that such a service would have provided continuity of care and psychiatric input. The only available psychiatry input at Fairfield hospital for the acute staff is either within the A&E department where there are psychiatric nurses or using the on-call psychiatrist, this post being on call for all psychiatry matters within the whole of Bury. There is no specific liaison psychiatric service for the Acute Hospital.
The evidence was that there is no Consultant Psychiatrist allocated to the CEDS in Bury or the 6 other boroughs of Manchester . However even though the CEDS is provided by the same mental health trust, it is only one of Manchester that does have an allocated Consultant Psychiatrist.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct incident reviews of referral failures
Wider context from the report “7) Delay in Re-Referral
For GMMH/PRIORY
Due to a misunderstanding following the telephone discussion between the Priory and FGH on 11th June Nichola was clearly removed from the Priory waiting list. This led to confusion for the GP practice who did not know why she had been removed. There was then a delay by the CEDS in re-referring Nichola which meant only one bed being available. This should not have occurred and more worryingly had not been noted as there had been no incident review of this case by either the Priory or the CEDS .
” 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 closely monitor food intake and purging behaviours
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care. There were no nutrition / fluid charts on her first admission in June. There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting information.
” 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 pathways for acute clinicians to access specialist eating disorder advice
Wider context from the report “2) Accessing Specialist Advice
For National, NCA/GMMH/PRIORY
None of the practitioners in Nichola’s case knew how to access specialist eating disorder advice including medical or dietetic advice . There are no pathways to assist acute clinicians in how to access this specialist advice . To this day the clinicians told the Court they would not know where to go other than to try and contact the Priory. The Court heard from the Priory they are not commissioned to provide advice.
” 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 formally commissioned community monitoring provision for moderate- or high-risk eating disorder patients
Wider context from the report “5) Community Monitoring of patients with an Eating Disorder
For BURY CCG / NATIONAL / ICB/ GMHSCP
There is a lack of clarity as to whether there is any formally commissioned provision for the monitoring of moderate or high risk Eating Disorder patients within the community . The Court heard from GMHSCP that this was the responsibility of primary care however it was unclear whether this was known by those working in primary care and whether this service had ever been commissioned .
” 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 patients with BMI below 14 from the Community Eating Disorder Service
Wider context from the report “3) Referral Criteria for the Priory and Community Eating Disorder Service
For GMMH, PRIORY, BURY CLINICAL COMMISSIONING, ICB
In Greater Manchester the Community Eating Disorder Service (CEDS) do not accept patients who have a BMI of less than 14 . The court heard this is in part due to the structure and commissioning of the service. Adherence to this criteria had the following implications for Nichola’s care:
• As the only service who can refer to the Priory, CEDS became aware of Nichola. CEDS involvement created the impression that they were providing care to her. This created a confused picture as to who was co-ordinating her care.
• This meant that monitoring of Nichola was undertaken by the GP practice who were not specialists and had limited knowledge of eating disorders. It would have been more clinically appropriate for CEDS to have taken on this role and the court heard that in many other areas of the country the CEDS accept patients with BMIs lower than 14 and have responsibility for the monitoring and co-ordination of patients.
The Court heard evidence from a number of practitioners as to their understanding of the referral criteria for Nichola to be admitted to The Priory. The clear impression given by The Priory was that Nichola would not be accepted until 1) a bed became available but also 2) her BMI increased to somewhere around 12/13. The Court was told that the rationale for this is that a patient with a BMI below 13 is at high risk of refeeding according to MARSIPAN and more likely to require an acute hospital admission.
This impression meant that hospital clinicians and the GP understood that Nichola would not be accepted by the Priory until her weight had increased. However the court heard that the Priory can take someone with a BMI of less than 13 if medically stable and the benefits of specialist care outweigh the risks of refeeding. Given the impression created by the Priory no attempt was made to obtain an emergency bed for Nichola who was medically stable for some time after the 11th June.
” 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 maintain nutrition and fluid charts
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care. There were no nutrition / fluid charts on her first admission in June . There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting information.
” Open source report
Concerns raised 3 Lack of accessibility to records held by different healthcare trusts View source Failure of Emergency Department staff to access vital pre-admission and paramedic records View source Lack of access by other police forces to information held on individual police force systems View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Felicity Jane Clough · 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
Felicity Jane Clough was taken to hospital on 24 November 2019 after being prescribed Tramadol, discharged during the early morning, and later found collapsed and unresponsive in a field. The concerns included limited information-sharing between healthcare trusts and police forces, and the failure to consistently review paramedic records containing potentially critical information at Yeovil District Hospital.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of accessibility to records held by different healthcare trusts
Wider context from the report “i. There could be future deaths nationally due to the lack of accessibility to records held by different healthcare trusts . I would request consideration is given to the sharing of records between healthcare trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of Emergency Department staff to access vital pre-admission and paramedic records
Wider context from the report “iii. I have concerns that future deaths could occur at Yeovil District hospital due to the missing of vital information within the pre admission documentation due to the fact that the staff within the Emergency Department at Yeovil District Hospital are not always accessing admission documentation, especially the paramedic records when a person is brought into the Accident and Emergency department. I request that consideration is given to issuing further guidance to remind staff of the need to review this documentation or amending the current policy 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 access by other police forces to information held on individual police force systems
Wider context from the report “ii. I have concerns that future deaths could occur due to the lack of access to information held on individual Police force systems by other forces , especially neighbouring forces who may both have contact with individuals. Whilst I understand there is some work being done on a regional basis to address this, I would request that the issue is considered nationally as to how information held on all Police systems, not just the Police National Database, can be shared to assist in the management and assessment of individuals and the risk they pose to themselves or others.
” 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 the Shared Care Records programme to enable information sharing across integrated care systems and, subsequently, regions and nationally.
Verbatim wording from the response “NHS England have a programme of work – the Shared Care Records initiative – which is seeking to rectify this.” Source location Response from Secretary of State for Health and Social Care, Minister for Crime and Polici
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 hospital-record access concern was considered answered by the Trust’s response and did not require a national response.
Verbatim wording from the response “Regarding your concerns around future deaths at Yeovil District hospital due to the missing of vital information within the pre admission documentation because the staff within the Emergency Department at Yeovil District Hospital are not always accessing admission documentation, especially the paramedic records when a person is brought into the Accident Emergency department. I have read the Trust’s reply and consider concern answered and therefore does not need national response.” Source location Response from Secretary of State for Health and Social Care, Minister for Crime and Polici
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 exchange of information between police forces is outside NHS England’s remit for comment.
Verbatim wording from the response “The initial focus is on sharing within the boundaries of the Integrated Care Systems – in this case within Dorset and within Somerset – and 41 of the 42 Integrated Care Systems have already implemented a basic solution. There is a commitment to get these to interwork and this was set out in the most recent NHS Priorities and Operational Planning Guidance for 2022/23. The intention is for this to work regionally by the end of 2022/23 and nationally no later than 2023/24.
Details of the Dorset Care Record are at https://www.dorsetccg.nhs.uk/project/dorset-care-record/ and the Somerset Integrated Care Record at https://www.somersetccg.nhs.uk/about-us/digital-projects/sider/
The exchange of information between police forces is not a matter NHS England can comment on.” Source location Response from Secretary of State for Health and Social Care, Minister for Crime and Polici
Open published response
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