23 Sep 2020 Mrs Christine Forbes · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 2 Delays in transferring patients' medical notes and history to GP practices View source Failure to ensure clinicians know patients' full medical history before treating and prescribing View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mrs Christine Forbes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Christine Forbes, a 72-year-old woman with a history of oxycodone stockpiling and misuse, died on 2 February 2020 after taking oxycodone and zolpidem. The principal concern was that patients registering with GP surgeries may be prescribed medication before their medical notes and relevant history are available.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring patients' medical notes and history to GP practices
Wider context from the report “1. That when patients register at GP surgeries (across England) they do so without their medical notes and history . This material can take a significant amount of time to be sent to a GP practice after a request is sent to Primary Care Support England . Doctors and other medical practitioners are therefore treating and prescribing in situations where a full medical history is not known.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure clinicians know patients' full medical history before treating and prescribing
Wider context from the report “1. That when patients register at GP surgeries (across England) they do so without their medical notes and history. This material can take a significant amount of time to be sent to a GP practice after a request is sent to Primary Care Support England. Doctors and other medical practitioners are therefore treating and prescribing in situations where a full medical history is not known .
” Open source report
Concerns raised 1 Failure to provide appropriate places of safety for autistic patients with additional mental health problems View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Siân Frances HEWITT · 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
Siân Frances HEWITT died on 6 April 2019 at Milton Keynes University Hospital after collapsing at the Campbell Centre. The report describes failures to recognise and treat her deteriorating condition, including risks associated with pulmonary embolism, and concerns that the Campbell Centre was not an appropriate placement for people with autism and additional mental health problems.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate places of safety for autistic patients with additional mental health problems
Wider context from the report “It would appear from the circumstances of Ms Hewitt’s death that the NHS are unable to provide a place of safety for those who are suffering from Asperger’s syndrome, or indeed other forms of autism, when they are also suffering additional mental health problems such as bipolar . The Campbell Centre in Milton Keynes was not an appropriate placement and I believe this matter should be looked at by NHS England and for more appropriate provision to be made for such patients.
” Open source report
Concerns raised 4 Failure to communicate outbreak information to relevant patients outside the local area View source Failure of hospital trusts to send Listeria isolates View source Failure of private laboratories to share Listeria isolates with PHE View source Failure of private laboratories to retain Listeria isolates View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Brenda Elmer · 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
Brenda Elmer acquired a Listeria infection after consuming a contaminated sandwich while attending St Richard’s Hospital and died on 17 July 2019 after becoming seriously ill. Concerns included inadequate communication with patients who had left the area during the outbreak, which delayed recognition and appropriate treatment, and the absence of requirements for laboratories and hospital trusts to retain or share Listeria isolates, hindering the identification of connected outbreaks.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate outbreak information to relevant patients outside the local area
Wider context from the report “3. Whilst it was accepted that details of the possible outbreak were shared locally with other medical professionals (and therefore there was a local knowledge of the Listeria outbreak) there did not appear to be any attempt by NHS England or PHE (by way of a Public Health message) to communicate with those patients who were treated within the Trust but who were now out of the area in different parts of the Country .
4. It was unfortunately that when Mrs Elmer fell ill, neither her GP who initially treated her, nor her family had any idea that her illness may be connected to the Listeria outbreak. This meant that she was not prioritised for a blood test and this delayed her being treated appropriately for Listeriosis. This diagnosis was only made when she was admitted to Tunbridge Wells Hospital, her local hospital in Kent following an emergency admission. It is unknown whether earlier treatment would have changed the outcome but it may have eased Mrs Elmer’s suffering.
5. Consideration needs to be given to how communications should be disseminated following such an outbreak so that as many patients as possible, who had been in the hospital at the relevant time, are made aware and can seek medical assistance if they become unwell.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 hospital trusts to send Listeria isolates
Wider context from the report “1. During the course of the Inquest evidence was given by the representative of Public Health England that there was no legal requirement for Private Laboratories who identify Listeria in food to share the Listeria isolate with PHE or indeed keep this isolate for any period of time. If a problem is subsequently identified by PHE then it makes it particularly difficult to check if particular products have been implicated.
2. Similarly there is no legal requirement of Hospital Trusts to send in Listeria isolates when Listeria has been identified . This therefore does not allow PHE to match particular strains and identify outbreaks which are connected earlier.
3. In both these circumstances this leads to missed opportunities to deal with any outbreak.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 private laboratories to share Listeria isolates with PHE
Wider context from the report “1. During the course of the Inquest evidence was given by the representative of Public Health England that there was no legal requirement for Private Laboratories who identify Listeria in food to share the Listeria isolate with PHE or indeed keep this isolate for any period of time. If a problem is subsequently identified by PHE then it makes it particularly difficult to check if particular products have been implicated.
2. Similarly there is no legal requirement of Hospital Trusts to send in Listeria isolates when Listeria has been identified. This therefore does not allow PHE to match particular strains and identify outbreaks which are connected earlier.
3. In both these circumstances this leads to missed opportunities to deal with any outbreak.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 private laboratories to retain Listeria isolates
Wider context from the report “1. During the course of the Inquest evidence was given by the representative of Public Health England that there was no legal requirement for Private Laboratories who identify Listeria in food to share the Listeria isolate with PHE or indeed keep this isolate for any period of time . If a problem is subsequently identified by PHE then it makes it particularly difficult to check if particular products have been implicated.
2. Similarly there is no legal requirement of Hospital Trusts to send in Listeria isolates when Listeria has been identified. This therefore does not allow PHE to match particular strains and identify outbreaks which are connected earlier.
3. In both these circumstances this leads to missed opportunities to deal with any outbreak.
” Open source report
Concerns raised 2 Unavailability of electronic access to regular GP records in out-of-hours care View source Failure to transfer complete patient data when patients move between general practices View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Amy Hogan · 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
Amy Hogan reported feeling unwell from around September 2019 and attended an out-of-hours doctor on 20 January 2020 with light-headedness, weakness and exhaustion. She became acutely unwell and collapsed at home the following day, dying at hospital aged 23. The principal concerns were that her previous GP records had not transferred and that the out-of-hours GP could not electronically access her regular records, including information that she was prescribed the oral contraceptive pill.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unavailability of electronic access to regular GP records in out-of-hours care
Wider context from the report “2) Notwithstanding numerous previous initiatives as to information-sharing and digitisation of patient data, it is a matter of concern that the out of hours GP receiving Miss Hogan had no electronic access to her regular GP records . Access to such records would have revealed, amongst other things, Miss Hogan was prescribed the oral contraceptive pill, which is likely to have led the doctor to ask additional questions about her symptoms. Again, it is a matter of particular concern that an inability to access regular GP records in the out of hours setting raises additional risks for vulnerable 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 Failure to transfer complete patient data when patients move between general practices
Wider context from the report “1) The inquest heard evidence from Miss Hogan’s regular GP that, despite being requested, the General Practice records from her previous practice never arrived . It is a matter of concern that delayed, incomplete or non-existent transfer of patient data from one practice to another on moving places an unfair burden on patients to accurately recall and relay their own medical histories. It is a matter of particular concern that such issues create particular problems for vulnerable patients, who simply may not be in a position to do so;
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and address root causes of electronic GP2GP record-transfer failures.
Verbatim wording from the response “There is an ongoing programme of work to review and establish and reduce the root cause of electronic GP2GP (GP2GP is the formal term for the programme) record transfer failures. In March 2020 there was an increase applied by GP system suppliers to GP2GP transfer ‘file size’ from 50MB to 100MB, this will subsequently help to reduce the rate of failures further. Due to COVID-19 competing priorities, statistics are not yet available to demonstrate the effect this change has had. However, we anticipate analysis and collection of these metrics will resume as part of the recovery work.” Source location 2020-0147-Response-from-NHS-England.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enable authorised professionals to access GP records through GP-Connect across primary care settings.
Verbatim wording from the response “Over recent months significant progress has been made around the access to GP records out of hours. As a response to the pandemic, we have enabled the use of GP-Connect across the whole primary care estate. This eases facilitation for authorised professionals in multiple care settings to directly access in a safe and secure manner GP records which are held at GP out of hours services, CCAS, Extended Access Hubs and NHS 111.” Source location 2020-0147-Response-from-NHS-England.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase the GP2GP transfer file-size limit from 50MB to 100MB.
Verbatim wording from the response “There is an ongoing programme of work to review and establish and reduce the root cause of electronic GP2GP (GP2GP is the formal term for the programme) record transfer failures. In March 2020 there was an increase applied by GP system suppliers to GP2GP transfer ‘file size’ from 50MB to 100MB, this will subsequently help to reduce the rate of failures further. Due to COVID-19 competing priorities, statistics are not yet available to demonstrate the effect this change has had. However, we anticipate analysis and collection of these metrics will resume as part of the recovery work.” Source location 2020-0147-Response-from-NHS-England.pdf
Open published response
Concerns raised 5 Insufficient detail in final investigation reports View source Factual errors and inaccuracies in initial investigation reports View source Delays in final investigation report completion View source Delays in HSIB investigation completion View source Restriction of Trust-led investigation during HSIB investigations View source See 2 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.
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AI-generated summary
Theo Benjamin Young · 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
Theo Benjamin Young was born by emergency caesarean section in a very poor condition after persistent abnormalities in fetal monitoring were not recognised during labour. He suffered non-survivable injuries from intrapartum hypoxia and died three days after delivery. Concerns included failures in staffing, fetal monitoring, escalation and oxytocin management, as well as delays and deficiencies in the subsequent HSIB investigation.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail in final investigation reports
Wider context from the report “3. The initial draft report contained factual errors and inaccuracies requiring considerable input by the Trust to resolve. The final report is insufficiently detailed and was completed 18 months after the death, during which time further deaths could have resulted.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Factual errors and inaccuracies in initial investigation reports
Wider context from the report “3. The initial draft report contained factual errors and inaccuracies requiring considerable input by the Trust to resolve. The final report is insufficiently detailed and was completed 18 months after the death, during which time further deaths could have resulted.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 final investigation report completion
Wider context from the report “3. The initial draft report contained factual errors and inaccuracies requiring considerable input by the Trust to resolve. The final report is insufficiently detailed and was completed 18 months after the death , during which time further deaths could have resulted.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 HSIB investigation completion
Wider context from the report “2. HSIB indicated to the Trust at the outset that their investigation would take approximately six months which is highly likely to delay the introduction of any immediate necessary measures by the Trust to prevent further 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 Restriction of Trust-led investigation during HSIB investigations
Wider context from the report “1. The HSIB specifically requested the Trust not to undertake their own investigation effectively preventing the recognition of causes of concern and therefore being unable to undertake any immediate and necessary remedial action at the earliest opportunity to prevent future deaths.
” Open source report
11 Mar 2020 Rifky GROSSBERGER · Prevention of Future Deaths report Inner North London
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Concerns raised 3 Lack of accessible safety information for new parents about metal blind cord dangers View source Unavailability of a national leaflet on metal blind cord dangers View source Lack of reminders for midwives and district nurses to warn new parents about metal blind cord dangers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Rifky GROSSBERGER · 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
Rifky Grossberger became entangled in a metal blind cord in her cot on 31 July 2019 and died five days later after resuscitation. The principal concern was that her parents were unaware of the danger, and that safety information about blind cords may not be consistently provided to new parents by leaflets, healthcare professionals or other sources.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of accessible safety information for new parents about metal blind cord dangers
Wider context from the report “Before Rifky became entangled in the metal blind cord, her parents were unaware of its potential danger . The instruction leaflet provided with the blinds had long since been discarded and so they did not see this.
I asked Rifky’s mum what would have been the most useful source of warning, and she thought the leaflets she was given after Rifky was born, and also her healthcare professionals .
Professor Powis, I have attempted to locate a national leaflet, but so far unsuccessfully. It occurs to me that you may have input into local leaflets.
████████ the midwives and district nurses who look after new mums and their babies are well placed to offer advice, but may need a reminder to warn of this particular danger.
I appreciate that new parents receive a lot of paperwork and a lot of information generally. That can be overwhelming of course, but I am sure that methods could be devised of delivering such safety advice that would make this situation less likely in the future .
The NHS website would also be a good place to provide this information, though it might not have assisted in this case, as Orthodox Jewish families do not necessarily access the internet.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a national leaflet on metal blind cord dangers
Wider context from the report “Before Rifky became entangled in the metal blind cord, her parents were unaware of its potential danger. The instruction leaflet provided with the blinds had long since been discarded and so they did not see this.
I asked Rifky’s mum what would have been the most useful source of warning, and she thought the leaflets she was given after Rifky was born, and also her healthcare professionals.
Professor Powis, I have attempted to locate a national leaflet, but so far unsuccessfully . It occurs to me that you may have input into local leaflets.
████████ the midwives and district nurses who look after new mums and their babies are well placed to offer advice, but may need a reminder to warn of this particular danger.
I appreciate that new parents receive a lot of paperwork and a lot of information generally. That can be overwhelming of course, but I am sure that methods could be devised of delivering such safety advice that would make this situation less likely in the future.
The NHS website would also be a good place to provide this information, though it might not have assisted in this case, as Orthodox Jewish families do not necessarily access the internet.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 reminders for midwives and district nurses to warn new parents about metal blind cord dangers
Wider context from the report “Before Rifky became entangled in the metal blind cord, her parents were unaware of its potential danger. The instruction leaflet provided with the blinds had long since been discarded and so they did not see this.
I asked Rifky’s mum what would have been the most useful source of warning, and she thought the leaflets she was given after Rifky was born, and also her healthcare professionals.
Professor Powis, I have attempted to locate a national leaflet, but so far unsuccessfully. It occurs to me that you may have input into local leaflets.
████████ the midwives and district nurses who look after new mums and their babies are well placed to offer advice, but may need a reminder to warn of this particular danger .
I appreciate that new parents receive a lot of paperwork and a lot of information generally. That can be overwhelming of course, but I am sure that methods could be devised of delivering such safety advice that would make this situation less likely in the future.
The NHS website would also be a good place to provide this information, though it might not have assisted in this case, as Orthodox Jewish families do not necessarily access the internet.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Healthy Child Programme and health visitors’ established safety advice are considered sufficient to address reminders about baby strangulation risks.
Verbatim wording from the response “You also asked NHSEI to address your concern around the need for healthcare professionals such as midwives and district nurses who look after new mums and their babies to be reminded of this particular danger.” Source location 2020-0070-Response-from-NHS-England-and-NHS-Improvement
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing NHS website advice on blind safety is considered sufficient to address accessible safety information for parents.
Verbatim wording from the response “Following the inquest, you asked NHS England and Improvement (hereafter ‘NHSEI’) to address your concern regarding the need to find methods of delivering safety advice in an easily accessible format. This could be in the form of local and national leaflets to provide parents with the safety advice they need to look after their new born baby.” Source location 2020-0070-Response-from-NHS-England-and-NHS-Improvement
Open published response
Concerns raised 2 Failure to accurately complete and reconcile fluid balance charts View source Lack of a pathway for investigating dysphagia caused by an oesophageal stricture View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Lynda Pedersen · 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
Lynda Pedersen died on 7 September 2018 in hospital from aspiration pneumonitis, pneumonia and fluid overload due to a stricture caused by an adenocarcinoma of the oesophagogastric junction. The adenocarcinoma was not identified during her admission or during earlier medical care following an admission for dysphagia. Concerns included the lack of a pathway for investigating dysphagia caused by a stricture, which contributed to the need to investigate malignancy being lost, and deficiencies in fluid balance charting and recording of fluid output before her death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately complete and reconcile fluid balance charts
Wider context from the report “(2) Fluid balance charts were not correctly completed in the period leading to Lynda Pedersen’s death. The evidence from the fluid balance charts showed that she was carrying fluids forward until the time of her death; there being an imbalance to the tune of some 3 1/2 litres. That there was a significant fluid overload was also evident from the pathology. That she had a fluid overload was only identified by the hospital at a time that she was temporally close to death. It was accepted at the inquest that the charts were deficient in their completion, that nursing staff had not recorded output properly or reconciled the balance as required .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 pathway for investigating dysphagia caused by an oesophageal stricture
Wider context from the report “(1) Lynda Pedersen was admitted to William Harvey Hospital on 6th September 2017 with dysphagia. A gastroscopy conducted two days later identified a stricture within the oesophagus with the appearance of the mucosa suggestive of a submucosal infiltration. A CT scan did not identify a malignancy but indicated that the area of concern could not be evaluated as it had not been distended by the orally ingested contrast. Lynda Pedersen had a number of further gastroscopies to attempt to dilate her oesophagus between 2017 and 2018 some of which reported a benign appearance but the cause of the stricture was never investigated despite the risk of variceal bleeding having been significantly reduced by a TIPS procedure having been conducted on 11th October 2017. It was accepted that a biopsy should have been undertaken but the need for investigation as to whether there was a malignancy was lost in that the clinicians’ focus was on attempting to improve her nutritional status and quality of life. The reason for the loss of the need for an investigation was twofold: there was no pathway in place for dysphagia presentation caused by a stricture and the fact of multiple presentations. It was agreed by the treating clinicians and an independent expert that had there been a pathway in place, the investigation for cancer was less likely to have been lost . The clinicians who gave evidence at the Inquest were of the view that this was a matter most appropriately addressed by NHS England and NHS Improvements.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Developing clinical pathways for oesophageal stricture is outside NHS England and NHS Improvement’s role.
Verbatim wording from the response “While it is not the role of NHS England and Improvement to develop clinical pathways for conditions such as oesophageal stricture, other national bodies have done this. For example, the British Society of Gastroenterology 2018 guideline on managing dysphagia states: “obtain biopsies from all strictures to exclude malignancy” and “repeat biopsy after cross-sectional imaging in cases where biopsies are negative but clinical or endoscopic features are atypical or suspicious of malignancy”.” Source location 2020-0112-Response-from-NHS-England-and-NHS-Improvement_Redacted.pdf
Open published response
Concerns raised 7 Failure to share complex and high-risk patients between units early in the inpatient stay View source Failure to consider bespoke placements early for complex patients View source Failure to verbally communicate increased suicidal risk to the responsible nurse View source Failure to prioritise timely safer placements for patients at high risk of self-harm View source Failure to base staff handovers on clinical-record examination and update care plans for risk management View source Lack of deadlines for finding alternative placements View source Risk of clinical silos between sections of mental health services View source See 4 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.
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AI-generated summary
Rebecca Jane Hursey · 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
Rebecca Jane Hursey died at St George’s Hospital on 4 May 2018 after taking an aspirin overdose while detained under Section 3 of the Mental Health Act and receiving care on the Avalon Ward. The report identifies concerns about suicidal-risk information not being verbally communicated during handover, observations and searches not mitigating her self-harm risk, and the prolonged failure to find a suitable alternative placement.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to share complex and high-risk patients between units early in the inpatient stay
Wider context from the report “6. That consideration be given to the “sharing” of such complex and high-risk patients between units early on the in-patient stay to help provide the patient with more suitable care and share the stress of caring for such unwell patients on staff and other patients. One way this could be done would be to consider a network arrangement between different units to avoid the risk of clinical silos between the different sections of the mental health services and encourage a more wholistic approach to service provision.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to consider bespoke placements early for complex patients
Wider context from the report “5. That bespoke placements are considered early in the discharge process for complex 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 Failure to verbally communicate increased suicidal risk to the responsible nurse
Wider context from the report “2. That practitioners who recognise increase in suicidal risk of a patient should pass this on verbally to the nurse on charge of the ward or the nurse allocated to the patient .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise timely safer placements for patients at high risk of self-harm
Wider context from the report “4. That placements for patients with high risk of self-harm , such as Rebecca are prioritised such that safer placements are found within a timely fashion .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 base staff handovers on clinical-record examination and update care plans for risk management
Wider context from the report “1. That staff handovers be led by examination of the clinical record such that recent progress can be assessed especially in relation to risk management and care plans amended accordingly .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 deadlines for finding alternative placements
Wider context from the report “3. That NHS England consider a system of introducing deadlines for alternative placements to be found for such patients, so that they must be found in a timely fashion .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Risk of clinical silos between sections of mental health services
Wider context from the report “6. That consideration be given to the “sharing” of such complex and high-risk patients between units early on the in-patient stay to help provide the patient with more suitable care and share the stress of caring for such unwell patients on staff and other patients. One way this could be done would be to consider a network arrangement between different units to avoid the risk of clinical silos between the different sections of the mental health services and encourage a more wholistic approach to service provision .
” Open source report
Concerns raised 2 Failure to ensure timely and geographically consistent access to thrombectomy services View source Lack of public awareness of the risk of stroke arising from cocaine use View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Name not published · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
████████ ingested cocaine, suffered a basilar artery occlusion and posterior stroke, underwent thrombolysis and thrombectomy, and was declared brainstem dead on 13 June 2019. Concerns related to limited public awareness of the stroke risks associated with cocaine use and variation in access to thrombectomy services.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure timely and geographically consistent access to thrombectomy services
Wider context from the report “2. I heard evidence during this inquest that the availability of thrombectomy is currently variable and dependent on geographical location and timing . I am concerned that this variation will mean that future deaths will occur in similar circumstances , unless access to thrombectomy services is improved .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 public awareness of the risk of stroke arising from cocaine use
Wider context from the report “1. ████████ family raised concerns that the risk of stroke arising from cocaine use was not known to him nor his family members . They were concerned that future deaths could occur in similar circumstances and that there is limited public awareness of such risks . I share these concerns and ask that Public Health England consider this point.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and imminently roll out a bespoke GMC- and Health Education England-endorsed training programme to address the shortage of thrombectomy practitioners.
Verbatim wording from the response “NHS England is rolling out access to thrombectomy nationally via specialised neuroscience centres over a 5-year period. This commenced in April 2017 with the mapping of services against a specification. Neuroscience centres were asked to develop implementation plans that include being able to move to a fully staffed 24/7 service over 5 years. It is recognised that there is currently an insufficient number of suitably qualified medical teams to support the expansion of thrombectomy services and this is a rate-limiting factor in terms of being able to provide comprehensive geographical coverage. NHS England is developing a bespoke training programme endorsed by the General Medical Council and Health Education England to address this shortfall in practitioners. This is due for roll out imminently.” Source location Response from NHS England and NHS Improvement
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with service providers to develop regional solutions, including joint rotas, providing 24/7 thrombectomy access within regions.
Verbatim wording from the response “There are currently 22 providers of thrombectomy services across the country, with 6 planning to provide 24/7 access to thrombectomy and a further total of 13 who plan to provide a 7 day a week service. Regional NHS England teams are working with their service providers to develop innovative solutions that include the development of joint rotas so that patients have 24/7 access to thrombectomy within a region. As the additional trained workforce becomes available the number of centres and the number of centres able to provide 24/7 care will increase.” Source location Response from NHS England and NHS Improvement
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out nationally accessible thrombectomy services through specialised neuroscience centres, including planning for fully staffed 24/7 provision.
Verbatim wording from the response “NHS England is rolling out access to thrombectomy nationally via specialised neuroscience centres over a 5-year period. This commenced in April 2017 with the mapping of services against a specification. Neuroscience centres were asked to develop implementation plans that include being able to move to a fully staffed 24/7 service over 5 years. It is recognised that there is currently an insufficient number of suitably qualified medical teams to support the expansion of thrombectomy services and this is a rate-limiting factor in terms of being able to provide comprehensive geographical coverage. NHS England is developing a bespoke training programme endorsed by the General Medical Council and Health Education England to address this shortfall in practitioners. This is due for roll out imminently.” Source location Response from NHS England and NHS Improvement
Open published response
2 Mar 2020 HARRY RICHFORD · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 20 Lack of cross-site clinical working opportunities View source Failure to notify the Coroner of a child death View source Uncertain auditing and logging of neonatal resuscitation pro forma completion View source Unclear guidance for obtaining anaesthetic help in paediatric emergencies View source Failure to retain placentae for examination after severe foetal distress View source Lack of clear requirements for consultant assessment of locum competence before overnight responsibility View source Failure to produce timely and sufficiently detailed statements after deaths View source Failure to assess and supervise locum clinicians View source Lack of clarity about when to call a consultant at night View source Failure to record consultant telephone advice View source Failure to record feedback and audit locum recruitment View source Insufficient consultant availability for night-time emergencies View source Lack of staff knowledge of applicable clinical guidelines and policies View source Failure to share important independent safety reports with staff View source Lack of paediatric team knowledge of neonatal collapse guidelines View source Lack of clarity about prompt action in obstetric emergencies View source Substandard obstetric record keeping View source Inaccurate and incomplete child death notification forms View source Inadequate neonatal resuscitation training View source Inaccurate MBRRACE maternal and neonatal death reporting View source See 17 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.
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AI-generated summary
HARRY RICHFORD · 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
Harry Richford was born at QEQM on 2 November 2017 and died at William Harvey Hospital on 9 November 2017 after being transferred there. The report describes delays in delivery, shortcomings in the caesarean delivery and neonatal resuscitation, and subsequent hypoxia and brain injury. Substantive concerns included locum recruitment, assessment and supervision; clarity about escalation to consultants; neonatal resuscitation training; record keeping and adherence to guidelines; and inaccurate death notifications and reporting.
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 cross-site clinical working opportunities
Wider context from the report “Concern 8
Prior to Harry's death both ████████████████, a senior member of staff who had the care of Harry at the William Harvey Hospital, accepted that there were no opportunities for cross site working between QEQM and the William Harvey Hospital . Currently two out of eight middle grade doctors have had the opportunity to spend time at the William Harvey, which has a much higher specification neo natal unit. ████████ described the lack of opportunities before Harry's death as ‘at best, very surprising'.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 notify the Coroner of a child death
Wider context from the report “Concern 17
The child death notification form was incorrectly completed in that Harry's death was recorded as 'expected'. No notification was made to the Coroner . No details were filled in on the notification form giving any detail of the problems leading to Harry's death. As a result, the Child Death Overview Panel would have been unaware of the problems encountered and could not have shared learning to prevent other such deaths occurring. I make no recommendation in respect of the lack of notification to the Coroner as I am aware that the Senior Coroner has already dealt with this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Uncertain auditing and logging of neonatal resuscitation pro forma completion
Wider context from the report “Concern 15
The East Kent Trust should consider a review as to the use or otherwise of a resuscitation pro forma. A pro forma has since Harry's death been adopted by the East Kent Trust which, on the evidence of ████████, has improved the oversight of neo natal training and governance. It is not clear whether that pro forma is being audited or logged , or what actions are being done to ensure its completion and preservation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 guidance for obtaining anaesthetic help in paediatric emergencies
Wider context from the report “Concern 9
The resuscitation of Harry was eventually carried out by ████████, the anaesthetist looking after ████████. His evidence was that leaving his own patient to help the paediatric team was an unusual action to take in the UK although he had often performed such actions in Nepal. Doctors at QEQM indicated that there was an informal policy that if a middle grade paediatrician found themselves in an emergency, they could seek help from their anaesthetic colleagues . It was unclear whether the anaesthetists were aware of this informal policy . This informal policy should be clarified, and guidance given because there is a risk, that in an emergency, it will be overlooked .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 placentae for examination after severe foetal distress
Wider context from the report “Concern 12
The placenta of Harry was not retained . Examination of the placenta will in some circumstances assist in cases of severe foetal distress. The Royal College of Pathologists states that it is 'essential' for the placenta to be sent for examination in cases of severe foetal distress requiring admission to a neo natal unit.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 requirements for consultant assessment of locum competence before overnight responsibility
Wider context from the report “Concern 2
The current policy of the East Kent Trust states that it is the responsibility of the healthcare professional who will be supervising the locum to assure themselves of his/her competence. This did not happen in this case. There is at present no requirement for a locum to be assessed on a day shift by a consultant before being left in charge overnight . There is no clear direction that it is the responsibility of the assessing consultant to satisfy themselves of the locum's experience and capability . One specialist from outside the East Kent Trust, ████████, also stated that it would assist the assessing consultants to be able to see not only the locum's CV but also their references and any training records 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 produce timely and sufficiently detailed statements after deaths
Wider context from the report “Concern 16
In order to try to prevent future deaths it is important that there are clear records and statements made when a death occurs so that lessons can be learnt. In this instance many of the statements were very scanty in their content and some were made a long time after the event . In some instances, staff had to make statements from memory without the advantage of seeing the medical notes . Contemporaneous (or as near as possible) notes are also very much in the interests of the staff involved so that they can give clear accounts of their actions and reasons for them if required to do so at a later date.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and supervise locum clinicians
Wider context from the report “Concern 1
████████ was recruited as a locum registrar by the Hospital Trust without there appearing to have been any assessment of his skills and abilities or any supervision of him at the hospital . This was not an emergency appointment after, for example, a doctor calling in sick at the last minute. ████████ gave evidence that the recruitment, assessment and supervision of locums is a national problem and that there is a need for a review on a national level. This raises concerns that there may be a risk to other lives both at this trust and at other trusts in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about when to call a consultant at night
Wider context from the report “Concern 5
There appeared to be from the evidence given at the inquest substantial confusion amongst staff as to when a consultant should be called at night . The East Kent Trust now has some 70 hours a week consultant attendance on the wards. That leaves 14 hours a day when there is no consultant present. Staff, whether doctors, nurses or midwives should know the circumstances in which consultant help should be sought and should not feel inhibited from making their views known. If staff are unaware or unsure of when the consultant should be called that potentially poses a continuing risk to life.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to record consultant telephone advice
Wider context from the report “Concern 14
There are no current records kept by consultants who are telephoned at home for advice . In this case there was a dispute about the number of calls made to ████████ and as to the content of these calls. The advice given and the actions taken as a result are important for the preservation of life.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to record feedback and audit locum recruitment
Wider context from the report “Concern 3
████████ had worked two night time shifts at the QEQM before the night of Harry's birth. The extent to which there was any feedback from the consultants on call those two nights to ████████ is unclear. She, erroneously, believed the East Kent Trust had employed ████████. There is no record of any written feedback . From the evidence of the medical director of the East Kent Trust it appears that the current locum recruitment policy is not being checked or audited . There is a potential for further risks to life arising from these shortfalls.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 consultant availability for night-time emergencies
Wider context from the report “Concern 6
The current contracts at the East Kent Trust permit consultants to live up to 30 minutes travel time from the hospital . This poses considerable problems and risks for night time emergencies .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 of applicable clinical guidelines and policies
Wider context from the report “Concern 10
There appeared to be considerable confusion among members of staff as to which, if any, guidelines and policies affected them . While two senior members of staff, ████████████████ (consultant), said that the East Kent Trust has systems in place to ensure knowledge of and compliance with Trust policies neither of them was able to say whether this was effective. Significant issues remain as to the knowledge of staff as to which guidelines govern their behaviour (this was also a finding of the Health and Safety Investigation Board in 2019). Such confusion or lack of knowledge increases 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 Failure to share important independent safety reports with staff
Wider context from the report “Concern 19
Important independent reports do not appear to have been shared within the East Kent Trust's staff , for instance the HSIB report into Harry's death appeared during the inquest to be unknown to a number of the staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of paediatric team knowledge of neonatal collapse guidelines
Wider context from the report “Concern 11
There was a lack of knowledge within the paediatric team of guidelines issued by the Department of Women's Health . The evidence from the East Kent Trust doctors was that the guidelines issued by the department directed to 'all maternity and neonatal staff who may be involved with the immediate care and support of a collapsed neonate' would not have been known to the paediatric team at the relevant time. Even senior clinicians, such as ████████, were not aware of the relevant guidelines.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about prompt action in obstetric emergencies
Wider context from the report “Concern 4
There is a risk to the life of both mothers and babies if there is a lack of clarity as to the processes or the need to take prompt action where it is necessitated in the event of an obstetric concern or emergency developing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Substandard obstetric record keeping
Wider context from the report “Concern 13
The standard of record keeping on the obstetric unit was substantially sub-standard . The quality of the note taking and records is of considerable importance to new staff taking over responsibility for mother and baby. Without there being clear accurate records there is a risk of further mistakes being made leading, at the worst, to the risk of death. An example of this in Harry's case is that the record of the syntocinon prescribed to ████████ over a long period of time is inconsistent with the evidence of the midwives and the registrar who gave it to her.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inaccurate and incomplete child death notification forms
Wider context from the report “Concern 17
The child death notification form was incorrectly completed in that Harry's death was recorded as 'expected' . No notification was made to the Coroner. No details were filled in on the notification form giving any detail of the problems leading to Harry's death . As a result, the Child Death Overview Panel would have been unaware of the problems encountered and could not have shared learning to prevent other such deaths occurring. I make no recommendation in respect of the lack of notification to the Coroner as I am aware that the Senior Coroner has already dealt with this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 neonatal resuscitation training
Wider context from the report “Concern 7
The evidence of ████████ raised substantial concerns about the quality of training and learning in respect of neonatal resuscitation at the East Kent Trust. His evidence was that it would be desirable for middle grade doctors to attend the ARNI course (the advanced resuscitation of the new born infant). He also recommended that there should be simulated drills in neo natal resuscitation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inaccurate MBRRACE maternal and neonatal death reporting
Wider context from the report “Concern 18
The MBRRACE form in respect of Harry Richford was inaccurate in a number of important areas . The form is important to provide robust national data to support the delivery of safe, high quality maternal and new born care as well as identifying errors and faults, if any, where there has been a maternal or infant death so that future deaths can be avoided.
” Open source report
Concerns raised 1 Lack of adequate monitoring of repeat medication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Peter COLE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter Cole was an older person with dementia who overdosed on Tramadol, which had been supplied on repeat prescription. The report raised concerns that repeat medication was not being adequately monitored, leading some older or mentally impaired patients to accumulate dangerous quantities of unused prescribed drugs and contributing to waste of healthcare resources.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate monitoring of repeat medication
Wider context from the report “(1) That repeat medication is not being adequately monitored , leading to many (often older and/or mentally infirm) patients building-up dangerous quantities of prescribed medication .
(2) That the inadequate supervision of prescribed (repeat) medication is so widespread that the consequent waste of resources has an adverse impact on the overall provision of healthcare.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish dementia care pathway guidance recommending medication review and management, including monitoring and review resources.
Verbatim wording from the response “In addition, to support improvement in dementia diagnosis and personalised care for people with dementia, NHS England published The Dementia Care Pathway: Full Implementation guidance. This resource sets out recommendations for reviewing and managing medication needs and provides examples of step-by-step best practice that includes monitoring and reviewing medication in the Appendices and Helpful Resources section of the guide.” Source location 2020-0123-Response-from-NHS-England.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake a review of NHS over-prescribing and produce recommendations to reduce overprescribing and medicines wastage.
Verbatim wording from the response “• Undertaking a review of over-prescribing in the NHS which is due to report in Spring 2020. The review covers: the role of digital technologies; research; culture change and social prescribing; repeat prescribing; and transfer of care. The report will provide recommendations to reduce overprescribing which will help to reduce medicines wastage;” Source location 2020-0123-Response-from-NHS-England.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Medicines Safety Improvement Programme to reduce medication-related harm, focusing on high-risk drugs, situations and vulnerable patients.
Verbatim wording from the response “• The Medicines Safety Improvement Programme (MSIP) aims to reduce medication related harm in the NHS, focusing on high risk drugs, situations and vulnerable patients. The programme will contribute to the WHO Challenge target to reduce severe avoidable medication-related harm globally by 50% over five years.” Source location 2020-0123-Response-from-NHS-England.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support medicines optimisation through the Medicines Value Programme, including reducing use of clinically or cost-ineffective medicines.
Verbatim wording from the response “• Supporting medicines optimisation through the Medicines Value Programme² to improve health outcomes from medicines through supporting people to take medicines as intended and, decreasing or stopping the use of medicines which are neither clinically - or cost-effective;” Source location 2020-0123-Response-from-NHS-England.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Carry out structured medication reviews for patients at increased risk of medication-related harm.
Verbatim wording from the response “has responsibility for. Several workstreams are currently in place to optimise prescribing and reduce medicines waste, these include:” Source location 2020-0123-Response-from-NHS-England.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refresh personalised dementia care and support planning guidance to emphasise medication reviews and appropriate medication access, continuation or cessation.
Verbatim wording from the response “NHS England and Improvement also recently refreshed the Dementia: Good Personalised Care and Support Planning guide to help further enhance the provision of personalised post diagnostic support. The guide emphasises the need to include medication reviews to help to reduce poly pharmacy, minimise use of” Source location 2020-0123-Response-from-NHS-England.pdf
Open published response
21 Feb 2020 Andrew Goldstraw · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 5 Failure of SystmOne search functions to extract key mental health risk information View source Failure to identify documented suicide and deliberate self-harm risk information View source SystmOne failing to facilitate retrieval of key suicide and deliberate self-harm risk information View source Failure to maintain accurate and usable summary and active-problem risk information View source Lack of effective SystmOne training and competency in suicide and deliberate self-harm risk assessment View source See 2 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.
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AI-generated summary
Andrew Goldstraw · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Andrew Goldstraw was found hanging in a cell at HM Prison, Winchester, on 14 November 2018, having taken his own life using a ligature made from torn bed linen. The report raised concerns that relevant information about his previous suicidal ideation and self-harm attempts was difficult for healthcare staff to identify in SystmOne, that the system could hinder effective risk assessment, and that staff training may have been inadequate. The inquest jury found that an ACCT should have been opened and that its absence would have more than minimally helped to prevent his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of SystmOne search functions to extract key mental health risk information
Wider context from the report “B. SystmOne makes it difficult for a doctor or mental health nurse to ascertain the key information needed to undertake a risk assessment and to decide whether or not to open an ACCT. Too much reliance is placed on the individual prisoners presentation and how he answers a series of pre-set questions.
C. At best, SystmOne makes it difficult for a mental health nurse to ascertain the relevant information and at worst it actively misleads them. For example, a search can be made of the "journal" section but this would rely on the exact words being searched (such as "suicide" or "deliberate self-harm") and it would then be necessary to go through the various entries (in Mr Goldstraw's case spread over 111 pages) using the "Key Word Search" function. Further, the functions that would (on the face of it) serve to assist in this situation (such as the "Summary" page or "Active Problems" section) were not populated with the information relevant to an accurate assessment. It was conceded by the legal representatives acting on behalf of CNWL that the "Summary" section is "very limited in its contents" and is not routinely used by healthcare staff within the prison in order to gain an insight into a prisoner's past medical history.
D. The "Active Problems" section of SystmOne is subdivided in to a number of distinct areas and it appears to be wholly inadequate in terms of identifying key areas of concern such as the risk of suicide or deliberate self-harm. The only information contained in the "Active Problems" section of SystmOne in Mr Goldstraw's case was four years out of date. None of the relevant information was contained in "Active Problems" but a great deal of irrelevant information was there!
E. The "Communications" section of SystmOne contains a chronological record of correspondence with the hospital, GP surgery and psychiatric units. However, the "Key Word Search" facility does not function at all and short of going through all of the correspondence there is no way of identifying the key information needed to undertake an effective risk assessment. The "Communications" section in Mr Goldstraw's case amounted to 83 pages. Although the relevant information concerning Mr Goldstraw's mental health issues was contained within the "Communications" section of SystmOne there was no way of easily extracting it .
F. Accordingly, a busy, under pressure mental health nurse or doctor is very likely to struggle to find the relevant entries using SystmOne, which may explain why (in Mr Goldstraw's case) too much reliance was placed on how he presented during interview. A prisoner who chooses not to disclose his true state of mind or suicidal ideation is unlikely to come to the notice of the healthcare staff whose job it is to identify the risk that he may pose to himself because SystmOne does not facilitate this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 documented suicide and deliberate self-harm risk information
Wider context from the report “A. The computer system used by CNWL is known as SystmOne. Healthcare staff working on Reception when Mr Goldstraw first arrived at the prison had access to his previous medical notes and history (around 240 pages in all) stored on SystmOne. The records contained numerous references to suicidal ideation and previous attempts at deliberate self-harm. Mr Goldstraw had attempted to take his own life on several previous occasions, the most recent of which was only three months prior to his arrival at the prison. However, despite a proliferation of entries making reference to his mental health history the mental health nurse who had access to SystmOne was seemingly unaware of the relevant entries . Had he been, he said he would have opened an ACCT.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation SystmOne failing to facilitate retrieval of key suicide and deliberate self-harm risk information
Wider context from the report “B. SystmOne makes it difficult for a doctor or mental health nurse to ascertain the key information needed to undertake a risk assessment and to decide whether or not to open an ACCT . Too much reliance is placed on the individual prisoners presentation and how he answers a series of pre-set questions.
C. At best, SystmOne makes it difficult for a mental health nurse to ascertain the relevant information and at worst it actively misleads them. For example, a search can be made of the "journal" section but this would rely on the exact words being searched (such as "suicide" or "deliberate self-harm") and it would then be necessary to go through the various entries (in Mr Goldstraw's case spread over 111 pages) using the "Key Word Search" function. Further, the functions that would (on the face of it) serve to assist in this situation (such as the "Summary" page or "Active Problems" section) were not populated with the information relevant to an accurate assessment. It was conceded by the legal representatives acting on behalf of CNWL that the "Summary" section is "very limited in its contents" and is not routinely used by healthcare staff within the prison in order to gain an insight into a prisoner's past medical history.
D. The "Active Problems" section of SystmOne is subdivided in to a number of distinct areas and it appears to be wholly inadequate in terms of identifying key areas of concern such as the risk of suicide or deliberate self-harm. The only information contained in the "Active Problems" section of SystmOne in Mr Goldstraw's case was four years out of date. None of the relevant information was contained in "Active Problems" but a great deal of irrelevant information was there!
E. The "Communications" section of SystmOne contains a chronological record of correspondence with the hospital, GP surgery and psychiatric units. However, the "Key Word Search" facility does not function at all and short of going through all of the correspondence there is no way of identifying the key information needed to undertake an effective risk assessment. The "Communications" section in Mr Goldstraw's case amounted to 83 pages. Although the relevant information concerning Mr Goldstraw's mental health issues was contained within the "Communications" section of SystmOne there was no way of easily extracting it.
F. Accordingly, a busy, under pressure mental health nurse or doctor is very likely to struggle to find the relevant entries using SystmOne, which may explain why (in Mr Goldstraw's case) too much reliance was placed on how he presented during interview. A prisoner who chooses not to disclose his true state of mind or suicidal ideation is unlikely to come to the notice of the healthcare staff whose job it is to identify the risk that he may pose to himself because SystmOne does not facilitate this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 accurate and usable summary and active-problem risk information
Wider context from the report “B. SystmOne makes it difficult for a doctor or mental health nurse to ascertain the key information needed to undertake a risk assessment and to decide whether or not to open an ACCT. Too much reliance is placed on the individual prisoners presentation and how he answers a series of pre-set questions.
C. At best, SystmOne makes it difficult for a mental health nurse to ascertain the relevant information and at worst it actively misleads them. For example, a search can be made of the "journal" section but this would rely on the exact words being searched (such as "suicide" or "deliberate self-harm") and it would then be necessary to go through the various entries (in Mr Goldstraw's case spread over 111 pages) using the "Key Word Search" function. Further, the functions that would (on the face of it) serve to assist in this situation (such as the "Summary" page or "Active Problems" section) were not populated with the information relevant to an accurate assessment . It was conceded by the legal representatives acting on behalf of CNWL that the "Summary" section is "very limited in its contents" and is not routinely used by healthcare staff within the prison in order to gain an insight into a prisoner's past medical history.
D. The "Active Problems" section of SystmOne is subdivided in to a number of distinct areas and it appears to be wholly inadequate in terms of identifying key areas of concern such as the risk of suicide or deliberate self-harm . The only information contained in the "Active Problems" section of SystmOne in Mr Goldstraw's case was four years out of date. None of the relevant information was contained in "Active Problems" but a great deal of irrelevant information was there!
E. The "Communications" section of SystmOne contains a chronological record of correspondence with the hospital, GP surgery and psychiatric units. However, the "Key Word Search" facility does not function at all and short of going through all of the correspondence there is no way of identifying the key information needed to undertake an effective risk assessment. The "Communications" section in Mr Goldstraw's case amounted to 83 pages. Although the relevant information concerning Mr Goldstraw's mental health issues was contained within the "Communications" section of SystmOne there was no way of easily extracting it.
F. Accordingly, a busy, under pressure mental health nurse or doctor is very likely to struggle to find the relevant entries using SystmOne, which may explain why (in Mr Goldstraw's case) too much reliance was placed on how he presented during interview. A prisoner who chooses not to disclose his true state of mind or suicidal ideation is unlikely to come to the notice of the healthcare staff whose job it is to identify the risk that he may pose to himself because SystmOne does not facilitate this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of effective SystmOne training and competency in suicide and deliberate self-harm risk assessment
Wider context from the report “G. There also appeared to be a lack of training in relation to the effective use of SystmOne . In particular, it was not clear whether any steps had been taken to ensure that the staff who were working at the prison at the time of Mr Goldstraw's death had been retrained or had their competencies assessed in light of the failures identified. There is a real concern that some staff are still failing adequately to carry out assessments of a prisoners risk of suicide / deliberate self-harm.
H. The Head of Healthcare at HM Prison, Winchester has indicated that she intends to provide (in conjunction with the Prison Governor) a joint learning bulletin to all staff, stressing the importance of sharing information, most notably in reception and during the early days in custody. However, this does not address the technical shortcomings of SystmOne which present a matter of considerable concern, even if healthcare staff undertake all reasonable steps to ascertain a prisoner's previous mental health history as part of the prison induction process.
” Open source report
Concerns raised 3 Toxic effects from excessive amounts of drugs taken with other medication View source Permitting patients to opt out of GP notification View source Permitting patient self-certification without checks View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Joseph James Gingell · 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
Joseph James Gingell, who had a long history of mental illness and opioid and benzodiazepine dependence, was found deceased in a hotel near the Dartford Crossing. His cause of death was mixed drug toxicity with alcohol, and he had obtained drugs online without a prescription. Concerns included the toxic effects of combining drugs, self-certification without checks, and allowing patients not to inform their GP, which could remove a safeguard for people with addiction problems.
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 Toxic effects from excessive amounts of drugs taken with other medication
Wider context from the report “(1) The drugs found in Mr Gingell’s system are known to have toxic effects when taken in excessive amounts in conjunction with other medication.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Permitting patients to opt out of GP notification
Wider context from the report “(3) Permitting the patient the option of not having a GP informed removes an otherwise effective safeguard .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Permitting patient self-certification without checks
Wider context from the report “(2) Permitting the patient to “self certify” without any checks can allow abuse of the system by those most vulnerable who have addiction problems.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working nationally, regionally and locally with key partners to improve controlled-drug and online-prescribing safety.
Verbatim wording from the response “NHSE&I remains committed to improving the safety of controlled drugs and online prescribing. We will continue to work across the system with key partners nationally, regionally and locally to ensure patient safety. We would also suggest that contact is made directly with the CQC and MRHA who would be better placed should you wish to understand their work in this area further.” Source location Response from NHS England
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Coordinate a programme implementing Prescribed medicines review recommendations with relevant arm’s-length bodies to improve cross-system safety.
Verbatim wording from the response “In the wider context of this issue, Public Health England published in 2019 a Prescribed medicines review⁷. This reported on the evidence for dependence on, and withdrawal from, prescribed medicines with the aim of making sure that local healthcare systems build awareness and support to enhance clinician and patient decision making. In support of this NHSE&I are co-ordinating a programme to implement the review recommendations, working closely with relevant Arm’s Length Bodies (ALBs) to ensure cross system improvements. The programme covers five classes of medicines including:” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt a quality assurance, safety and security standards system for online consultations.
Verbatim wording from the response “One of the questions CQC’s inspectors asked during these inspections included how the service makes sure the identity of the patient is authenticated and requested that where a treatment might have the potential to affect safe care or decrease the ability of the patient’s GP to provide safe and effective care that the patient’s NHS GP is kept informed of any treatment, with the exception of sexual health services. These issues are important for NHSE&I and we will ensure that NHS online consultations provide a safe and secure way for patients to discuss their health concerns with an appropriate clinician connected to their own GP practice and place centred around their needs. NHSE&I has adopted a robust system of quality assurance, safety and security standards so that patients and clinicians can feel confident in using online consultations.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure NHS online consultations provide safe, secure access to appropriate clinicians connected with patients’ GP practices.
Verbatim wording from the response “One of the questions CQC’s inspectors asked during these inspections included how the service makes sure the identity of the patient is authenticated and requested that where a treatment might have the potential to affect safe care or decrease the ability of the patient’s GP to provide safe and effective care that the patient’s NHS GP is kept informed of any treatment, with the exception of sexual health services. These issues are important for NHSE&I and we will ensure that NHS online consultations provide a safe and secure way for patients to discuss their health concerns with an appropriate clinician connected to their own GP practice and place centred around their needs. NHSE&I has adopted a robust system of quality assurance, safety and security standards so that patients and clinicians can feel confident in using online consultations.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHSE&I lacks powers to stop illegal supply of dependence-forming controlled drugs outside the legislative framework.
Verbatim wording from the response “The sale or supply of controlled drugs outside of the legislative framework is the responsibility of the Home Office, and NHSE&I does not have powers to stop illegal supply of dependence forming drugs with toxic potential. However, we can and do take this into account in the provision of NHS services. NHSE&I expects all NHS providers to follow the NICE guidance on Coexisting severe mental illness (psychosis) and substance misuse: assessment and management in healthcare settings² which directs people to consider the use of drugs, prescribed or otherwise when providing clinical care.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Home Office is responsible for controlling the sale or supply of controlled drugs outside the legislative framework.
Verbatim wording from the response “The sale or supply of controlled drugs outside of the legislative framework is the responsibility of the Home Office, and NHSE&I does not have powers to stop illegal supply of dependence forming drugs with toxic potential. However, we can and do take this into account in the provision of NHS services. NHSE&I expects all NHS providers to follow the NICE guidance on Coexisting severe mental illness (psychosis) and substance misuse: assessment and management in healthcare settings² which directs people to consider the use of drugs, prescribed or otherwise when providing clinical care.” Source location Response from NHS England
Open published response
Concerns raised 21 Provision of incorrect advice that an adrenaline auto injector switch is only a brand substitution View source Failure to reconsider adrenaline auto injector dose after switching device View source Inadequate and incorrect national training content for 111 call handlers on adrenaline auto injectors View source Failure to identify patients at particularly high risk from allergies and asthma View source Lack of named accountability for allergy services and provision View source Failure to assess patients’ access to and understanding of adrenaline auto injector advice View source Failure of the Adastra system to update location information across screens in real time View source Failure to establish whether specialist allergy care was being provided View source Inconsistency in anaphylaxis ambulance categorisation between 999 and 111 services View source Failure to explain the need for sequential administration of two adrenaline auto injectors in acute anaphylaxis View source Failure of 111 call audits to identify all significant call-handling failings View source Rare provision of practical placebo-device adrenaline auto injector training View source Failure to provide healthcare-professional training after an adrenaline auto injector switch View source Failure to communicate device-specific training requirements for adrenaline auto injectors View source Failure of NHS Digital to retain and act on previously identified call-handling safety issues View source Failure of AAI leaflets to specify the need for device-specific healthcare-professional training View source Failure of the 999 service to safety-net inappropriate 111 categorisation View source Single-sale availability of Emerade adrenaline auto injectors View source Failure to record and emphasise the need to carry two adrenaline auto injector pens View source Failure to advise prescribers to reconsider adrenaline auto injector dose after a device switch View source Failure to display the advice to carry two adrenaline auto injectors on the outside of the box View source See 18 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Shanté Andrée Marie TURAY-THOMAS · 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
Shanté Andrée Marie Turay-Thomas ate hazelnuts on 18 September 2018 and died soon afterwards from acute anaphylaxis. The report identifies concerns about inadequate allergy care, advice and training concerning adrenaline auto-injectors, prescribing and clinical communication, and errors in the NHS 111 response and ambulance categorisation.
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 Provision of incorrect advice that an adrenaline auto injector switch is only a brand substitution
Wider context from the report “7. The GPs relied upon the advice given by Enfield Clinical Commissioning Group (CCG) that the scriptswitch was simply the replacement of one branded product with another branded product of the same drug/device . This gave false reassurance. The CCG joint formulary committee introduced a new drug for GPs, but then gave the wrong advice to accompany this .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 reconsider adrenaline auto injector dose after switching device
Wider context from the report “5. When Shanté’s AAI was changed from an EpiPen to an Emerade, her GPs failed to reconsider the prescription and to increase her dose from 300mgs to 500mcgs .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 and incorrect national training content for 111 call handlers on adrenaline auto injectors
Wider context from the report “17. In terms of national training for 111 call handlers, the NHS Digital distance learning pack contains advice that is in part inadequate and in part wrong . It does not give the crucial information that one dose of adrenaline, by whichever device it is administered, is very unlikely to be sufficient in the case of acute anaphylaxis . It contains a photograph to illustrate the use of an AAI, but in the photograph the device is held incorrectly .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 patients at particularly high risk from allergies and asthma
Wider context from the report “1. At the time of her death, Shanté was not receiving specialist care for her allergies. However, her general practitioners (GPs) failed to appreciate this. They assumed that she was being treated for her allergies at the transitional asthma clinic to which she had been referred following her paediatric discharge. This was an incorrect assumption.
The GPs had not identified Shanté (who had a high BMI and was severely allergic) as being at particularly high risk from her allergies and asthma, and had no awareness that they were the sole providers of Shanté’s allergy 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 named accountability for allergy services and provision
Wider context from the report “20. The issues within this prevention of future deaths report are predominantly national issues, but I heard at inquest that there is no person with named accountability for allergy services and allergy provision at NHS England or the Department of Health as a whole .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 patients’ access to and understanding of adrenaline auto injector advice
Wider context from the report “2. Shanté’s GPs knew that she should carry two adrenaline auto injector (AAI) pens at all times, and they may have mentioned this to her, but they failed to record this and they did not emphasise it to her.
They failed to emphasise to Shanté and her family that the reason for carrying two pens is primarily because in the event of severe acute anaphylaxis, the very strong likelihood is that both pens will need to be administered, one five minutes after the other, to keep the patient alive until the arrival of an emergency ambulance.
The GPs did not explore with Shanté the reason for her erratic requests for a pen . They did not explore with her where she kept her pens . They did not test her understanding of medical 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 Failure of the Adastra system to update location information across screens in real time
Wider context from the report “14. When Shanté became ill following the ingestion of nuts, her mother rang NHS 111 and got through to the London Central & West (LCW) service. However, the call handler incorrectly recorded Shanté’s location: he failed to untick a box and so her grandmother’s address was recorded as her location, rather than her mother’s address where she was staying at the time.
In an example of good practice, this error was recognised by the clinician who later took over the call. However, what nobody at LCW realised was that the Adastra computer system would not then update in real time for any screens save that of the particular clinician inputting the information .
The staff at LCW have since been made aware of this and have been trained to walk over and look at the primary screen to check the address, but it is not clear to me that there is now a national understanding of that element of the system.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to establish whether specialist allergy care was being provided
Wider context from the report “1. At the time of her death, Shanté was not receiving specialist care for her allergies. However, her general practitioners (GPs) failed to appreciate this . They assumed that she was being treated for her allergies at the transitional asthma clinic to which she had been referred following her paediatric discharge. This was an incorrect assumption.
The GPs had not identified Shanté (who had a high BMI and was severely allergic) as being at particularly high risk from her allergies and asthma, and had no awareness that they were the sole providers of Shanté’s allergy 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 Inconsistency in anaphylaxis ambulance categorisation between 999 and 111 services
Wider context from the report “16. The individuals making these errors were working within the context of NHS Digital’s categorisation of anaphylaxis as needing a category 2 ambulance rather than a category 1 ambulance, on the Adastra computer system that supports the LCW 111 service.
This was the wrong categorisation and not the categorisation that the call would have received if 999 had been called and the London Ambulance Service contacted in the first instance. Acute anaphylaxis is immediately life threatening and must be treated as a category 1.
I heard at inquest that NHS Digital has since changed its categorisation. However, I also heard that for those areas (I think approximately half the country, though this is not completely clear to me), where the 999 service and the 111 service are supported by different computer systems rather than the same system being common to both services, there could remain inconsistencies of categorisation between 999 and 111 .
Even where there are inconsistencies in categorisation, the 999 service will not re-categorise following a 111 clinician’s categorisation, unless a 999 clinician has spoken to the patient, so inappropriate 111 categorisation will not be safety netted by the 999 service. This must be recognised and factored 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 Failure to explain the need for sequential administration of two adrenaline auto injectors in acute anaphylaxis
Wider context from the report “2. Shanté’s GPs knew that she should carry two adrenaline auto injector (AAI) pens at all times, and they may have mentioned this to her, but they failed to record this and they did not emphasise it to her.
They failed to emphasise to Shanté and her family that the reason for carrying two pens is primarily because in the event of severe acute anaphylaxis, the very strong likelihood is that both pens will need to be administered, one five minutes after the other , to keep the patient alive until the arrival of an emergency ambulance.
The GPs did not explore with Shanté the reason for her erratic requests for a pen. They did not explore with her where she kept her pens. They did not test her understanding of medical 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 Failure of 111 call audits to identify all significant call-handling failings
Wider context from the report “15. During the course of the 111 call, a number of errors were made. These were the errors of LCW individuals. When LCW audited the call in the first instance, the audit identified the problem with the address, but failed to recognise how badly the call had gone in other ways . Without effective audit and recognition of failings, it is difficult to see how there can be effective 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 Rare provision of practical placebo-device adrenaline auto injector training
Wider context from the report “13. I heard that the gold standard of training for use of any AAI is to give the patient the relevant pen (whichever that patient is prescribed) containing a placebo rather than adrenaline and, following appropriate instruction, ask the patient actually to administer a dose.
I heard at inquest that the incidence of this standard of training (in any setting) is rare . That may be for good reasons, but it seems that revisiting best practice training at a national level would be helpful.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 healthcare-professional training after an adrenaline auto injector switch
Wider context from the report “6. Following the scriptswitch, the GPs failed to ask Shanté to come in to the surgery for training in use of the Emerade . This would also have presented an ideal opportunity to explore Shanté’s understanding of the use of her pens and to ensure that she understood she needed to carry two at all 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 Failure to communicate device-specific training requirements for adrenaline auto injectors
Wider context from the report “9. The CCG failed to inform prescribers that the Emerade pen requires different training to the EpiPen because different AAIs do not operate in the same way. In fact, the CCG gave the opposite 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 Failure of NHS Digital to retain and act on previously identified call-handling safety issues
Wider context from the report “19. One of the errors made by the first 111 call handler was a failure to ask to speak direct to the patient. This was the error of an individual.
However, this is not the first time that the issue has been brought to the attention of NHS Digital. At inquest, I asked the witness who appeared on behalf of NHS Digital, and indeed had been chosen by NHS Digital as the person best able to assist the court, if this had been an issue in the past. He said no. However, on 18 December 2018, Peter Harrowing, HM Assistant Coroner for Avon, sent a prevention of future deaths report to NHS Digital following the inquest touching the death of David Longden.
It was only when I asked the witness appearing on behalf of NHS Digital specifically about Coroner Harrowing’s report in respect of Mr Longden, pointing out that Coroner Harrowing had raised the need for NHS Digital to place greater emphasis on the call handler speaking to the patient, that the witness remembered that he had indeed seen that report.
I choose to characterise this as a memory lapse rather than as an intention wilfully to mislead the court. (A witness who lies whilst giving evidence on oath at inquest may be found in contempt of court and may even be prosecuted for the crime of perjury.) Nevertheless, if NHS Digital does not have a grasp of this sort of detail, specifically brought to its attention by a coroner in a prevention of future deaths report, it is difficult to see how there can be effective 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 Failure of AAI leaflets to specify the need for device-specific healthcare-professional training
Wider context from the report “12. The Emerade AAI (and I assume the EpiPen and JEXT) leaflet does not specifically advise that training from a healthcare professional is needed in how to use this particular AAI as opposed to any other .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 999 service to safety-net inappropriate 111 categorisation
Wider context from the report “16. The individuals making these errors were working within the context of NHS Digital’s categorisation of anaphylaxis as needing a category 2 ambulance rather than a category 1 ambulance, on the Adastra computer system that supports the LCW 111 service.
This was the wrong categorisation and not the categorisation that the call would have received if 999 had been called and the London Ambulance Service contacted in the first instance. Acute anaphylaxis is immediately life threatening and must be treated as a category 1.
I heard at inquest that NHS Digital has since changed its categorisation. However, I also heard that for those areas (I think approximately half the country, though this is not completely clear to me), where the 999 service and the 111 service are supported by different computer systems rather than the same system being common to both services, there could remain inconsistencies of categorisation between 999 and 111.
Even where there are inconsistencies in categorisation, the 999 service will not re-categorise following a 111 clinician’s categorisation, unless a 999 clinician has spoken to the patient , so inappropriate 111 categorisation will not be safety netted by the 999 service . This must be recognised and factored 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 Single-sale availability of Emerade adrenaline auto injectors
Wider context from the report “4. The Emerade AAI is sold singly . It could be sold in boxes of two as the norm and only singly in the alternative.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to record and emphasise the need to carry two adrenaline auto injector pens
Wider context from the report “2. Shanté’s GPs knew that she should carry two adrenaline auto injector (AAI) pens at all times, and they may have mentioned this to her, but they failed to record this and they did not emphasise it to her .
They failed to emphasise to Shanté and her family that the reason for carrying two pens is primarily because in the event of severe acute anaphylaxis, the very strong likelihood is that both pens will need to be administered, one five minutes after the other, to keep the patient alive until the arrival of an emergency ambulance.
The GPs did not explore with Shanté the reason for her erratic requests for a pen. They did not explore with her where she kept her pens. They did not test her understanding of medical 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 Failure to advise prescribers to reconsider adrenaline auto injector dose after a device switch
Wider context from the report “8. The CCG failed to draw prescribers’ attention to the need, following scriptswitch from EpiPen to Emerade, to reconsider the dose and to prescribe the higher dose of 500mcgs for patients at higher risk (which would have included Shanté).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 display the advice to carry two adrenaline auto injectors on the outside of the box
Wider context from the report “3. The Emerade AAI accompanying leaflet does include the advice that two pens should be carried at all times, but the advice is not re-iterated on the outside of the box . Consideration will need to be given to whether this is the appropriate advice in all cases, but it seems worthwhile to review the issue as a whole.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend and release the Distance Learning Pack with stronger anaphylaxis guidance, second-dose adrenaline advice and accurate images of adrenaline autoinjectors.
Verbatim wording from the response “NHS Digital welcomed the evidence given by the expert witness, Professor Fox, at the inquest and immediately recognised that the distance learning pack could be improved, assuring the Coroner (in evidence and in the supplementary second witness statement dated 20th December 2019) that a review would be undertaken, in consultation with Professor Fox, to address the points raised during his evidence.” Source location 2020-0124-Response-from-NHS-Digital_Redacted-1.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend NHS Pathways guidance so a second adrenaline autoinjector is advised after five minutes without improvement, through Release 20.
Verbatim wording from the response “NHS Pathways has always prompted call handlers to give instructions in respect of a second administration of AAI if there is no improvement, as NHS Digital stated in the PFD submissions, dated 17 January 2020. This is NHS Pathways content and is not affected by the system into which NHS Pathways is embedded (e.g. Adastra in this case).” Source location 2020-0124-Response-from-NHS-Digital_Redacted-1.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and apply an audit framework for NHS Pathways providers, including audit standards, frequencies, qualifications and training requirements.
Verbatim wording from the response “NHS Digital has developed an extensive audit framework that applies to providers using NHS Pathways. This was described in NHS Digital’s: supplementary second witness statement dated 20th December 2019; submissions on conclusion dated 3 January 2020; and PFD submissions dated 17 January 2020.” Source location 2020-0124-Response-from-NHS-Digital_Redacted-1.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Change NHS Pathways ambulance categorisation so symptoms suggesting life-threatening anaphylaxis receive a category 1 response, and deploy the changes nationally.
Verbatim wording from the response “Following the Ambulance Response Program, NHS England led (supported by NASMED and ECPAG) a “clinical coding review” in May 2019, reviewing the category 1 ambulance response definition. Consequently, it was decided that symptoms which may suggest life-threatening anaphylaxis should receive a category 1 ambulance response and the necessary changes were made by NHS Pathways. These were beta tested in September 2019 and deployed nationally from October 2019.” Source location 2020-0124-Response-from-NHS-Digital_Redacted-1.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider whether communication routes or commissioning levers can support uptake and embedding of new allergy guidance and resources.
Verbatim wording from the response “We are deeply saddened by Shante’s death. We are grateful to have had the opportunity to respond to your concerns relevant to NHSEI. We will continue to work with HEE, the professional Royal Colleges and the other organisations addressed in your report to keep abreast of any new guidance or resources that they produce that would support better management of people with severe allergies. We will consider whether any of our communication routes or commissioning levers can help with their uptake and embedding.” Source location 2020-0124-Response-from-NHS-England_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Have commissioning teams liaise with relevant organisations to facilitate uptake of new guidance and resources supporting management of severe allergies.
Verbatim wording from the response “• I will ensure your report is sent to HEE and the Royal College of General Practitioners. Our commissioning teams will liaise directly with all relevant organisations to facilitate uptake of any new guidance and resource that would support better management of people with severe allergies.” Source location 2020-0124-Response-from-NHS-England_Redacted.pdf
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 Information about specific adrenaline auto-injector doses is a prescriber’s responsibility, not the call handler’s.
Verbatim wording from the response “Information about the specific dose required in respect of each AAI has not been included. This is because the appropriate dose is a matter for the prescriber, not the call handler issuing system-generated instructions on how to administer the medication.” Source location 2020-0124-Response-from-NHS-Digital_Redacted-1.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Providers are responsible for operating the audit system and managing failed call audits within NHS Digital’s framework.
Verbatim wording from the response “Clinical providers of services using NHS Pathways (‘providers’) must enter into a Licence Agreement with the Secretary of State for Health and Social Care, including requirements relating to implementation, operation, training and auditing. This licence and the supporting materials are managed by NHS Digital.” Source location 2020-0124-Response-from-NHS-Digital_Redacted-1.pdf
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 Matters of concern 1–14 and 20 do not concern NHS Pathways and fall outside its remit.
Verbatim wording from the response “HM Coroner raised matters of concern numbered 1 - 20 in the PFD report. Matters of concern 1 – 14 and 20 are not applicable to NHS Pathways. We set out below our response to matters of concern 15 to 19.” Source location 2020-0124-Response-from-NHS-Digital_Redacted-1.pdf
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 distance learning pack does not direct calls or communicate call-handler advice; NHS Pathways provides real-time support instead.
Verbatim wording from the response “As NHS Digital described in evidence and subsequent submissions, the distance learning pack is provided as a foundation of background information to all call handlers before they start training. It does not direct the progress of specific calls nor is it relied upon to communicate advice which a call handler should give. It would not be clinically safe or appropriate for non-clinical call handlers to be required to exercise knowledge or judgement, or act prompted by the system, in this way. Call handlers are instead supported by the questions and care advice presented by the NHS Pathways system. The system contains ‘supporting information’ to help call handlers understand the clinical essence of what is being asked or advised. This is presented in ‘real-time’ so that the call handler has the required information in front of them, rather than having to rely on memory.” Source location 2020-0124-Response-from-NHS-Digital_Redacted-1.pdf
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 Ambulance categorisation and alignment of NHS Pathways with MPDS are not NHS Digital’s responsibility or oversight function.
Verbatim wording from the response “Ambulance response categorisation, and the alignment of different triage systems, is not the responsibility of NHS Digital. This was set out in the following submissions made on behalf of NHS Digital:” Source location 2020-0124-Response-from-NHS-Digital_Redacted-1.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England oversees both systems and must address ambulance categorisation or inconsistencies between MPDS and NHS Pathways.
Verbatim wording from the response “NHS England is the organisation charged with overseeing both NHS Pathways and MPDS, and has the remit and ability to review potential inconsistencies or change ambulance categorisation. Accordingly, concerns regarding ambulance categorisation or inconsistencies between MPDS and NHS Pathways can only be properly answered by NHS England.” Source location 2020-0124-Response-from-NHS-Digital_Redacted-1.pdf
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 Additional primary-care allergy training and training requirements are assigned to professional organisations, Health Education England and CCGs.
Verbatim wording from the response “• The British Society for Allergy & Clinical Immunology (BSACI) provide training for primary care staff across the country (workshops and educational meetings). Additional training of primary care staff / establishing training requirements would be via their professional organisations (e.g. Royal College of GPs), Health Education England and CCGs.” Source location 2020-0124-Response-from-NHS-England_Redacted.pdf
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 Curriculum content for health professionals’ education and training is outside NHSEI’s direct role.
Verbatim wording from the response “NHSEI has an assurance role for CCGs and their commissioning of healthcare services. NHSEI does not have any direct role in offsetting the curriculum content for health professionals’ education and training. However, I can set out the following which sets out NHSEI’s work and commitment in this area:” Source location 2020-0124-Response-from-NHS-England_Redacted.pdf
Open published response
Concerns raised 2 Under-appreciation of clozapine side effects relating to smoking and pneumonia View source Insufficient BNF clarity about clozapine side effects 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
Katharine Eva Stamp · 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
Katharine Eva Stamp died while detained under the Mental Health Act from sudden cardiac arrhythmia due to hypoxia, with the hypoxia described as involving aspiration pneumonia, probable sleep apnoea, obesity, smoking and clozapine effects. The report raised concerns that clozapine side effects, particularly in relation to smoking and pneumonia, were under-appreciated and that the BNF did not provide sufficient clarity to prescribers; it also stated that the lack of an effective national weight-gain monitoring programme for mental health inpatients was causally linked to her obesity and probable sleep apnoea.
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-appreciation of clozapine side effects relating to smoking and pneumonia
Wider context from the report “The side effects of clozapine, with specific reference to smoking and pneumonia, are under-appreciated Professor ████████ gave expert evidence to the Court These side effects may be rare, but they are still important The BNF does not provide sufficient clarity to prescribers about these side-effects
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 BNF clarity about clozapine side effects
Wider context from the report “The side effects of clozapine, with specific reference to smoking and pneumonia, are under-appreciated Professor ████████ gave expert evidence to the Court These side effects may be rare, but they are still important The BNF does not provide sufficient clarity to prescribers about these side-effects
” Open source report
Concerns raised 2 Ineffective communication across departments about patient treatment View source Ineffective management of patient records across multiple systems and paper records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Suzanne Roberts · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Suzanne Roberts died at The Dene on 18 October 2015 following a sudden cardiac arrest arising from acute kidney injury, pyelonephritis, chronic dehydration and an underlying high-output stoma. The inquest jury found neglect and identified fragmented information sharing, ineffective use of clinical records and poor communication between departments at the Royal Sussex County Hospital as concerns. The report states that multiple record systems, paper records and a portal were in use without mandatory rules or quality assurance, creating a continuing 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 Ineffective communication across departments about patient treatment
Wider context from the report “A Senior Consultant at the RSCH gave evidence at the Inquest in December 2019 and described the current system of managing patient records at the RSCH as “sub-optimal” and “flawed” and that a similar death to that of Suzanne Roberts could occur (in the same circumstance as seen in October 2015) in December 2019
The Jury found the management of patient records at the RSCH to be ineffective, as was cross Department communication in relation to patient treatment The Jury also found ineffective communication and ineffective use of patient records within the Department of Trauma and Orthopaedics in relation to patient treatment
Whilst there was evidence that £30m had been recently spent by the Brighton and Sussex Universities Hospital NHS Trust on a failed attempt to create a single electronic patient record, the Inquest revealed that
There were at least three software systems in use by different Departments at RSCH, alongside paper records, and that a portal system, Panda, was also potentially in place In the absence of mandatory rules for the use of those systems or portal, and mandatory quality assurance about data uploaded to those systems or portal, there is a continuing risk of future deaths due to ineffective management of patient records and ineffective communication across departments at RSCH
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Ineffective management of patient records across multiple systems and paper records
Wider context from the report “A Senior Consultant at the RSCH gave evidence at the Inquest in December 2019 and described the current system of managing patient records at the RSCH as “sub-optimal” and “flawed” and that a similar death to that of Suzanne Roberts could occur (in the same circumstance as seen in October 2015) in December 2019
The Jury found the management of patient records at the RSCH to be ineffective , as was cross Department communication in relation to patient treatment The Jury also found ineffective communication and ineffective use of patient records within the Department of Trauma and Orthopaedics in relation to patient treatment
Whilst there was evidence that £30m had been recently spent by the Brighton and Sussex Universities Hospital NHS Trust on a failed attempt to create a single electronic patient record, the Inquest revealed that
There were at least three software systems in use by different Departments at RSCH, alongside paper records, and that a portal system, Panda, was also potentially in place In the absence of mandatory rules for the use of those systems or portal, and mandatory quality assurance about data uploaded to those systems or portal , there is a continuing risk of future deaths due to ineffective management of patient records and ineffective communication across departments at RSCH
” Open source report
Concerns raised 4 Failure to provide GPs with timely and reliable blood-results and follow-up information View source Shortage of interventional radiologists delaying access to drainage procedures View source Lack of a clear communication strategy and treatment plan between DGHs and tertiary centres View source Delays and impracticability in transferring patients to tertiary centres for drainage procedures View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Joyce Marchant · 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
Joyce Marchant died at Tameside General Hospital on 1 June 2019 from complications of a liver abscess, including biliary sepsis and multi-organ failure. The report identified concerns about delays in arranging drainage because of limited interventional radiology capacity, delayed communication of abnormal results to her GP through the postal system, and the lack of a clear communication strategy between the district general hospital and tertiary centre.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide GPs with timely and reliable blood-results and follow-up information
Wider context from the report “2. The inquest heard that the Manchester Royal Infirmary use the postal system to provide GPs with information about blood results/follow up information . Faxes are no longer used due to GDPR. The trust propose to move to an email system for notifying GPs recognising that the use of the postal system carries delay and risk of information not reaching the GP(7% was the figure given to the inquest) . Their IT system at this time is not capable of this information transfer and the information was that it would be about another 2-3 years before that was achieved. In the interim they would continue to use the postal system ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Shortage of interventional radiologists delaying access to drainage procedures
Wider context from the report “1. During the course of the Inquest the evidence given was that the delay in offering the drainage procedure was attributable to a shortage of interventional radiologists which meant that the Trust could not accommodate the need for a drainage procedure until 31st May . There was greater availability at tertiary centres but transfers to tertiary centre could take time and not be practicable. The inquest heard that if she had been at the tertiary centre when the abscess was identified she would probably have had the drainage procedure almost straight away;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear communication strategy and treatment plan between DGHs and tertiary centres
Wider context from the report “3. The MRI was the treating centre for Mrs Marchant’s underlying medical problems which led to her deterioration. However there was no evidence of a clear communication strategy or treatment plan involving the DGH and Tertiary Centre . This was attributed in part to the sheer volume of demand on tertiary centres and the extent of support they can provide to DGHs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays and impracticability in transferring patients to tertiary centres for drainage procedures
Wider context from the report “1. During the course of the Inquest the evidence given was that the delay in offering the drainage procedure was attributable to a shortage of interventional radiologists which meant that the Trust could not accommodate the need for a drainage procedure until 31st May. There was greater availability at tertiary centres but transfers to tertiary centre could take time and not be practicable . The inquest heard that if she had been at the tertiary centre when the abscess was identified she would probably have had the drainage procedure almost straight away;
” Open source report
9 Dec 2019 John Michael WELLS · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 8 Failure to obtain complete medical and medication information from relevant sources View source Early exit from NHS Pathways Module 0 for third-party calls View source Failure to transfer important and accurate medical information to telecare and emergency services View source Lack of a facility for call handlers to pass calls directly to ambulance triage staff View source Lack of automatic flagging of medical and medication-related risks View source Failure of unanswered patient call attempts to trigger clinical review of triage decisions View source Different ambulance-call handling for third-party callers View source Unavailability of responder telephone numbers within the call handling system 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 Michael WELLS · 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 Michael Wells died at the scene after lacerating a varicose vein and suffering severe blood loss while prescribed anticoagulant medication. The report identified concerns about incomplete medical information, the accessibility and handling of responder contact details, the absence of automatic risk flagging, and the triage of third-party emergency calls.
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 obtain complete medical and medication information from relevant sources
Wider context from the report “(1) The information regarding Mr Wells’ medical conditions and medication held by RedAssure/Worthing Homes was not complete.
RedAssure were the providers of the telecare service to Mr Wells and were part of Worthing Homes. RedAssure had contracted Apello to answer out of hours calls.
During the inquest I heard evidence that when a resident moves into Worthing Homes sheltered housing they are asked to provide medical information; as are any persons who happen to accompany them. I heard that updates are requested from the residents by sending out a form.
Neither Worthing Homes nor RedAssure seek permission from the residents to obtain medical information from their GP or other third parties.
I heard evidence that the staff at Worthing Homes had been aware of Mr Wells’ special needs and vulnerability but this did not appear on the resident information sheet; which provides the information accessed by Appello.
Whilst I heard evidence that Worthing Homes are no longer providing telecare support they still provide the medical information recorded on their residents to telecare providers.
Subsequent to the inquest Worthing Homes provided further information to assist with the preparation of this report. This confirmed that RedAssure no longer existed and that Worthing Homes, as a social housing provider, were not involved in providing care or medical assistance. They state that medical information gathered at the application stage is solely for the purpose of ascertaining the prospective resident’s suitability for a property.
Worthing Homes provided a full version of a review record from 2015 clearly stating that Mr Wells had learning difficulties. In addition a GP letter provided to Worthing Homes in 2008 states that Mr Wells had a low IQ. Neither of these pieces of information were transferred on the front sheet of the record, which appears to have been the source of the information entered onto Carenet.
As a result of the incomplete records and summary Appello & SECAMB were not provided with important and accurate information regarding Mr Wells.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 exit from NHS Pathways Module 0 for third-party calls
Wider context from the report “(5) An early exit from the NHS Pathways Module 0 occurs when a call is received from a third party. Subsequent unanswered calls direct to the patient do not necessarily lead to a clinical review of the triage decision.
From the evidence heard at inquest it was established that the EMA would exit module 0 of NHS Pathways at an early stage when a call received from a third party. All subsequent actions are largely dependant on the EMA correctly identifying the clinical position of the patient and correctly triaging it despite the limited number of questions asked of the caller.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 transfer important and accurate medical information to telecare and emergency services
Wider context from the report “(1) The information regarding Mr Wells’ medical conditions and medication held by RedAssure/Worthing Homes was not complete.
RedAssure were the providers of the telecare service to Mr Wells and were part of Worthing Homes. RedAssure had contracted Apello to answer out of hours calls.
During the inquest I heard evidence that when a resident moves into Worthing Homes sheltered housing they are asked to provide medical information; as are any persons who happen to accompany them. I heard that updates are requested from the residents by sending out a form.
Neither Worthing Homes nor RedAssure seek permission from the residents to obtain medical information from their GP or other third parties.
I heard evidence that the staff at Worthing Homes had been aware of Mr Wells’ special needs and vulnerability but this did not appear on the resident information sheet; which provides the information accessed by Appello.
Whilst I heard evidence that Worthing Homes are no longer providing telecare support they still provide the medical information recorded on their residents to telecare providers.
Subsequent to the inquest Worthing Homes provided further information to assist with the preparation of this report. This confirmed that RedAssure no longer existed and that Worthing Homes, as a social housing provider, were not involved in providing care or medical assistance. They state that medical information gathered at the application stage is solely for the purpose of ascertaining the prospective resident’s suitability for a property.
Worthing Homes provided a full version of a review record from 2015 clearly stating that Mr Wells had learning difficulties. In addition a GP letter provided to Worthing Homes in 2008 states that Mr Wells had a low IQ. Neither of these pieces of information were transferred on the front sheet of the record , which appears to have been the source of the information entered onto Carenet.
As a result of the incomplete records and summary Appello & SECAMB were not provided with important and accurate information regarding Mr Wells.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 facility for call handlers to pass calls directly to ambulance triage staff
Wider context from the report “(4) Under NHS Pathways triage system ambulance calls received from third party callers are handled in a different way from those received from persons present with a patient.
The SECAMB SIR identified that the receipt of a call from a third party was a contributory factor, partly as it required a first party call back. Mr Wells stated he was not able to talk to the ambulance service on the telephone.
From the evidence before the inquest it was clear that the Appello operator was still connected to Mr Wells when in contact with SECAMB. However there was no way for the operator pass the call though thereby allowing direct contact between Mr Wells and the SECAMB EMA.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 automatic flagging of medical and medication-related risks
Wider context from the report “(3) There is no mechanism for the automatic flagging of risks related to particular medical conditions or medications within Carenet.
I heard evidence that Appello operators are not medically trained and are employed to handle a wide variety of calls. There is no system in place highlighting risk factors which might allow the operators to respond more appropriately to medical emergencies and ensure that they pass the most important information to the emergency services.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of unanswered patient call attempts to trigger clinical review of triage decisions
Wider context from the report “(5) An early exit from the NHS Pathways Module 0 occurs when a call is received from a third party. Subsequent unanswered calls direct to the patient do not necessarily lead to a clinical review of the triage decision.
From the evidence heard at inquest it was established that the EMA would exit module 0 of NHS Pathways at an early stage when a call received from a third party. All subsequent actions are largely dependant on the EMA correctly identifying the clinical position of the patient and correctly triaging it despite the limited number of questions asked of the caller.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Different ambulance-call handling for third-party callers
Wider context from the report “(4) Under NHS Pathways triage system ambulance calls received from third party callers are handled in a different way from those received from persons present with a patient.
The SECAMB SIR identified that the receipt of a call from a third party was a contributory factor, partly as it required a first party call back . Mr Wells stated he was not able to talk to the ambulance service on the telephone.
From the evidence before the inquest it was clear that the Appello operator was still connected to Mr Wells when in contact with SECAMB. However there was no way for the operator pass the call though thereby allowing direct contact between Mr Wells and the SECAMB EMA.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 responder telephone numbers within the call handling system
Wider context from the report “(2) The telephone numbers for the RedAssure responders are not contained within the Appello call handling system (Carenet).
Under the contract between RedAssure and Appello the operator should have called a responder once he had spoken to SECAMB. The operator phoned telephone numbers from the ‘listed contacts’ screen and believed that this included a responder. It did not.
The RedAssure responders’ contact details are accessed via a separate policy document that the operator needs to open. No link to these numbers is provided from Carenet nor are they listed in the ‘contacts’ section of Carenet.
” Open source report
14 Nov 2019 Joanna Clare Alice Flynn · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2 Inadequate training and education for general practitioners and GP practices in care for patients dependent on prescribed opiates View source Lack of specialised assistance and referral agencies for general practitioners supporting patients dependent on prescribed opiates View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joanna Clare Alice Flynn · 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
Joanna Clare Alice Flynn, aged 31, was found slumped over her bed on 26 May 2019 after last being seen on 23 May 2019. The inquest returned an Open conclusion against a background of long-standing prescribed opiate addiction, with concerns about the lack of specialised support and referral pathways for patients needing help to withdraw from addictive prescription drugs, as well as GP training and education.
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 training and education for general practitioners and GP practices in care for patients dependent on prescribed opiates
Wider context from the report “The General Practitioner who gave evidence told the court that there was a lacuna in the healthcare provided for patients such as the deceased in terms of giving assistance for weaning off addictive prescription drugs such as opiates. It was clear that General Practitioner’s require highly specialised assistance in order to help such patients and agencies within the healthcare system to which to refer them. This was all lacking in this particular sad set of circumstances. The court was informed about a proposed pilot scheme – a substance misuse Locally Enhanced Service for people with dependence to prescribed opiates. There was no assurance that this had commenced or indeed yet been funded. I would like an assurance that this hopeful initiative has got off the ground and indeed I would like to have information about any other initiatives to endeavour to address this dreadful problem. I would also like to hear what strides have been taken to improve training and education for general practitioners and GP practices in this worrying area of 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 specialised assistance and referral agencies for general practitioners supporting patients dependent on prescribed opiates
Wider context from the report “The General Practitioner who gave evidence told the court that there was a lacuna in the healthcare provided for patients such as the deceased in terms of giving assistance for weaning off addictive prescription drugs such as opiates . It was clear that General Practitioner’s require highly specialised assistance in order to help such patients and agencies within the healthcare system to which to refer them . This was all lacking in this particular sad set of circumstances . The court was informed about a proposed pilot scheme – a substance misuse Locally Enhanced Service for people with dependence to prescribed opiates. There was no assurance that this had commenced or indeed yet been funded . I would like an assurance that this hopeful initiative has got off the ground and indeed I would like to have information about any other initiatives to endeavour to address this dreadful problem. I would also like to hear what strides have been taken to improve training and education for general practitioners and GP practices in this worrying area of care.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue supporting primary care through additional funding, staff and organisational development for vulnerable, high-risk patients.
Verbatim wording from the response “It is important to acknowledge the current pressures on primary care. NHSE continues to support primary care with additional funding, staff and organisational development to ensure time and resources are available to care for these vulnerable patients who are potentially high risk and will often need input from the most experienced staff.” Source location 2019-0369-Response-from-NHS-England-and-NHS-Improvement
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 appropriate expertise and resources are universally available to support patients dependent on prescribed medicines and reduce associated morbidity and mortality.
Verbatim wording from the response “NHSE is committed to fully understanding contributing factors to this serious problem and ensuring that all appropriate expertise and resources are universally available to support these patients and reduce the likelihood of future associated morbidity and mortality.” Source location 2019-0369-Response-from-NHS-England-and-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 Specialist support beyond general practice is usually delivered through services commissioned by clinical commissioning groups.
Verbatim wording from the response “Many of these patients will require input beyond ‘conventional’ general practice, usually via a CCG commissioned service that could take the form of a Locally Commissioned Service (in effect an enhanced GP service) or through a contract with an alternative provider, usually across a CCG footprint.” Source location 2019-0369-Response-from-NHS-England-and-NHS-Improvement
Open published response
Concerns raised 3 Failure of electronic prescriptions to remain available for download after system details are reset View source Failure to act on urine test results after patient discharge View source Lack of awareness among medical professionals of the electronic prescribing system peculiarity 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
Sandra Dawne Scott · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sandra Dawne Scott was prescribed treatment for a urinary infection, but the prescription was not available for collection after changes were made to the electronic prescribing system. She was admitted to hospital with worsening symptoms on 22 April 2019, deteriorated, and died on 23 April 2019. Concerns included the failure to act on hospital urine-test results and the lack of awareness among healthcare professionals of the electronic prescribing system issue; the evidence was that receiving the prescribed or indicated medication would have meant she did not die when she did.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of electronic prescriptions to remain available for download after system details are reset
Wider context from the report “1. The GP issued a prescription to a nominated chemist, but a few minutes later put the system details back to what they were before the prescription was issued. Unknown to the GP these changes meant the prescription was no longer available for download by the chemist .
2. This resulted in the patient not getting required medication.
3. The evidence was that the GPs colleagues were also unaware of this peculiarity of the system.
4. Other medical professionals are also likely to be unaware.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 act on urine test results after patient discharge
Wider context from the report “5. The Royal Hallamshire Hospital received the results of a urine test on the 20.4.19 but did not act upon them as the patient had been discharged .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness among medical professionals of the electronic prescribing system peculiarity
Wider context from the report “1. The GP issued a prescription to a nominated chemist, but a few minutes later put the system details back to what they were before the prescription was issued. Unknown to the GP these changes meant the prescription was no longer available for download by the chemist.
2. This resulted in the patient not getting required medication.
3. The evidence was that the GPs colleagues were also unaware of this peculiarity of the system .
4. Other medical professionals are also likely to be unaware .
” Open source report
6 Nov 2019 Stuart Clarke · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1 Lack of national referral guidelines for patients with known valvular disease 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
Stuart Clarke · 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
Stuart Clarke presented with breathlessness in February 2018 and underwent a TAVI procedure on 25 June 2019 after a prolonged pathway to treatment. He did not recover following the procedure and died at Wythenshawe Hospital on 27 June 2019. The principal concern was the absence of national guidelines for referral between primary, secondary and tertiary care for patients with known valvular disease, alongside concern about the timeliness of intervention.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of national referral guidelines for patients with known valvular disease
Wider context from the report “However, I was concerned that there remain no national guidelines for referral from primary care to secondary care and/or from secondary care to tertiary care for patients with known valvular disease .
” Open source report
5 Nov 2019 Neville Lewis MCNAIR · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 4 Unavailability of Naloxone on prison wings outside the healthcare wing View source Lack of a local protocol for accessing and administering Naloxone View source Lack of prison officer training in Naloxone use View source Failure of prison staff to know the Naloxone requirement and availability View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Neville Lewis MCNAIR · 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
Neville Lewis MCNAIR was found unresponsive in his cell at HMP Lewes on 16 June 2018 and could not be revived after extensive CPR. The inquest concluded that the cause involved heroin toxicity with aspiration, and raised concerns about the availability of Naloxone in prison wings and prison officers’ training and awareness of its use.
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 Naloxone on prison wings outside the healthcare wing
Wider context from the report “In the Drug misuse and dependence: UK guidelines on clinical management “Orange Book” setting out UK guidelines on clinical management, section 5.4.9.1 states that ‘all staff including non-health care staff and operational/security staff should have training in recognising and responding to opiate overdose including using available Naloxone. Naloxone should be available in resuscitation kits and risk assessed areas in the prison so that it can be accessed and administered by clinical and non-clinical staff as per the local protocol.’ The Inquest was unable to establish that there was a local protocol and none of the prison staff were aware of the requirement. I am concerned that there is no Naloxone stored on the wings other than in healthcare wing and no prison officers appear to have been trained in its use or know of its existence. I believe this may be a national issue and not limited to HMP Lewes and in these circumstances this report should be seen as a concern for all prisons and NHS staff working in prisons nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a local protocol for accessing and administering Naloxone
Wider context from the report “In the Drug misuse and dependence: UK guidelines on clinical management “Orange Book” setting out UK guidelines on clinical management, section 5.4.9.1 states that ‘all staff including non-health care staff and operational/security staff should have training in recognising and responding to opiate overdose including using available Naloxone. Naloxone should be available in resuscitation kits and risk assessed areas in the prison so that it can be accessed and administered by clinical and non-clinical staff as per the local protocol.’ The Inquest was unable to establish that there was a local protocol and none of the prison staff were aware of the requirement. I am concerned that there is no Naloxone stored on the wings other than in healthcare wing and no prison officers appear to have been trained in its use or know of its existence. I believe this may be a national issue and not limited to HMP Lewes and in these circumstances this report should be seen as a concern for all prisons and NHS staff working in prisons nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of prison officer training in Naloxone use
Wider context from the report “In the Drug misuse and dependence: UK guidelines on clinical management “Orange Book” setting out UK guidelines on clinical management, section 5.4.9.1 states that ‘all staff including non-health care staff and operational/security staff should have training in recognising and responding to opiate overdose including using available Naloxone. Naloxone should be available in resuscitation kits and risk assessed areas in the prison so that it can be accessed and administered by clinical and non-clinical staff as per the local protocol.’ The Inquest was unable to establish that there was a local protocol and none of the prison staff were aware of the requirement. I am concerned that there is no Naloxone stored on the wings other than in healthcare wing and no prison officers appear to have been trained in its use or know of its existence. I believe this may be a national issue and not limited to HMP Lewes and in these circumstances this report should be seen as a concern for all prisons and NHS staff working in prisons nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of prison staff to know the Naloxone requirement and availability
Wider context from the report “In the Drug misuse and dependence: UK guidelines on clinical management “Orange Book” setting out UK guidelines on clinical management, section 5.4.9.1 states that ‘all staff including non-health care staff and operational/security staff should have training in recognising and responding to opiate overdose including using available Naloxone. Naloxone should be available in resuscitation kits and risk assessed areas in the prison so that it can be accessed and administered by clinical and non-clinical staff as per the local protocol.’ The Inquest was unable to establish that there was a local protocol and none of the prison staff were aware of the requirement . I am concerned that there is no Naloxone stored on the wings other than in healthcare wing and no prison officers appear to have been trained in its use or know of its existence . I believe this may be a national issue and not limited to HMP Lewes and in these circumstances this report should be seen as a concern for all prisons and NHS staff working in prisons nationally.
” Open source report
Concerns raised 2 Lack of necessary training for senior staff making x-ray requests View source Failure of systems to ensure timely resolution of x-ray and CT requests 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
Mrs Elizabeth Glen Self · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Elizabeth Glen Self was admitted to hospital following a heart attack and later suffered a serious fall after becoming entangled in a line attached to her left leg. Injuries were not immediately recognised, and there were delays of more than thirteen hours in dealing with requested x-rays and a CT scan. The concerns included inadequate training in making x-ray requests, a possible breakdown in communications, and systems that allowed imaging requests to remain unresolved for hours.
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 necessary training for senior staff making x-ray requests
Wider context from the report “a) A moderately senior doctor had put in not one but two x-ray requests that had to be rejected which is suggestive of a lack of necessary training
b) A valid CT request had laid unattended for a full morning, the reasons for which were never established but the hospitals own investigation report team formed an impression of a breakdown in communications.
c) The overall circumstances were such that neither requests was actually completed until more than thirteen hours after what was a significant fall. The inquest found this to be a criticism of the system then in place rather than of particular individuals.
In essence my concern is that those inspecting hospitals in other places should include in their programme establishing that senior staff do actually know how to make a proper x-ray request which will not therefore be rejected and checking systems to ensure that x-ray and CT requests cannot go for a period of hours without resolution.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 systems to ensure timely resolution of x-ray and CT requests
Wider context from the report “a) A moderately senior doctor had put in not one but two x-ray requests that had to be rejected which is suggestive of a lack of necessary training
b) A valid CT request had laid unattended for a full morning , the reasons for which were never established but the hospitals own investigation report team formed an impression of a breakdown in communications.
c) The overall circumstances were such that neither requests was actually completed until more than thirteen hours after what was a significant fall . The inquest found this to be a criticism of the system then in place rather than of particular individuals.
In essence my concern is that those inspecting hospitals in other places should include in their programme establishing that senior staff do actually know how to make a proper x-ray request which will not therefore be rejected and checking systems to ensure that x-ray and CT requests cannot go for a period of hours without resolution .
” Open source report
22 Oct 2019 Nigel Byron Abbott · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 10 Inadequacy of the Home Treatment Standard Operational Procedure for initially assessed and detainable patients awaiting a bed in the community View source Failure to learn and correct identified unsafe beliefs about section 135 warrants View source Mental health professionals operating caseloads well in excess of recommended levels View source Failure of agencies to work together effectively View source Failure to use section 4 for urgent cases View source Failure to provide section 140 beds View source Misunderstanding of the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments View source Chronic shortage of psychiatric beds View source Failure of agencies to work together effectively on mental health detention processes View source Misunderstanding between agencies about urgent section 135 warrant requirements 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
Nigel Byron Abbott · 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 27 July 2018, Nigel Byron Abbott was killed in a sustained assault by a man experiencing an acute psychotic episode who had been identified as posing a threat of violence but was not detained after mental health beds were reported to be unavailable. The report raised concerns about agencies misunderstanding the urgent use of section 135 powers and failing to work together effectively, potentially leaving acutely unwell people who pose risks to themselves or others unnecessarily free in public.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of the Home Treatment Standard Operational Procedure for initially assessed and detainable patients awaiting a bed in the community
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 learn and correct identified unsafe beliefs about section 135 warrants
Wider context from the report “It appears on the current evidence that there is a misunderstanding between the agencies as to how section 135 Mental Health Act 1983 can work in an urgent situation. This includes both whether or not WMP need 24 hours’ notice and whether or not a bed first needs to be available. All agencies need to urgently review the ‘Joint Memorandum of Understanding For Mental Health Professionals Requesting Police Assistance With Mental health Act Assessments and s135(1) & (2) Warrants, June 2018’ and their own practices both individually and jointly to ensure that all staff working in this area understand what is achievable and how.
The context for this report is:
(1) The evidence from WMP is that they do not require 24 hours’ notice to execute a section 135 warrant, whereas the AMHPs (BCC) are of the view there was no point in applying for a section 135 warrant because WMP need 24 hours’ notice.
(2) BSMHFT have stated that BCC refused to co-operate with their Root Cause Analysis process, reviewing what lessons could be learnt from the incident.
(3) I was only made aware that BCC had conducted an Internal Management Review Report - that acknowledged AMHPs were fixed on the operational difficulties of applying for the warrant out of hours and police availability as they required 24 hours’ notice – by a witness on day 1 of the inquest. BCC had not volunteered this report existed.
(4) The BCC Internal Management Review Report – which is designed to be the ‘organisational learning process’ - confirms that BCC has not learnt lessons from the incident effectively. In the action plan there is no mention of the incorrect belief amongst AMHPs, that WMP require 24 hours’ notice, having been corrected .
My on-going concern is that the agencies involved in this area are not working together effectively. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Mental health professionals operating caseloads well in excess of recommended levels
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 agencies to work together effectively
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 section 4 for urgent cases
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used .
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 section 140 beds
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT .
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Misunderstanding of the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments .
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Chronic shortage of psychiatric beds
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds .
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 agencies to work together effectively on mental health detention processes
Wider context from the report “It appears on the current evidence that there is a misunderstanding between the agencies as to how section 135 Mental Health Act 1983 can work in an urgent situation. This includes both whether or not WMP need 24 hours’ notice and whether or not a bed first needs to be available. All agencies need to urgently review the ‘Joint Memorandum of Understanding For Mental Health Professionals Requesting Police Assistance With Mental health Act Assessments and s135(1) & (2) Warrants, June 2018’ and their own practices both individually and jointly to ensure that all staff working in this area understand what is achievable and how.
The context for this report is:
(1) The evidence from WMP is that they do not require 24 hours’ notice to execute a section 135 warrant, whereas the AMHPs (BCC) are of the view there was no point in applying for a section 135 warrant because WMP need 24 hours’ notice.
(2) BSMHFT have stated that BCC refused to co-operate with their Root Cause Analysis process , reviewing what lessons could be learnt from the incident.
(3) I was only made aware that BCC had conducted an Internal Management Review Report - that acknowledged AMHPs were fixed on the operational difficulties of applying for the warrant out of hours and police availability as they required 24 hours’ notice – by a witness on day 1 of the inquest. BCC had not volunteered this report existed.
(4) The BCC Internal Management Review Report – which is designed to be the ‘organisational learning process’ - confirms that BCC has not learnt lessons from the incident effectively. In the action plan there is no mention of the incorrect belief amongst AMHPs, that WMP require 24 hours’ notice, having been corrected.
My on-going concern is that the agencies involved in this area are not working together effectively . The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Misunderstanding between agencies about urgent section 135 warrant requirements
Wider context from the report “It appears on the current evidence that there is a misunderstanding between the agencies as to how section 135 Mental Health Act 1983 can work in an urgent situation . This includes both whether or not WMP need 24 hours’ notice and whether or not a bed first needs to be available . All agencies need to urgently review the ‘Joint Memorandum of Understanding For Mental Health Professionals Requesting Police Assistance With Mental health Act Assessments and s135(1) & (2) Warrants, June 2018’ and their own practices both individually and jointly to ensure that all staff working in this area understand what is achievable and how.
The context for this report is:
(1) The evidence from WMP is that they do not require 24 hours’ notice to execute a section 135 warrant, whereas the AMHPs (BCC) are of the view there was no point in applying for a section 135 warrant because WMP need 24 hours’ notice.
(2) BSMHFT have stated that BCC refused to co-operate with their Root Cause Analysis process, reviewing what lessons could be learnt from the incident.
(3) I was only made aware that BCC had conducted an Internal Management Review Report - that acknowledged AMHPs were fixed on the operational difficulties of applying for the warrant out of hours and police availability as they required 24 hours’ notice – by a witness on day 1 of the inquest. BCC had not volunteered this report existed.
(4) The BCC Internal Management Review Report – which is designed to be the ‘organisational learning process’ - confirms that BCC has not learnt lessons from the incident effectively. In the action plan there is no mention of the incorrect belief amongst AMHPs, that WMP require 24 hours’ notice, having been corrected.
My on-going concern is that the agencies involved in this area are not working together effectively. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
” Open source report
15 Oct 2019 Mr Derek Weaver · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 1 Lack of capacity for regional referrals during surges View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Derek Weaver · 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 Derek Weaver was admitted to hospital with community-acquired pneumonia and an empyema, which required surgery. He died on 31 May 2018 after becoming septic and developing a systemic inflammatory response following delayed transfer for surgery. The principal concern was that the 14-day transfer delay, related to exceptional pressure on bed capacity, contributed to his death and that similar risks could recur during referral surges without additional capacity.
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 capacity for regional referrals during surges
Wider context from the report “A consultant thoracic surgeon who was involved in his care after transfer said that had a higher chance of death because surgery was at a time of SIRS. If he had been transferred earlier he would have had surgery when he was not septic. It would have been two stages, the first being key hole surgery, with mortality of only 1 in 100. That may have obviated the necessity of second stage decortication surgery, with mortality of 5%, but it was probably needed anyway. The delay in transfer related to a surge in referrals, limiting capacity. Most regional referrals of this sort needed to be treated at weekends to maintain treatment of cancer cases in the week. There had been pressure to secure greater resources. The risk of potentially preventable deaths will recur whenever there is such a surge in referrals and be mitigated by provision of more beds.
” 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 Keep thoracic surgery pathway performance and access under review.
Verbatim wording from the response “Within London we do have other thoracic providers (eg. University College Hospitals and Imperial Hospitals amongst others) so there is the possibility to change the thoracic surgery pathway for both lung cancer patients and patients with conditions such as empyema that require urgent surgery too, if we felt insufficient progress was being made on meeting the nationally set response standards. We can confirm we will keep this under review as we recognise the importance of making sure that all patients needing thoracic surgery can get quick access to high quality services.” Source location 2019-0345-Response-from-NHS-England-Redacted-1
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations