4 Oct 2019 Michael Lobban · Prevention of Future Deaths report London Inner (West)
View report summary
Concerns raised 7 Delays in investigating controlled-drug discrepancies View source Failure to fully follow through contact with regular methadone prescription users View source Lack of sanctions for pharmacies mislaying controlled drugs View source Lack of regulatory investigative powers for controlled-drug discrepancies View source Lack of physical checking of prescription-box contents during controlled-drug audits View source Lack of double-checking in controlled-drug audits View source Lack of pharmacy reporting requirements for schedule 2 controlled-drug discrepancies 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
Michael Lobban · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Lobban, who had drug dependency and mental illness, was found dead at home on 23 October 2017 with a significant methadone overdose and other drugs in his body. The report raised concerns about the speed and completeness of Boots’ investigation into missing methadone, the robustness of its controlled-drug audit procedures, and the General Pharmaceutical Council’s reporting and investigative arrangements for discrepancies in controlled drugs.
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How this individual concern was interpreted PFD Monitor created a 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 investigating controlled-drug discrepancies
Wider context from the report “1. The investigation carried out by The Boots Company PLC into the disparity of Methadone tablets on this occasion was slow and efforts to contact patients who were regular prescription users of methadone was not fully followed through.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to fully follow through contact with regular methadone prescription users
Wider context from the report “1. The investigation carried out by The Boots Company PLC into the disparity of Methadone tablets on this occasion was slow and efforts to contact patients who were regular prescription users of methadone was not fully followed through .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 sanctions for pharmacies mislaying controlled drugs
Wider context from the report “4. The General Pharmaceutical Council (“The Council”) being the Regulator of Pharmaceutical industry in England and Wales does not have any reporting requirements for pharmacies when discovering a discrepancy in schedule 2 controlled drugs. Moreover there appear to be no investigative powers by The Council where it discovers a disparity of these controlled drugs and as a consequence there are no sanctions in circumstances where pharmacies have mislaid drugs during the course of their handling of controlled drugs .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 regulatory investigative powers for controlled-drug discrepancies
Wider context from the report “4. The General Pharmaceutical Council (“The Council”) being the Regulator of Pharmaceutical industry in England and Wales does not have any reporting requirements for pharmacies when discovering a discrepancy in schedule 2 controlled drugs. Moreover there appear to be no investigative powers by The Council where it discovers a disparity of these controlled drugs and as a consequence there are no sanctions in circumstances where pharmacies have mislaid drugs during the course of their handling of controlled drugs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 physical checking of prescription-box contents during controlled-drug audits
Wider context from the report “3. There appears to be no physical check of the contents of prescription boxes when carrying out the audit of schedule 2 controlled drugs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 double-checking in controlled-drug audits
Wider context from the report “2. The audit checking of controlled drugs by The Boots Company PLC is not robust in that there is no double check in place in relation to the audit checking procedure followed by Boots.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 pharmacy reporting requirements for schedule 2 controlled-drug discrepancies
Wider context from the report “4. The General Pharmaceutical Council (“The Council”) being the Regulator of Pharmaceutical industry in England and Wales does not have any reporting requirements for pharmacies when discovering a discrepancy in schedule 2 controlled drugs . Moreover there appear to be no investigative powers by The Council where it discovers a disparity of these controlled drugs and as a consequence there are no sanctions in circumstances where pharmacies have mislaid drugs during the course of their handling of controlled drugs.
” Open source report
Concerns raised 3 Failure to consider and seek consent for family involvement in care planning View source First aid training lacking hanging-specific response content View source Failure to cut down a person found hanging View source
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AI-generated summary
Ceara Marie Thacker · 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
Ceara Marie Thacker, a 19-year-old University of Liverpool student with a history of self-harm and contact with mental health services, was found deceased hanging on 11 May 2018. Concerns included the lack of discussion about involving her family in care planning and the absence of attempts to cut her down after she was found hanging; the first-aid training received by the person who found her did not cover hangings.
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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 consider and seek consent for family involvement in care planning
Wider context from the report “1. Throughout Ceara’s involvement with the medical professionals and therapists, whether Mersey Care, Mental Health Advisory team at the University or the GPs there is no evidence of any discussion around involving Ceara’s family in drawing up a plan or consideration of requesting consent from Ceara to discuss her situation with parents/family . It is accepted that Ceara was an adult and had full capacity, however, Ceara was a young adult, first time away from home who had history of mental health issues. It would have been helpful to have had these discussions so that if Ceara wanted that additional support from her family this could have been facilitated. That said it is unclear as to whether Ceara would have agreed to her family being involved, however, this line of enquiry would have been helpful.
The general approach with young people appears to be to encourage them to discuss their issues with their parents/family rather than asking for consent for the professionals to discuss it with the parents/family .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation First aid training lacking hanging-specific response content
Wider context from the report “2. Concern was raised that once Ceara was found hanging, no attempts were made to cut her down. The pathologist gave evidence to the effect it would be difficult to say how quick the death would have occurred, however, there was a very small window after the hanging where a person could survive, be it with brain damage. He stated it was rare that an individual was not cut down. The Residential Adviser who found Ceara had received first aid training but this did not include anything in relation to hangings .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 cut down a person found hanging
Wider context from the report “2. Concern was raised that once Ceara was found hanging, no attempts were made to cut her down . The pathologist gave evidence to the effect it would be difficult to say how quick the death would have occurred, however, there was a very small window after the hanging where a person could survive, be it with brain damage. He stated it was rare that an individual was not cut down . The Residential Adviser who found Ceara had received first aid training but this did not include anything in relation to hangings.
” 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 Develop information-sharing guidance and a consensus statement with Universities UK on when information can be shared without breaching confidentiality.
Verbatim wording from the response “Increasingly universities are routinely asking for consent to contact students’ parents if support is felt to be needed, through registration questions phrased to ensure students understand the need for this. We are currently working with Universities UK to develop information sharing guidance and a consensus statement on when information can be shared without breaching confidentiality, and expect Universities UK to open consultation on draft guidance in the near future.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Transform community mental-health care, including for young adults, through co-produced personalised care and support planning that centres carer and family involvement.
Verbatim wording from the response “We will also continue to link with Health Education England who deliver a range of workstreams focused on improving the skills of all staff working in mental health services,² as these skills underpin sensitive and challenging discussions with service users and care plans that genuinely engage family support. Our Long Term Plan work to transform community mental health care, including for young adults, has a specific focus on improving co-produced personalised care and support planning, in which carer and family involvement is central.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue linking with Health Education England on work to improve mental-health staff skills for family-engagement discussions and care planning.
Verbatim wording from the response “We will also continue to link with Health Education England who deliver a range of workstreams focused on improving the skills of all staff working in mental health services,² as these skills underpin sensitive and challenging discussions with service users and care plans that genuinely engage family support. Our Long Term Plan work to transform community mental health care, including for young adults, has a specific focus on improving co-produced personalised care and support planning, in which carer and family involvement is central.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore linking electronic-record consent prompts to national datasets to enable measurement and targeted improvement support.
Verbatim wording from the response “NHSX and NHS Digital to bring together key stakeholders to scope whether it would be possible to routinely prompt seeking consent to involve families within electronic clinical record systems. We will also explore if the completion of those prompts can be directly linked to national datasets, as this would open the potential for measurement and for targeting improvement support where it is most needed.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Bring stakeholders together to scope routine electronic-record prompts for seeking consent to involve families in mental healthcare.
Verbatim wording from the response “There is clear existing guidance on the importance of seeking consent to involve family and friends.¹ Because of this we will focus our action to prevent future deaths on steps that would help ensure it is more reliably and consistently considered. This is potentially a complex undertaking, given the range of electronic patient record systems used in mental health services, and differing patient groups with different needs that need to be reflected within formats used to record information across a range of mental health services, and the need to work within the relevant legal frameworks, including giving due regard to information governance law, the Mental Capacity Act and the Mental Health Act. The NHS England & NHS Improvement mental health programme team will work with our partners in” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for considering changes to public first aid course content rests with the British Red Cross.
Verbatim wording from the response “One of the actions to prevent future deaths that you directed to NHS Improvement was related to the content of first aid courses for members of the public. The NHS does not determine the content of public first aid courses. We understand the appropriate body to consider action would be the British Red Cross who are a direct provider of first aid training and whose curriculum is the basis for most first training provided by a range of independent training organisations in workplaces, etc. They can be contacted at contactus@redcross.org.uk” Source location Response from NHS England
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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 NHS does not determine the content of public first aid courses.
Verbatim wording from the response “One of the actions to prevent future deaths that you directed to NHS Improvement was related to the content of first aid courses for members of the public. The NHS does not determine the content of public first aid courses. We understand the appropriate body to consider action would be the British Red Cross who are a direct provider of first aid training and whose curriculum is the basis for most first training provided by a range of independent training organisations in workplaces, etc. They can be contacted at contactus@redcross.org.uk” Source location Response from NHS England
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19 Sep 2019 Mark Jarvis · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 3 Lack of a direct link between prescribed medicines and previous diagnoses View source Difficulty removing no-longer-needed prescriptions from the medication system View source Failure of the prescription system to provide clear, accessible information on patients’ current and previous medicines 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
Mark Jarvis · 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
Mark Jarvis was found apparently deceased in his cell at HMP Warren Hill on 30 December 2015 and was later pronounced dead. The inquest concluded that the death resulted from a cardiac event precipitated by ingestion of a New Psychoactive Substance, with ischaemic heart disease recorded as the medical cause of death. Concerns included difficulties with the prison prescription system, including the inability to readily verify current and previous prescriptions, and the potential misuse of medications.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a direct link between prescribed medicines and previous diagnoses
Wider context from the report “1. During the course of the inquest a GP who was responsible for medical care at HMP Warren Hill gave evidence in relation to the computer system, SytmOne which was used to review and prescribed medicines to the prisoners at the time of Mark’s death.
The court was told that the SystmOne online prescription ‘module’ was not clear to read or easy to understand and appeared incompatible with the prison’s own IT system.
The GP described that this left them in the situation of not being sure what a patient had been previously prescribed, not being sure what repeat prescriptions were in place and that they had no way of readily understanding what had been taken by a particular patient or when they were supposed to have taken it.
It was also explained that there was no direct link on the system between medications prescribed and previous diagnoses. Due to the time it took to navigate the records it was reported that some GP’s used their experience to identify a previous diagnosis from the repeat prescriptions recorded in the prescription module.
The GP further described that removing a prisoner’s prescription from the system when it was no longer necessary was very difficult.
One of the contributing factors the jury found to Mark’s death was directly related with poor adherence to his blood pressure medication regime on repeat prescription. Considering the difficulties GPs are facing when using the prescription module, and the testimony given by the GP in this case, it would appear there is no easy system for a doctor to verify exactly what their patient has already been prescribed and whether or not that prescription is still current.
Further, in relation to the potential misuse of drugs incorrectly or over-prescribed the GP explained that some medications, such as opioids or anti depression medication (including amitriptyline and sertraline) had ‘currency’ within the prison and it was known they would be traded by some prisoners. Therefore, not being able to readily identify what a prisoner should be, or already is being prescribed at the time of any specific consultation is again clearly a cause for concern.
In an interview the GP had with investigators from the Prisons and Probation Ombudsman’s Office on the 30th December 2015 (just one day after Mark’s death) the GP described the prescription module as “an absolute nightmare and we are banging our heads against a brick wall. We’re trying hard to get some changes done because we are concerned about safety”
When specifically questioned at the inquest on the 3rd September 2019 the GP stated that the situation as it stood at the end of December 2015 had still not been resolved.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Difficulty removing no-longer-needed prescriptions from the medication system
Wider context from the report “1. During the course of the inquest a GP who was responsible for medical care at HMP Warren Hill gave evidence in relation to the computer system, SytmOne which was used to review and prescribed medicines to the prisoners at the time of Mark’s death.
The court was told that the SystmOne online prescription ‘module’ was not clear to read or easy to understand and appeared incompatible with the prison’s own IT system.
The GP described that this left them in the situation of not being sure what a patient had been previously prescribed, not being sure what repeat prescriptions were in place and that they had no way of readily understanding what had been taken by a particular patient or when they were supposed to have taken it.
It was also explained that there was no direct link on the system between medications prescribed and previous diagnoses. Due to the time it took to navigate the records it was reported that some GP’s used their experience to identify a previous diagnosis from the repeat prescriptions recorded in the prescription module.
The GP further described that removing a prisoner’s prescription from the system when it was no longer necessary was very difficult.
One of the contributing factors the jury found to Mark’s death was directly related with poor adherence to his blood pressure medication regime on repeat prescription. Considering the difficulties GPs are facing when using the prescription module, and the testimony given by the GP in this case, it would appear there is no easy system for a doctor to verify exactly what their patient has already been prescribed and whether or not that prescription is still current.
Further, in relation to the potential misuse of drugs incorrectly or over-prescribed the GP explained that some medications, such as opioids or anti depression medication (including amitriptyline and sertraline) had ‘currency’ within the prison and it was known they would be traded by some prisoners. Therefore, not being able to readily identify what a prisoner should be, or already is being prescribed at the time of any specific consultation is again clearly a cause for concern.
In an interview the GP had with investigators from the Prisons and Probation Ombudsman’s Office on the 30th December 2015 (just one day after Mark’s death) the GP described the prescription module as “an absolute nightmare and we are banging our heads against a brick wall. We’re trying hard to get some changes done because we are concerned about safety”
When specifically questioned at the inquest on the 3rd September 2019 the GP stated that the situation as it stood at the end of December 2015 had still not been resolved.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 prescription system to provide clear, accessible information on patients’ current and previous medicines
Wider context from the report “1. During the course of the inquest a GP who was responsible for medical care at HMP Warren Hill gave evidence in relation to the computer system, SytmOne which was used to review and prescribed medicines to the prisoners at the time of Mark’s death.
The court was told that the SystmOne online prescription ‘module’ was not clear to read or easy to understand and appeared incompatible with the prison’s own IT system.
The GP described that this left them in the situation of not being sure what a patient had been previously prescribed, not being sure what repeat prescriptions were in place and that they had no way of readily understanding what had been taken by a particular patient or when they were supposed to have taken it.
It was also explained that there was no direct link on the system between medications prescribed and previous diagnoses. Due to the time it took to navigate the records it was reported that some GP’s used their experience to identify a previous diagnosis from the repeat prescriptions recorded in the prescription module.
The GP further described that removing a prisoner’s prescription from the system when it was no longer necessary was very difficult.
One of the contributing factors the jury found to Mark’s death was directly related with poor adherence to his blood pressure medication regime on repeat prescription. Considering the difficulties GPs are facing when using the prescription module, and the testimony given by the GP in this case, it would appear there is no easy system for a doctor to verify exactly what their patient has already been prescribed and whether or not that prescription is still current.
Further, in relation to the potential misuse of drugs incorrectly or over-prescribed the GP explained that some medications, such as opioids or anti depression medication (including amitriptyline and sertraline) had ‘currency’ within the prison and it was known they would be traded by some prisoners. Therefore, not being able to readily identify what a prisoner should be, or already is being prescribed at the time of any specific consultation is again clearly a cause for concern.
In an interview the GP had with investigators from the Prisons and Probation Ombudsman’s Office on the 30th December 2015 (just one day after Mark’s death) the GP described the prescription module as “an absolute nightmare and we are banging our heads against a brick wall. We’re trying hard to get some changes done because we are concerned about safety”
When specifically questioned at the inquest on the 3rd September 2019 the GP stated that the situation as it stood at the end of December 2015 had still not been resolved.
” Open source report
8 Sep 2019 Reece Tristan Lapina-Amarelle · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 6 Insufficient emphasis on safety and preserving life in the Mental Health Act View source Lack of resources for people with serious mental illness and alcohol or drug misuse histories View source Inability to require access to and cooperation with voluntary substance and alcohol misuse services outside the criminal justice system View source Insufficient information sharing between mental health and substance and alcohol misuse services View source Lack of a treatment system for people with serious mental illness and alcohol or drug misuse histories View source Failure of the Mental Health Act to provide responsibility for an action plan View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Reece Tristan Lapina-Amarelle · 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
Reece Tristan Lapina-Amarelle, aged 20, died by suicide after being discharged from hospital with the expectation that he would immediately attempt to take his life. The report identifies concerns about insufficient resources and treatment for people with serious mental illness and substance misuse, inadequate information-sharing between services, limitations of voluntary support, and the Mental Health Act's failure to provide an appropriate plan of action focused on safety.
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How this individual concern was interpreted PFD Monitor created a 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 emphasis on safety and preserving life in the Mental Health Act
Wider context from the report “(5) Twenty years ago the connection between the use of strong drugs in teenage years and subsequent mental health (often very serious) was not fully recognised. However nowadays there is far greater use of drugs which are growing ever stronger, and a very considerable number of people with mental health issues in prison or in the community have developed or worsened their conditions by the use of cannabis and other illegal substances. The Mental Health Act still concentrates on therapy without giving sufficient emphasis, in my view, to safety and, in blunt terms, keeping people alive .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 resources for people with serious mental illness and alcohol or drug misuse histories
Wider context from the report “(1) There are no resources and no system of treatment for people who present with serious mental illness and alcohol or drug misuse histories.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inability to require access to and cooperation with voluntary substance and alcohol misuse services outside the criminal justice system
Wider context from the report “(3) That latter service is voluntary and, outside the criminal justice system, the subject cannot be forced to access and receive help or to cooperate with that service .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 information sharing between mental health and substance and alcohol misuse services
Wider context from the report “(2) There is insufficient sharing of information between the Mental Health Trust and CGL (the Substance and Alcohol Misuse Service) .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 treatment system for people with serious mental illness and alcohol or drug misuse histories
Wider context from the report “(1) There are no resources and no system of treatment for people who present with serious mental illness and alcohol or drug misuse histories .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 Mental Health Act to provide responsibility for an action plan
Wider context from the report “(4) In my opinion the Mental Health Act is out of date in that it does not recognise or accept responsibility for providing a plan of action to deal with people such as Reece.
” 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 Develop and implement integrated community mental health models providing psychological, physical-health, employment, personalised-care, medicines-management and substance-use support.
Verbatim wording from the response “In recognition of the above, we are taking specific steps to improve access to, and quality of, support for people with co-existing SMI and substance misuse. The NHS Long Term Plan, published earlier this year, details how new and integrated models of primary and community health services will transform the delivery of mental health care for adults and older adults with SMI, including people with a ‘personality disorder’ and those with co-existing substance misuse. As the NHS Mental Health Implementation Plan 2019/20 – 2023/24 sets out, this new community-based offer, backed by significant investment over the next five years, will include access to psychological therapies, improved physical health care, employment support, personalised and trauma-informed care, medicines management and support for self-harm and coexisting substance use.” Source location 2019-0274-Response-by-NHS-England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and implement secure digital record-sharing arrangements across NHS and partner organisations, including comprehensive shared care records.
Verbatim wording from the response “The NHS Long Term Plan is committed to ensuring that by 2024 secondary care providers in England, including acute, community and mental health care settings, will be fully digitised, including clinical and operational processes across all settings, locations and departments. Data will be captured, stored and transmitted electronically, supported by robust IT infrastructure and cyber security, and Local Health and Care Records will cover the whole county.” Source location 2019-0274-Response-by-NHS-England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support the Department of Health and Social Care’s development of a response to the Independent Review of the Mental Health Act.
Verbatim wording from the response “As the government department responsible for this legislation, the Department of Health and Social Care is currently developing a response to the Independent Review’s recommendations, and NHS England and NHS Improvement are involved in, and supporting this process. The Government has committed to publishing a White Paper before the end of the year.” Source location 2019-0274-Response-by-NHS-England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Department of Health and Social Care is responsible for responding to recommendations to amend the Mental Health Act.
Verbatim wording from the response “As the government department responsible for this legislation, the Department of Health and Social Care is currently developing a response to the Independent Review’s recommendations, and NHS England and NHS Improvement are involved in, and supporting this process. The Government has committed to publishing a White Paper before the end of the year.” Source location 2019-0274-Response-by-NHS-England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local authorities hold statutory responsibility for commissioning public health services, including drug and alcohol services.
Verbatim wording from the response “The Health and Social Care Act 2012 transferred statutory responsibility for the commissioning of public health services, including drug and alcohol services, to local authorities. NHS England and NHS Improvement do recognise it as a very important issue, with significant implications for the mental health of individuals, particularly for those affected by coexisting severe mental illnesses (SMI) and substance misuse, like Mr Lapina-Amarelle. We also recognise the importance of ensuring closer working between mental health services and substance misuse services to ensure people’s needs are met in an integrated, holistic and timely manner. As such, the ongoing move towards Integrated Care Systems (ICSs) across England is intended to help address some of these issues and to provide joined up health and care to whole populations across the NHS, social care and public health.” Source location 2019-0274-Response-by-NHS-England
Open published response
23 Aug 2019 Thelma Joyce · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 2 Unavailability of approved tests for DPD deficiency View source Lack of national guidance for routine DPD deficiency testing before Capecitabine and 5FU chemotherapy View source
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AI-generated summary
Thelma Joyce · 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
Thelma Joyce commenced chemotherapy for gall bladder cancer, developed a severe reaction, was admitted to hospital and died on 14 February 2019. The principal concern was whether updated guidance and routine testing for DPD deficiency should be introduced for patients due to receive Capecitabine or 5FU chemotherapy.
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How this individual concern was interpreted PFD Monitor created a 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 approved tests for DPD deficiency
Wider context from the report “The MATTER OF CONCERN therefore is in relation to the possible need for updated guidance in respect of testing for DPD deficiency for patients due to embark on Capecitabine and 5FU chemotherapy.
It is reassuring that OUH NHS Trust have a two-year pilot in place to test for DPD deficiency. As far as I understand it, there are as yet no national guidelines or approved tests in respect of DPD deficiency . If it is the case that new technology and developments mean there is now a reliable test, I enquire if there should be guidelines issued concerning the use of a routine test.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for routine DPD deficiency testing before Capecitabine and 5FU chemotherapy
Wider context from the report “The MATTER OF CONCERN therefore is in relation to the possible need for updated guidance in respect of testing for DPD deficiency for patients due to embark on Capecitabine and 5FU chemotherapy .
It is reassuring that OUH NHS Trust have a two-year pilot in place to test for DPD deficiency. As far as I understand it, there are as yet no national guidelines or approved tests in respect of DPD deficiency. If it is the case that new technology and developments mean there is now a reliable test, I enquire if there should be guidelines issued concerning the use of a routine test .
” 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 Reach a decision by April 2020 on whether to routinely commission DPD deficiency testing and include it in the National Genomic Test Directory.
Verbatim wording from the response “In England, the NHS Long Term Plan sets out the ambition and commitment to establish a genomics service providing access to cutting edge genomic technologies which will help to pave the way for wider advances, particularly in relation to personalised medicine. The introduction of an effective testing strategy for DPD deficiency, to better tailor treatment decisions to individual patients, is a clear example of this. To that end, I can confirm that work to review the evidence for DPD testing is underway within NHS England and NHS Improvement, with a view to reaching a decision about whether to routinely commission DPD testing and include the testing within the National Genomic Test Directory. A decision is expected to be made by April 2020 and, if approved, will be supported with a plan for implementation in order to achieve equitable access to testing across England.” Source location 2019-0500-Response-from-NHS-England-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the evidence for DPD deficiency testing to inform a decision on routine NHS commissioning and inclusion in the National Genomic Test Directory.
Verbatim wording from the response “In England, the NHS Long Term Plan sets out the ambition and commitment to establish a genomics service providing access to cutting edge genomic technologies which will help to pave the way for wider advances, particularly in relation to personalised medicine. The introduction of an effective testing strategy for DPD deficiency, to better tailor treatment decisions to individual patients, is a clear example of this. To that end, I can confirm that work to review the evidence for DPD testing is underway within NHS England and NHS Improvement, with a view to reaching a decision about whether to routinely commission DPD testing and include the testing within the National Genomic Test Directory. A decision is expected to be made by April 2020 and, if approved, will be supported with a plan for implementation in order to achieve equitable access to testing across England.” Source location 2019-0500-Response-from-NHS-England-Redacted
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 Evidence supporting the adequacy of DPD testing is not compelling, so national testing requirements remain under review.
Verbatim wording from the response “In relation to the matter of concern raised, evidence as to the adequacy of DPD testing has hitherto been far from compelling, which is alluded to in your report. Underlining this, the European Medicines Agency (EMA) in March 2019 began a review of the evidence for testing and use of these medicines under Article 31 of Directive 2001/83/EC. Ultimately, the review may result in changes to marketing authorisations of the relevant medicines which would be mandatory. While these medicines are unlicensed for use in gall bladder cancer, it would be normal practice for marketing authorisation requirements, such as for testing and patient monitoring, to also apply to off label uses and would be managed through Trust arrangements for off label medicines. The EMA review is not yet complete.” Source location 2019-0500-Response-from-NHS-England-Redacted
Open published response
16 Aug 2019 Martin Leslie Haines · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 7 Failure to carry out diagnostic testing and monitoring for diabetes View source Fragmentation of responsibility for prison healthcare across multiple organisations View source Standard of care falling below community level View source Failure to confirm cardiovascular disease View source Availability of means to brew or distil alcohol View source Lack of protocols or agreements for responding to an unresponsive body View source Insufficient communication and information sharing between prison healthcare organisations View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Martin Leslie Haines · 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
Martin Leslie Haines was detained at Lewes Prison and was found dead in his cell on 18 March 2018. He had Type II Diabetes and warning signs of cerebrovascular disease, but the appropriate diagnostic tests were not carried out; alcohol, Venlafaxine and Amitriptyline were later found in his system and considered by the pathologist to have contributed to his death. The principal concerns included inadequate diabetes and cardiovascular monitoring, healthcare falling below community standards, the ability to brew or distil alcohol in prison, a lack of protocols for responding to an unresponsive body, and insufficient communication between healthcare providers and the prison service.
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 carry out diagnostic testing and monitoring for diabetes
Wider context from the report “(2) The failure to carry out diagnostic testing and monitoring for his diabetes and to confirm his considerable cardiovascular disease.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Fragmentation of responsibility for prison healthcare across multiple organisations
Wider context from the report “(5) In my opinion, the underlying problems were due to the fact that responsibility for healthcare in the prison was split between the prison service, Sussex Partnership Foundation Trust (which is a mental health provider but was also contracted to run all healthcare, both physical and mental within the prison), Medco Ltd who provided the GPs and Forward Trust who were contracted to treat alcohol and substance misuse in the prison . There was insufficient communication between these bodies and they had separate IT databases.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Standard of care falling below community level
Wider context from the report “(3) The standard of care appears to have fallen well below that which he could have received in the community .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to confirm cardiovascular disease
Wider context from the report “(2) The failure to carry out diagnostic testing and monitoring for his diabetes and to confirm his considerable cardiovascular disease .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Availability of means to brew or distil alcohol
Wider context from the report “(1) The fact that the deceased was able to brew or distil his own alcohol .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 protocols or agreements for responding to an unresponsive body
Wider context from the report “(4) There were no protocols or agreements between healthcare staff and the prison service as to how best to respond to an unresponsive body .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 communication and information sharing between prison healthcare organisations
Wider context from the report “(5) In my opinion, the underlying problems were due to the fact that responsibility for healthcare in the prison was split between the prison service, Sussex Partnership Foundation Trust (which is a mental health provider but was also contracted to run all healthcare, both physical and mental within the prison), Medco Ltd who provided the GPs and Forward Trust who were contracted to treat alcohol and substance misuse in the prison. There was insufficient communication between these bodies and they had separate IT databases .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review providers’ use of SystmOne tasks in response to concerns about communication and messages going astray.
Verbatim wording from the response “the Prime Provider model, giving them greater control over use of more innovative IT and software solutions. All users of SystmOne can create tasks for other team members and which are linked to patient records where applicable, thus reduces the risk of messages going astray. NHS E Commissioners will review the use of tasks by providers by end of October 2019, as a result of concerns raised in this Regulation 28 notice.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Agree and monitor a Service Development Improvement Plan addressing provider performance and embedding required care improvements.
Verbatim wording from the response “A Quality Improvement Plan was implemented following Mr Haines death, actions were agreed and achieved in 2018 but further reviews found they had not all been embedded into practice. As a result, SPFT was served with a Contract Notice in November 2018 relating to poor performance and a further Service Development Improvement Plan (dated 8 June 2019) was agreed with commissioners. Actions from this are in various stages of completion with some having been achieved, and others noted as in progress whilst embedding into practice.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Procure and award an integrated single-provider healthcare contract for HMP Lewes, using one provider and database to support integrated delivery.
Verbatim wording from the response “NHS E have undertaken a procurement process for provision of these services after those dates. The services procured is an integrated model of delivery which means that the contract has been awarded to one provider for the delivery of all services to HMP Lewes residents. This is a tried and tested form of service delivery and puts the responsibility for delivery of all elements of the contract with one provider only. This will negate any communication issues and the provider will use one database system only.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for addressing prisoners’ ability to brew or distil alcohol lies with the Ministry of Justice, which will respond directly.
Verbatim wording from the response “1) The fact that Mr Haines was able to brew or distil his own alcohol.” Source location Response from NHS England
Open published response
16 Aug 2019 Justin Peter Gallagher · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 9 Failure to identify and diagnose cancer View source Failure to obtain previous medical history View source Lack of a system for arranging external hospital visits View source Lack of a single clinician responsible for patient care View source Failure to draft proper care plans View source Lack of resources for attending external hospital appointments View source Fragmented responsibility for prison healthcare View source Failure of healthcare organisations to use integrated database systems View source Failure to involve family in obtaining important patient information View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Justin Peter Gallagher · 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
Justin Peter Gallagher was received at HMP Lewes on 20 March 2016 and was later found collapsed in his segregation-block cell on 24 May 2016. He was taken to hospital, where he died on 17 June 2016; the post-mortem recorded hypoxic brain injury, cardiac arrest and laryngeal carcinoma with upper airway obstruction among the causes. Concerns included the absence of his previous medical history, a proper care plan and a single clinician responsible for his care, cancelled hospital appointments, missed opportunities to diagnose his cancer, lack of family involvement, and separate healthcare organisations using unconnected database systems.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and diagnose cancer
Wider context from the report “(3) The deceased died of cancer but this had never been diagnosed and opportunities to have discovered his condition were missed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 previous medical history
Wider context from the report “(1) The prison never obtained his previous medical history. No proper care plan was drafted for him and there was no single clinician responsible for his 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 a system for arranging external hospital visits
Wider context from the report “(2) A number of external hospital appointments were cancelled at short notice because of lack of resources (no available escorts etc.) and there was no system available for arranging such visits .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 single clinician responsible for patient care
Wider context from the report “(1) The prison never obtained his previous medical history. No proper care plan was drafted for him and there was no single clinician responsible for his care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to draft proper care plans
Wider context from the report “(1) The prison never obtained his previous medical history. No proper care plan was drafted for him and there was no single clinician responsible for his 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 resources for attending external hospital appointments
Wider context from the report “(2) A number of external hospital appointments were cancelled at short notice because of lack of resources (no available escorts etc.) and there was no system available for arranging such visits.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Fragmented responsibility for prison healthcare
Wider context from the report “(5) The underlying problem was that healthcare in the prison was the responsibility of three different organisations , namely the prison service, the local mental health NHS Trust (who were given the responsibility of dealing with all physical health matters and running the healthcare centre), and a separate organisation who supplied GPs. These three organisations had entirely separate database systems.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 healthcare organisations to use integrated database systems
Wider context from the report “(5) The underlying problem was that healthcare in the prison was the responsibility of three different organisations, namely the prison service, the local mental health NHS Trust (who were given the responsibility of dealing with all physical health matters and running the healthcare centre), and a separate organisation who supplied GPs. These three organisations had entirely separate database systems.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 involve family in obtaining important patient information
Wider context from the report “(4) There was no involvement of the family and so a source of important information was missed .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review postponed hospital appointments clinically, prioritise attendance by need and risk, and automatically rebook cancellations with hospital trusts.
Verbatim wording from the response “Regional commissioners are aware that there is an ongoing shortage of trained officers at HMP Lewes which can result in a restricted regime resulting in less access to healthcare and attendance at external hospital appointments. There also continues to be issues with the re-booking of appointments and commissioners are working with Sussex Partnership Foundation Trust (SPFT) to resolve this.” Source location 2019-0491-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit healthcare-record requests to verify that the records-request process is effective.
Verbatim wording from the response “• an audit of healthcare record requests in March 2017 to ensure the process was effective and efficient. As a result of your report I can confirm commissioners have asked SPFT to undertake a further audit which was completed in November with the outcome due to be shared by the end of December 2019. A CQC focus visit took place on 21 and 22 October 2019 and it was reported to the commissioners that record keeping and care planning in particular had significantly improved with the input of additional resources to support this process.” Source location 2019-0491-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission prison healthcare through a Prime Provider model using a single contract, provider and database.
Verbatim wording from the response “In 2017, NHS England (NHSE) reviewed the model of commissioning in Kent, Surrey and Sussex as it was becoming increasingly apparent that the model was not delivering the benefits anticipated and services were not integrating effectively. In line with other prison groups in England, NHSE made the decision to commission services using a Prime Provider model. I can confirm that this model ensures a single contract and provider, and therefore better accountability for the delivery of integrated healthcare in a prison (or group of prisons). This will negate any communication issues and the single provider will use one database system only.” Source location 2019-0491-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Run regular SystmOne reports checking whether newly arrived prisoners’ healthcare records have been requested.
Verbatim wording from the response “• the running of a regular report via SystmOne to ensure that healthcare records have been requested; and” Source location 2019-0491-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Check that newly arrived prisoners receive a full health assessment and care plan within seven days, recording checks for healthcare staff.
Verbatim wording from the response “• a nominated member of staff checking that all newly arrived prisoners have been offered a full general health assessment to include the drafting of a care plan within 7 days of arrival. The checks to be noted on an internal document which is shared with all healthcare staff.” Source location 2019-0491-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request community medical records for newly arrived prisoners within one week.
Verbatim wording from the response “The Clinical Reviewer recommended that the Head of Healthcare at HMP Lewes should ensure that the past medical history is obtained for new prisoners with chronic conditions, and that their care should be assigned to a named clinician. I can confirm an action plan was implemented with all actions achieved by 1 April 2017 which included:” Source location 2019-0491-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assign prisoners with chronic conditions to a named clinician.
Verbatim wording from the response “The Clinical Reviewer recommended that the Head of Healthcare at HMP Lewes should ensure that the past medical history is obtained for new prisoners with chronic conditions, and that their care should be assigned to a named clinician. I can confirm an action plan was implemented with all actions achieved by 1 April 2017 which included:” Source location 2019-0491-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The recurrence was not an undiagnosed cancer: the cancer had previously been diagnosed and treated.
Verbatim wording from the response “The Clinical Reviewer’s report states that Mr Gallagher had been diagnosed with laryngeal cancer 2 years prior to reception at HMP Lewes, and that Mr Gallagher died from events caused by the recurrence of a laryngeal tumour that had been treated the previous year with radiotherapy.” Source location 2019-0491-Response-by-NHS-England
Open published response
7 Aug 2019 Joseph Kevin Lafferty · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure of priority dispatch systems to take patient age into account when determining response speed and acuity View source Failure to require inspectors to include external aspects of registered premises in every CQC inspection View source Failure to require inspectors to include external aspects of registered premises in every CQC inspection 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
Joseph Kevin Lafferty · 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 Kevin Lafferty, who had dementia and required 24-hour residential care, left The Cedars Rest Home unsupervised and was found outside the care home with serious injuries after a fall. He was taken to hospital and died on 24 June 2018; the inquest concluded that he died following the fall and access to an area of the grounds not intended for resident access. Concerns included that external areas of registered premises were not required to be routinely included in CQC inspections, and that the ambulance dispatch system did not specifically take the patient’s age into account when determining response speed and acuity.
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 priority dispatch systems to take patient age into account when determining response speed and acuity
Wider context from the report “In the course of the inquest, evidence was heard to the effect that, like other ambulance services, North West Ambulance Service NHS Foundation Trust utilises a priority dispatch system to triage calls whereby the answers callers gave to standard questions determined the level of response provided, and the timescales within which a response can ordinarily be expected.
It is a matter of concern that, according to the evidence of the Care Quality Commission Inspector who gave evidence at court, there is no requirement on inspectors to include external aspects of a registered premises in the course of a CQC inspection in every case.
It is a matter of concern that the system in use at this and other ambulance Trusts does not specifically take into account the age of the patient when determining the speed and acuity of response to be provided .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 require inspectors to include external aspects of registered premises in every CQC inspection
Wider context from the report “Over the course of the inquest, evidence was heard to the effect that The Cedars Rest Home had been inspected by the Care Quality Commission in 2016 and assessed as ‘Good’. Following Mr Lafferty’s death, a further inspection took place and a rating of ‘Requires Improvement’ was arrived at.
It is a matter of concern that, according to the evidence of the Care Quality Commission Inspector who gave evidence at court, there is no requirement on inspectors to include external aspects of a registered premises in the course of a CQC inspection in every case .
Consideration should be given to such areas automatically forming part and parcel of a CQC inspection where these are routinely in use by residents in the course of the provision of regulated activities.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 require inspectors to include external aspects of registered premises in every CQC inspection
Wider context from the report “In the course of the inquest, evidence was heard to the effect that, like other ambulance services, North West Ambulance Service NHS Foundation Trust utilises a priority dispatch system to triage calls whereby the answers callers gave to standard questions determined the level of response provided, and the timescales within which a response can ordinarily be expected.
It is a matter of concern that, according to the evidence of the Care Quality Commission Inspector who gave evidence at court, there is no requirement on inspectors to include external aspects of a registered premises in the course of a CQC inspection in every case .
It is a matter of concern that the system in use at this and other ambulance Trusts does not specifically take into account the age of the patient when determining the speed and acuity of response to be provided.
” Open source report
Concerns raised 2 Lack of adequate mental health facilities or safe rooms for potentially violent patients with complex needs View source Failure to facilitate general practitioners’ referrals for formal mental health assessment and treatment 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
Allan Graham Joslin · 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
Allan Graham Joslin was found deceased partially on top of a tent near the North Devon Leisure Centre, Barnstaple, on 23 May 2018, after not being seen or contacted for several days. The report states that referrals for mental health assessment were not facilitated because of his known previous violent behaviour, and that he therefore received no formal assessment or treatment before his death. Concerns included inadequate facilities and policies for safely assessing patients with complex mental health, substance dependency and potential violence-related needs.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate mental health facilities or safe rooms for potentially violent patients with complex needs
Wider context from the report “The Devon Partnership NHS Trust had no adequate mental health care facility or safe room to deal with a patient who presented with complex needs including the need for mental health assessment, and drug and alcohol dependency issues, who was potentially violent . There was no policy in place to facilitate the general practitioners’ referrals and therefore Mr Joslin received no formal assessment or treatment prior to his death. This may have impacted on his ability to receive additional services and assistance with his homeless status.
Although this Trust have now put policies and facilities in place to safely treat patients presenting with a history of violence, it was clear from the evidence that this is a concern and difficulty in other Trusts across the country and is not a problem unique to Devon . While working with Devon to find a solution to the problem, NHS England confirmed this was problematic for a number of Trusts regarding provision of secondary care . This is clearly a contravention of Equality legislation for those most vulnerable in society.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 facilitate general practitioners’ referrals for formal mental health assessment and treatment
Wider context from the report “The Devon Partnership NHS Trust had no adequate mental health care facility or safe room to deal with a patient who presented with complex needs including the need for mental health assessment, and drug and alcohol dependency issues, who was potentially violent. There was no policy in place to facilitate the general practitioners’ referrals and therefore Mr Joslin received no formal assessment or treatment prior to his death . This may have impacted on his ability to receive additional services and assistance with his homeless status.
Although this Trust have now put policies and facilities in place to safely treat patients presenting with a history of violence, it was clear from the evidence that this is a concern and difficulty in other Trusts across the country and is not a problem unique to Devon. While working with Devon to find a solution to the problem, NHS England confirmed this was problematic for a number of Trusts regarding provision of secondary care. This is clearly a contravention of Equality legislation for those most vulnerable in society.
” Open source report
12 Jul 2019 David Jonathon Jukes · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 9 Failure to follow through plans made to discuss and assess patients View source Failure to maintain accurate records of contacts, decisions and risk assessments View source Failure of the system to carry out necessary psychiatric assessments in police custody View source Failure to use all available means to locate patients requiring assessment View source Failure to ensure staff compliance with record-keeping duties is detected View source Failure to provide material arrest information for mental health assessments in custody View source Failure to attempt timely assessment after a high-risk patient re-establishes contact View source Failure to pass reliable information between mental health services View source Insufficient HTT capacity to maintain progress notes and risk assessments View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Jonathon Jukes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Jonathon Jukes was declared deceased on 9 October 2018 after being found hanging from a ligature fixed to a garden gate. The report identified concerns about inadequate information sharing, mental-health assessment and follow-up, attempts to locate and engage him, risk assessment, and clinical record keeping, with associated risks to life.
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 follow through plans made to discuss and assess patients
Wider context from the report “5. It was planned that Mr. Jukes would be discussed at a team meeting on the 3rd October 2018 after the psychologist raised concerns on the 2nd. There is no credible evidence he was discussed or a plan made to locate and assess him . No explanation was provided in evidence for why evidence given of a strategy to guard against this occurring in future. Therefore there continues to be a risk that plans to discuss patients in meetings will not be followed through which puts lives at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate records of contacts, decisions and risk assessments
Wider context from the report “7. Throughout the inquest evidence was given of alleged attempted contact and decision making with respect to Mr. Jukes that was not recorded in his BSMHT RIO notes . Furthermore, his Risk Screen was not updated after information came to HTT’s attention that affected his risk assessment . There was some evidence that HTT do not have capacity to fulfil their obligation to keep records but evidence from some witnesses suggested that they did not view record keeping as a necessity. If, for whatever reason, RIO notes are not an accurate reflection of contacts, actions and decision-making clinicians may be mis-led or ill-informed creating a risk to life. Evidence was given that there is an e-learning module on the topic of record keeping and a ‘Key message’ 3 minute video but it is not compulsory for staff to watch the video or feedback on it and staff are not tested or individually audited. Consequently there continues to be a risk that individuals will not comply with their duty to keep proper records and noncompliance will go undetected.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 system to carry out necessary psychiatric assessments in police custody
Wider context from the report “3. Despite not being informed by the BCPFT liaison and diversion nurse that Mr Jukes was in custody the HTT were made aware by his wife that he was in custody on the 28th September 2018. She also gave some information about the circumstances of his arrest, further information about the incident and police involvement had been reported to Street Triage during the night and was noted in the RIO notes. Despite this, no psychiatrist visited or attempted to visit Mr. Jukes in custody which it was stated in evidence was the usual practice of the team. It is not known why this was. Not having a robust and effective system to carry out necessary assessments whilst a patient is detained in police custody puts lives at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to use all available means to locate patients requiring assessment
Wider context from the report “4. Following his release from custody on the 28th September 2018 and evidence from a psychologist that he was treating suicide and harm to others, on the 2nd October 2018 the HTT’s only recorded attempt to contact Mr. Jukes before the 9th October 2018 was a single call (which probably mistakenly went to his wife’s phone) on the 4th October 2018. Despite the fact that his location was unknown and he had not attended a planned medical review on the 4th October 2018 there was no email communication to Mr. Jukes (although he had communicated this way with the team before and provided them with his email address) nor a call to his wife to ask her for assistance . There was evidence at inquest from the RCA Author that there should have been more effort to contact him at least from the 4th onwards if not before. Failure to utilise all means of locating a patient whereabouts are unknown, who requires assessment and who is not making contact with the team puts lives at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff compliance with record-keeping duties is detected
Wider context from the report “7. Throughout the inquest evidence was given of alleged attempted contact and decision making with respect to Mr. Jukes that was not recorded in his BSMHT RIO notes. Furthermore, his Risk Screen was not updated after information came to HTT’s attention that affected his risk assessment. There was some evidence that HTT do not have capacity to fulfil their obligation to keep records but evidence from some witnesses suggested that they did not view record keeping as a necessity. If, for whatever reason, RIO notes are not an accurate reflection of contacts, actions and decision-making clinicians may be mis-led or ill-informed creating a risk to life. Evidence was given that there is an e-learning module on the topic of record keeping and a ‘Key message’ 3 minute video but it is not compulsory for staff to watch the video or feedback on it and staff are not tested or individually audited . Consequently there continues to be a risk that individuals will not comply with their duty to keep proper records and noncompliance will go undetected.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 material arrest information for mental health assessments in custody
Wider context from the report “1. The psychiatric liaison and diversion practitioner employed by BCPFT who attended to review Mr. Jukes in Oldbury custody suite on the 28th September 2018 did not have sufficient information about the history of arrest to inform her decision making on assessment in custody . She was provided with a print out of the first two pages of the custody record which included the statutory arrest reason and the circumstances of arrest but nothing that indicated that he had barricaded himself in the loft, threatened suicide and harm to others and not come out in response to police negotiators. This information was not included in a verbal handover according to the nurse’s evidence and there is no record of it being handed over to her. She stated in evidence that if she had been aware of the extent of the events overnight on the 27th into the 28th she would have arranged a Mental Health Act assessment when he did not engage with her. There is a risk to life if assessments of mental health in custody are not informed by material information about circumstances connected with arrest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to attempt timely assessment after a high-risk patient re-establishes contact
Wider context from the report “6. On the 9th October 2018 an HTT clinician talked to Mr. Jukes on the phone at which time he sounded intoxicated, was calm and polite, gave his location and agreed to attend an appointment for a medical review on the 12th October 2018 if a bus pass were provided to his location for him to attend. No arrangements were made in an attempt to assess Mr Jukes before the 12th October 2018 . By this time he was reason to suspect Mr. Jukes was at risk of harm to self or others, was under the influence of substances, had not had a full assessment by the team, had recently not been engaging with services and his location had been unknown for over a week. This evidence indicates that those making the decision to ask Mr. Jukes to attend on the 12th underestimated his risk and were not pro-active in making contact . The staff involved maintained in evidence that they acted appropriately, evidence was given that this was not the finding of the Root Cause Analysis investigation review panel. In these circumstances to fail to attempt to assess as soon as reasonably practicable a patient who has come back into contact with the team as soon as reasonably practicable puts lives at risk . No evidence was given of specific action to address the decisions that were made on the 9th October 2018 with the individuals involved or the team generally and therefore the risk continues.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 pass reliable information between mental health services
Wider context from the report “2. The above psychiatric liaison and diversion practitioner gave evidence that she contacted either the duty bed manager for BSMHT or the BSMHT liaison and diversion team based at Perry Barr custody suite and was informed that Mr. Jukes was not known to the service. She stated that if she had been aware that he was open to the HTT she would have sought information about his involvement and would have made the team aware that he was in custody and the events of his previous evening. It was not established during the inquest and has not been established in BSMHT RCA investigation how this breakdown in communication occurred . Evidence was heard that the introduction of the Merit Vanguard system would not give a BCPFT employee in a custody suite access to some information and would mitigate against such circumstances arising again but it doesn’t explain why the nurse was left with the impression that he was not known to services. It is not unusual that clinicians from different mental health trusts will need to discuss patients and as full records are not available through the Merit Vanguard this will continue to arise . If reliable information is not being passed there is a risk to life from ill-informed decision making.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 HTT capacity to maintain progress notes and risk assessments
Wider context from the report “8. Evidence was given at the inquest that the reason HTT may not be maintaining good record keeping was due to insufficient capacity arising from a combination of too few staff arising from under-funding of the service and unnecessary referrals being made to the team . Evidence was given that there is work underway to introduce a systems to prevent inappropriate referrals and that funding has been granted for a further two CPNS for HTTs within BSMHT. However the evidence was that this will not be enough to enable staff to have the time to comply with their obligations to update progress notes and risk assessments . If funding is not sufficient to enable staff to fulfil their professional obligations to their patients, lives are at risk.
” 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 Conduct enhanced assurance of Birmingham and Solihull’s progress, including the effective use of transformation funding for local crisis resolution and home treatment functions.
Verbatim wording from the response “We are aware that Birmingham and Solihull Mental Health Trust are experiencing capacity constraints across their crisis and acute mental healthcare pathway, and they have identified a number of areas for improvement which they are working to address. We have provided some direct support to the trust in the form of clinically-led sessions focussed on effective crisis response and acute pathway capacity management. They are also part of a small group of STPs nationally which are subject to a more in-depth assurance process related to their progress against the ambition to reduce acute out of area placements.” Source location 2019-0220-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide information-sharing training to liaison and diversion teams and offer it to police healthcare providers.
Verbatim wording from the response “• All liaison and diversion teams have had information sharing training and this training offer has also been made to Police Healthcare providers” Source location 2019-0220-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide additional transformation funding to support expansion of crisis resolution and home treatment capacity.
Verbatim wording from the response “To support the delivery of this ambition, NHS England and Improvement have made significant new funding available (in addition to funding already allocated to CCGs since 2016) over the next two years via uplifts to local CCG baselines and through the targeted allocation of additional centrally held transformation funds. We have just finished the process of allocating the centrally held funding, which will be released to Sustainability and Transformation Partnerships (STPs) on a quarterly basis. Overall the additional funding available nationally in 2019/20 and 2020/21, primarily intended for ensuring 24/7 coverage of crisis resolution and intensive home treatment (CRHT) functions, is £80m and £140m respectively. More information on the funding profile is available in the Mental Health Implementation Plan for the NHS Long Term Plan.” Source location 2019-0220-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Advance the Local Integrated Health and Care Records programme to enable safe, secure sharing of comprehensive digital care records.
Verbatim wording from the response “The NHS Long Term Plan is committed to ensuring that by 2024, secondary care providers in England, including acute, community and mental health care settings, will be fully digitised, including clinical and operational processes across all settings, locations and departments. Data will be captured, stored and transmitted electronically, supported by robust IT infrastructure and cyber security, and Local Health and Care Records will cover the whole country.” Source location 2019-0220-Response-by-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 Hold a national event to debrief information-sharing issues and share lessons with liaison and diversion practitioners, commissioners and police representatives.
Verbatim wording from the response “We will commit to a national event by the end of March 2020 to debrief on this matter and any other information sharing/exchange issues that have been raised in other reports. We will invite liaison and diversion practitioners as well as NHS Commissioners and police representatives in order to share lessons learnt. Additionally, there has been work to address this concern at a regional level:” Source location 2019-0220-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with police forces to ensure liaison and diversion practitioners receive relevant arrest and presentation information.
Verbatim wording from the response “Sufficient information regarding arrests was not provided to liaison and diversion practitioner:” Source location 2019-0220-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support development of the Connect police IT system and liaison and diversion functionality to improve custody information access.
Verbatim wording from the response “• NHS England and NHS Improvement has been working with West Midland Police regarding their new IT system (‘Connect’) which the police are implementing in the summer 2020” Source location 2019-0220-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide clinically led support to improve crisis response and acute pathway capacity management.
Verbatim wording from the response “We are aware that Birmingham and Solihull Mental Health Trust are experiencing capacity constraints across their crisis and acute mental healthcare pathway, and they have identified a number of areas for improvement which they are working to address. We have provided some direct support to the trust in the form of clinically-led sessions focussed on effective crisis response and acute pathway capacity management. They are also part of a small group of STPs nationally which are subject to a more in-depth assurance process related to their progress against the ambition to reduce acute out of area placements.” Source location 2019-0220-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assure use of dedicated transformation funding to support progress toward properly resourced 24/7 crisis resolution and home treatment functions.
Verbatim wording from the response “To support the delivery of this ambition, NHS England and Improvement have made significant new funding available (in addition to funding already allocated to CCGs since 2016) over the next two years via uplifts to local CCG baselines and through the targeted allocation of additional centrally held transformation funds. We have just finished the process of allocating the centrally held funding, which will be released to Sustainability and Transformation Partnerships (STPs) on a quarterly basis. Overall the additional funding available nationally in 2019/20 and 2020/21, primarily intended for ensuring 24/7 coverage of crisis resolution and intensive home treatment (CRHT) functions, is £80m and £140m respectively. More information on the funding profile is available in the Mental Health Implementation Plan for the NHS Long Term Plan.” Source location 2019-0220-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce and operationalise an information-sharing protocol for co-commissioned Armed Forces mental health services.
Verbatim wording from the response “NHS England and Improvement will produce an information sharing protocol for the NHS and Independent sector Mental Health Trusts that are co-commissioned with the local NHS Clinical Commissioning Groups (CCGs) to deliver services to the Armed Forces. This will ensure that patient information can be shared thereby providing a comprehensive and simultaneous patient record. This protocol will be in place and operational by 1 April 2020. Where NHS England and NHS Improvement Armed Forces co-commission mental health services with CCGs we will strengthen the commissioning relationships already in place and work through an integrated approach to ensure that the appropriate Quality and Safety systems are in place to identify risk and have mechanisms to respond. NHS England and NHS Improvement Quality and Safety meetings are currently held with the providers only.” Source location 2019-0220-Response-by-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 Local NHS agencies are expected to address the report’s local concerns.
Verbatim wording from the response “Please note this response will address the matters of concern from a national level and we would expect the local NHS agencies, which I note are copied in to the letter, to address the local concerns raised.” Source location 2019-0220-Response-by-NHS-England
Open published response
Concerns raised 2 Lack of awareness among NHS trusts and ambulance services using NHSP of the overdose-triage deficiency View source Failure of NHSP overdose triage to account for drug type and sudden-collapse risk View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Allan Davies · 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
Allan Davies, who had a history of illicit drug misuse, telephoned 999 after unintentionally taking heroin, crack cocaine and mamba. Although he initially reported breathlessness, the ambulance response was delayed as dispatched ambulances were transferred to higher-category patients; he was later found in cardiac arrest and died, with the medical cause of death recorded as heroin overdose. The substantive concerns were that NHS Pathways triage treated overdose cases too generically, without regard to the drug taken and risk of sudden collapse, and that not all NHS trusts and ambulance services were aware of this deficiency.
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 awareness among NHS trusts and ambulance services using NHSP of the overdose-triage deficiency
Wider context from the report “I heard evidence from a West Midlands Ambulance Service (WMAS) Clinical Standards Manager and Emergency Operations Centre Clinical Manager. They explained that it is recognised certain drugs put overdose patients who are initially breathing and conscious at greater risk of sudden collapse. An example given of the two ends of spectrum was a paracetamol overdose – less risk of sudden collapse – and heroin overdose – greater risk of sudden collapse. However, when an overdose patient calls 999, the NHS Pathways Telephone Triage System (NHSP) does not distinguish between the type of drug(s) taken and the corresponding risk of sudden collapse. If the patient is breathing and conscious at the time of the call, NHSP advises a category 3 response (ambulance within two hours), regardless of the type of drug(s) taken. Both witnesses expressed concern that this is too generic and is placing patients at risk.
One of the witnesses sits on the NHSP user group, and added the generic triaging of overdose cases continues despite a number of different NHS trusts sharing the same concern and raising it with NHS Pathways via the user group. WMAS are sufficiently concerned about the on-going concern that in January 2019 they implemented a local policy adding a layer of triaging on top of NHSP to have regard to the type of drug(s) taken and its impact on the patient.
My on-going concern is:
(1) NHSP triaging of overdose cases is too generic, namely it fails to have regard to the type of drug(s) taken and the potential for sudden collapse in certain patients;
(2) Not all NHS trusts/ambulance services that utilise NHSP are aware of this apparent deficiency .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 NHSP overdose triage to account for drug type and sudden-collapse risk
Wider context from the report “I heard evidence from a West Midlands Ambulance Service (WMAS) Clinical Standards Manager and Emergency Operations Centre Clinical Manager. They explained that it is recognised certain drugs put overdose patients who are initially breathing and conscious at greater risk of sudden collapse. An example given of the two ends of spectrum was a paracetamol overdose – less risk of sudden collapse – and heroin overdose – greater risk of sudden collapse. However, when an overdose patient calls 999, the NHS Pathways Telephone Triage System (NHSP) does not distinguish between the type of drug(s) taken and the corresponding risk of sudden collapse . If the patient is breathing and conscious at the time of the call, NHSP advises a category 3 response (ambulance within two hours), regardless of the type of drug(s) taken . Both witnesses expressed concern that this is too generic and is placing patients at risk.
One of the witnesses sits on the NHSP user group, and added the generic triaging of overdose cases continues despite a number of different NHS trusts sharing the same concern and raising it with NHS Pathways via the user group. WMAS are sufficiently concerned about the on-going concern that in January 2019 they implemented a local policy adding a layer of triaging on top of NHSP to have regard to the type of drug(s) taken and its impact on the patient.
My on-going concern is:
(1) NHSP triaging of overdose cases is too generic, namely it fails to have regard to the type of drug(s) taken and the potential for sudden collapse in certain patients ;
(2) Not all NHS trusts/ambulance services that utilise NHSP are aware of this apparent deficiency.
” 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 Write to ambulance service chief executives and medical directors highlighting overdose-triage risks and requesting robust clinical oversight for higher-risk callers.
Verbatim wording from the response “In response I can confirm that NHS England and NHS Improvement, through the Ambulance Response Programme and Joint Ambulance Improvement Programme Board, are aware of this issue, and have taken steps to address it. On 2nd April 2019 Professor Jonathan Benger, the National Clinical Director for Urgent and Emergency Care at NHS England, wrote to all Ambulance Service Chief Executives and Ambulance Service Medical Directors in England to highlight this issue and ask them to:” Source location 2019-0291-Response-by-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 Deploy NHS Pathways Release 18 across NHS 111 and participating ambulance services, including staff updates and system implementation.
Verbatim wording from the response “This new disposition code to support further clinical assessment was finalised and included in Release 18 of NHS Pathways content. Beta testing occurred in August 2019 and widescale deployment of Release 18 to all providers of NHS111 and all ambulance services in England that use the NHS Pathways system begins on 7th October 2019, with services then having an 8 week period to update their staff and deploy in their systems.” Source location 2019-0291-Response-by-NHS-Digital
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 Disseminate information about the new Dx0124 disposition code to NHS Pathways users through the standard deployment process.
Verbatim wording from the response “Through our standard deployment process all users of NHS Pathways are aware of the new disposition code Dx0124 coming in Release 18.” Source location 2019-0291-Response-by-NHS-Digital
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 a proposed disposition code to identify symptomatic, non-suicidal overdose patients for urgent clinical assessment.
Verbatim wording from the response “NHS Pathways has also recognised that those patients who have overdosed without suicidal intent and have symptoms (and so receive a Dx012 disposition and Category 3 ambulance) would benefit from having the same visibility within the Category 3 cohort as those with suicidal intent, so they can also be easily identified by clinicians working within ambulance control rooms for urgent remote clinical assessment of the risk to life. Further work by the NHS Pathways team is commencing in this area and, subject to review by the National Clinical Governance Group, a new disposition code will be introduced (similar to Dx0124) to enable this to occur. The Ambulance Response Programme will be made aware of this proposed change.” Source location 2019-0291-Response-by-NHS-Digital
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 Introduce and ratify disposition code Dx0124 to identify higher-risk suicidal patients for early clinical review.
Verbatim wording from the response “To support this recommendation NHS Pathways have introduced a new disposition code (Dx0124), ratified by the NHS Pathways National Clinical Governance Group (NCGG) in February 2019. This new code, ‘Dx0124 Emergency Ambulance Response for Risk of Suicide (Category 3)’ is designed to facilitate the early identification of higher risk suicidal patients either following an intentional toxic overdose or persons who intend to end their life by violent means, so that they can undergo early clinical review within 111 and 999 call-handling centres.” Source location 2019-0291-Response-by-NHS-Digital
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 Reclassifying every overdose case as a Category 2 ambulance response would create wider clinical risks and delay responses to patients with greater need.
Verbatim wording from the response “I can confirm that the re-categorisation of all such cases from Dx012 (Category 3 ambulance) responses to a Category 2 ambulance response, without first differentiating the clinical risks of method, toxicity and social circumstance, was also considered. However given the large volume of low risk patients that would be included in such a change this would also introduce new clinical risks across the wider emergency care system and delay the ambulance response to other patients with greater need. Therefore again the introduction of a new code was felt to be the safest and best option.” Source location 2019-0291-Response-by-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 Automated identification of higher-risk overdose patients is not currently possible because patients may inaccurately identify the substance or quantity taken.
Verbatim wording from the response “This letter also offered to promote and share good practice in this regard, which several ambulance services have done. This letter from ████████ followed earlier work to examine whether there might be a way of identifying higher risk overdose patients automatically, given that NHS Pathways is a computer-based system operated by non-clinical call handlers. However unfortunately no such system exists at present, not least because patients who have taken an overdose may not be able to identify accurately the substance or quantity that they have taken, and for this reason active clinical oversight within ambulance control rooms was recommended.” Source location 2019-0291-Response-by-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 Automatically identifying higher-risk overdose patients from drugs taken is not possible because telephone triage has too many variables for non-clinical call handlers.
Verbatim wording from the response “Overdose cases (whether with suicidal intent or not) are very complex to assess within telephone triage due to different methods, lethality and social circumstances. In overdose cases the capacity of any drug to cause harm is dependent on multiple factors; for example, quantity of drug taken, interactions of other medication, the patient’s medical history and time of overdose, as well as the patient’s understanding of what exactly has been taken.” Source location 2019-0291-Response-by-NHS-Digital
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 Re-categorising all suicidal cases for faster ambulance responses would offer little benefit and could introduce wider clinical risks.
Verbatim wording from the response “4) Use of disposition Dx012 /Category 3 ambulance response” Source location 2019-0291-Response-by-NHS-Digital
Open published response
Concerns raised 2 Failure of the free text box to generate automatic red flags from identified symptoms View source Separate organisational time limits causing avoidable delay in the patient pathway View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jennifer Withey · 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
Jennifer Withey died from sepsis following infection associated with a spinal fusion operation, after contacting the 111 service three times. During one call, recorded symptoms included inability to weight bear, no urine for 30 hours, and a dead-feeling left arm and leg, but the call was not immediately referred to a clinician. The report raised concerns about the lack of an automatic sepsis alert and separate timeframes operated by the 111 and out-of-hours GP services, which could introduce avoidable delay.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of the free text box to generate automatic red flags from identified symptoms
Wider context from the report “A) The free text box could be set up so that identified symptoms, where appropriate, could generate an automatic red flag. By way of illustration, a non-blanching rash could automatically justify immediate hospital admission by ambulance in a case of suspected meningitis. Similarly, in this case, where a number of sepsis indicators were present, a red flag could have been raised requiring the call adviser specifically to consider a sepsis pathway . This would act as a second level of security, the first step being to allocate a patient to a correct pathway in the first instance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Separate organisational time limits causing avoidable delay in the patient pathway
Wider context from the report “B) is it possible to establish a single patient orientated pathway with a key performance indicator of, for example, ‘patient to be seen within two hours’ rather than two separate time limits for two or more organisations (here, 111 and Cornwall Health) which cumulatively introduces unnecessary and avoidable delay into the process .
” 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 Implement national Integrated Urgent Care key performance indicators across organisations in the patient pathway.
Verbatim wording from the response “With regard to a single patient-oriented pathway within NHS 111 services, NHS England has a set of national Key Performance Indicators (KPI) which measure the performance of this service. In the past, these KPIs only applied to the NHS 111 call receiving organisations, with other organisations in the patient pathway not monitored.” Source location 2019-0225-Response-by-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 Replace locally measured out-of-hours standards with Integrated Urgent Care key performance indicators applying to NHS 111 and out-of-hours organisations.
Verbatim wording from the response “In addition, since October 2018 we have updated and replaced the standards by which Out-of-hours organisations are measured, (The ‘National Quality Requirements), with the IUC KPIs. Previously these standards were only ever locally measured, but now both NHS 111 organisations and Out-of-hours organisations need to comply with the same IUC KPIs.” Source location 2019-0225-Response-by-NHS-England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS Digital is responsible for delivering NHS Pathways and its Directory of Service clinical decision tool.
Verbatim wording from the response “NHS Digital is responsible for the delivery of NHS Pathways and the ‘Directory of Service’ which is a clinical decision tool. Together this system is used throughout England and underpins how the public access all urgent and emergency care” Source location 2019-0225-Response-by-NHS-England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS Digital’s separate response is considered to cover and answer all specific NHS Pathways recommendations.
Verbatim wording from the response “As mentioned earlier, I note that NHS Digital has already responded separately to you on the specific NHS Pathways recommendations in your referral and I am content that its response suitably covers, and answers, all of the issues you raised.” Source location 2019-0225-Response-by-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 Free-text analysis cannot safely be introduced because sufficient expertise and evidence do not currently exist; developing technology remains under review.
Verbatim wording from the response “• It may be in time that technology, natural language processing and artificial intelligence develop such that free text analysis of this nature can successfully be deployed but NHS Pathways do not consider that sufficient expertise or evidence exists currently to safely introduce such a feature. Use of developing technology is something that remains under constant review in NHS Pathways.” Source location 2019-0225-Response-by-NHS-Digital
Open published response
Concerns raised 1 Failure to independently verify patients’ concurrent opiate replacement therapy and prescribing organisation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrew Peter McCall · 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 Peter McCall was found face down and unresponsive in supported living accommodation on 18 September 2018. A post-mortem examination and toxicology attributed his death to gastric aspiration associated with Pregabalin and Methadone use. The report raised concern that his GP was unaware of his Methadone prescription and could therefore prescribe medications that might be unsuitable or potentially harmful.
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 independently verify patients’ concurrent opiate replacement therapy and prescribing organisation
Wider context from the report “The evidence revealed a clear pattern of “medication seeking behaviour” with his GP to obtain additional amounts of Pregabalin. The evidence also showed that his GP was not aware that he was on a current Methadone script. The “One Recovery” clinic operated a system which was dependent upon the service user declaring which GP practice they were registered with. This was not checked or verified independently and therefore concern must exist that the GP may be unaware that a patient is on an opiate replacement regime, prescribed by another organisation , and may therefore prescribe medications which may not be suitable and which may potentially be harmful . It is suggested that, where patients are prescribed medication as part of “opiate replacement therapy”, GPs have the means to check the details and the organisation providing such a service. This puts in place a more robust system to ensure that the current GP is fully aware of the treatment programme.
” 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 Write to Staffordshire GP practices about the inquest risks, considering other agencies' opiate prescribing, and alerting the clinic when patients are registered elsewhere.
Verbatim wording from the response “Write to all GP practices within Staffordshire:
- making them aware of the inquest findings, and the risks this highlights;
- reminding them of the importance of considering whether other agencies might be prescribing opiate replacements; and
- asking them to alert the clinic directly if they receive information relating to a patient not registered at the practice (so the correct practice can be identified quickly).” Source location 2019-0228-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Contact the service lead and request reviews of GP-data collection, verification, and reliable information sharing with registered GPs.
Verbatim wording from the response “Dr Kenneth Deacon, Medical Director for System Improvement and Professional Standards (Midlands) will:” Source location 2019-0228-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Local Authority, rather than NHS England or the Clinical Commissioning Group, commissions these substance misuse services.
Verbatim wording from the response “In this case the service is provided by One Recovery Clinic, in conjunction with North Staffordshire Combined Healthcare NHS Trust. The lead provider is Addiction Dependency Solution. Substance misuse services are commissioned by the Local Authority, not NHS England or the Clinical Commissioning Group.” Source location 2019-0228-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is neither commissioner nor regulator of these substance misuse services and has no direct responsibility for them.
Verbatim wording from the response “Although NHS England is neither the commissioner or regulator of these services, and have no direct responsibility for them, we recognise the importance of the concerns you have raised, and are taking the following action:” Source location 2019-0228-Response-by-NHS-England
Open published response
Concerns raised 2 Failure to send discharge letters to all current medical attendants View source Failure to provide original prescribers with information about suspended or stopped medication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lewis James Doyle · 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
Lewis James Doyle, who had multiple medical conditions including coronary artery disease and recurrent depressive illness, died on 8 January 2019 after developing worsening respiratory illness and pulmonary oedema following traumatic injuries sustained when he fell in front of a train. The principal concern was that discharge letters, including information about suspended or stopped medication, should be sent to all current medical attendants across primary, secondary and tertiary care.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to send discharge letters to all current medical attendants
Wider context from the report “When Mr Doyle was discharged from the Liverpool Heart and Chest Hospital the GP discharge letter was sent to his GP. Mr GP Doyle was receiving treatment for Acute Coronary Syndrome but also mental health care for a Recurrent Depressive Illness (without Psychosis). Lithium had to be stopped not only because it was at a toxic level but also because of the effect of this and alternate medications on cardiac health. It occurred during the inquest that in similar scenarios better patient care could be delivered, if discharge letters were sent to all current medical attendants, whether in primary, secondary or tertiary care. Information with regarded to suspended or stopped medication was needed by the original prescribers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 original prescribers with information about suspended or stopped medication
Wider context from the report “When Mr Doyle was discharged from the Liverpool Heart and Chest Hospital the GP discharge letter was sent to his GP. Mr GP Doyle was receiving treatment for Acute Coronary Syndrome but also mental health care for a Recurrent Depressive Illness (without Psychosis). Lithium had to be stopped not only because it was at a toxic level but also because of the effect of this and alternate medications on cardiac health. It occurred during the inquest that in similar scenarios better patient care could be delivered, if discharge letters were sent to all current medical attendants, whether in primary, secondary or tertiary care. Information with regarded to suspended or stopped medication was needed by the original prescribers.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Fund EPMA implementation in an additional 25 NHS trusts.
Verbatim wording from the response “The use of Dictionary of medicines and Devices (dm+d), (a dictionary of descriptions and codes for medicines and devices in use across the NHS), compliant Electronic Prescribing and Medicines Administration (EPMA) systems makes the process of sending and receiving medicines related information between organisations and health professionals easier and more accurate. It is recognised that this would improve patient safety and hence there is now no national funding to support its roll out. I can confirm that NHS E/I provided funding for an additional 25 Trusts to have EPMA in this last week. The information standards for digital transfer of care do include changes to medicines albeit optional at present. These will be used for the basis for transfer of care in the future (PRSB standards https://theprsb.org/standards/edischarge summary/)” Source location 2019-0214-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 Individual trusts remain responsible for discharge summaries and transferring medication information after discharge.
Verbatim wording from the response “Whilst discharge summaries remain the responsibility of individual trusts, the NHS standard contract expects the transfer of information within 24 hours of discharge usually from provider to GP. The discharge information should contain a full and accurate summary record of medications (both prescribed and non-prescribed) including any that were discontinued and any reasons for this – in line with recommendations from the Academy of Medical Royal Colleges (AoMRC) and the Professional Record Standards Body (PRSB).¹” Source location 2019-0214-Response-from-NHS-England-and-NHS-Improvement
Open published response
Concerns raised 5 Failure to review support arrangements for non-clinically qualified call advisors referring unusual cases to clinically qualified colleagues View source Lack of NHS Pathways questioning about cold hands and feet in children aged over five View source Failure of NHS Pathways questions to allow meaningful assessment of pain in children View source Inappropriately high NHS Pathways threshold for questioning about green vomit in children over five View source Lack of a failsafe mechanism for rapid assessment and escalation after repeated enquiries about the same child health complaint View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sebastian · 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
Sebastian was a six-year-old boy who became ill on 10 October 2015 and deteriorated over the following weekend. He suffered a cardiac arrest and was confirmed deceased at Derriford Hospital on 12 October 2015. The concerns included limitations in NHS Pathways questions and support arrangements that may have hindered recognition and escalation of an acutely unwell child, as well as the absence of a failsafe mechanism for repeated enquiries about the same complaint.
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 review support arrangements for non-clinically qualified call advisors referring unusual cases to clinically qualified colleagues
Wider context from the report “Following the inquest I received submissions that without changes in the NHS Pathways the 111 call handlers will not be adequately assisted by the Pathways to recognise the acutely unwell child, in particular:
i at the conclusion of the inquest there was no question within the NHS Pathways questionnaire concerning cold hands and feet for children aged over five
ii at the time of the conclusion of the inquest the question regarding green vomit, asked in respect of children over five, had an inappropriately high threshold (that is required severe pain for more than four hours before the question was engaged) and would not have been activated in Sebastian’s case
iii there has no indication NHS Pathways/NHS Digital have reviewed the support arrangements for non-clinically qualified call advisors to refer unusual cases to clinically qualified colleagues
iv at the time of the conclusion of the inquest NHS Pathways’ questions did not allow a meaningful assessment of pain in a child; that is to say questions about severity of pain and ability of a child to communicate such pain should be reviewed at national governance level
One expert at the Hearing expressed the view that three contacts with medical providers about one concern should instigate a face to face meeting between patient and clinician.
Those providing health care are asked to review the need for a failsafe mechanism whereby, when there is a repeated enquiry regarding the same complaint over a child’s health within a period of time, there is a rapid assessment to determine whether or not that call requires urgent escalation to a review by an appropriate clinician and, where appropriate, a face to face meeting between the patient and an appropriate clinician.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of NHS Pathways questioning about cold hands and feet in children aged over five
Wider context from the report “Following the inquest I received submissions that without changes in the NHS Pathways the 111 call handlers will not be adequately assisted by the Pathways to recognise the acutely unwell child, in particular:
i at the conclusion of the inquest there was no question within the NHS Pathways questionnaire concerning cold hands and feet for children aged over five
ii at the time of the conclusion of the inquest the question regarding green vomit, asked in respect of children over five, had an inappropriately high threshold (that is required severe pain for more than four hours before the question was engaged) and would not have been activated in Sebastian’s case
iii there has no indication NHS Pathways/NHS Digital have reviewed the support arrangements for non-clinically qualified call advisors to refer unusual cases to clinically qualified colleagues
iv at the time of the conclusion of the inquest NHS Pathways’ questions did not allow a meaningful assessment of pain in a child; that is to say questions about severity of pain and ability of a child to communicate such pain should be reviewed at national governance level
One expert at the Hearing expressed the view that three contacts with medical providers about one concern should instigate a face to face meeting between patient and clinician.
Those providing health care are asked to review the need for a failsafe mechanism whereby, when there is a repeated enquiry regarding the same complaint over a child’s health within a period of time, there is a rapid assessment to determine whether or not that call requires urgent escalation to a review by an appropriate clinician and, where appropriate, a face to face meeting between the patient and an appropriate clinician.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of NHS Pathways questions to allow meaningful assessment of pain in children
Wider context from the report “Following the inquest I received submissions that without changes in the NHS Pathways the 111 call handlers will not be adequately assisted by the Pathways to recognise the acutely unwell child, in particular:
i at the conclusion of the inquest there was no question within the NHS Pathways questionnaire concerning cold hands and feet for children aged over five
ii at the time of the conclusion of the inquest the question regarding green vomit, asked in respect of children over five, had an inappropriately high threshold (that is required severe pain for more than four hours before the question was engaged) and would not have been activated in Sebastian’s case
iii there has no indication NHS Pathways/NHS Digital have reviewed the support arrangements for non-clinically qualified call advisors to refer unusual cases to clinically qualified colleagues
iv at the time of the conclusion of the inquest NHS Pathways’ questions did not allow a meaningful assessment of pain in a child ; that is to say questions about severity of pain and ability of a child to communicate such pain should be reviewed at national governance level
One expert at the Hearing expressed the view that three contacts with medical providers about one concern should instigate a face to face meeting between patient and clinician.
Those providing health care are asked to review the need for a failsafe mechanism whereby, when there is a repeated enquiry regarding the same complaint over a child’s health within a period of time, there is a rapid assessment to determine whether or not that call requires urgent escalation to a review by an appropriate clinician and, where appropriate, a face to face meeting between the patient and an appropriate clinician.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inappropriately high NHS Pathways threshold for questioning about green vomit in children over five
Wider context from the report “Following the inquest I received submissions that without changes in the NHS Pathways the 111 call handlers will not be adequately assisted by the Pathways to recognise the acutely unwell child, in particular:
i at the conclusion of the inquest there was no question within the NHS Pathways questionnaire concerning cold hands and feet for children aged over five
ii at the time of the conclusion of the inquest the question regarding green vomit, asked in respect of children over five, had an inappropriately high threshold (that is required severe pain for more than four hours before the question was engaged ) and would not have been activated in Sebastian’s case
iii there has no indication NHS Pathways/NHS Digital have reviewed the support arrangements for non-clinically qualified call advisors to refer unusual cases to clinically qualified colleagues
iv at the time of the conclusion of the inquest NHS Pathways’ questions did not allow a meaningful assessment of pain in a child; that is to say questions about severity of pain and ability of a child to communicate such pain should be reviewed at national governance level
One expert at the Hearing expressed the view that three contacts with medical providers about one concern should instigate a face to face meeting between patient and clinician.
Those providing health care are asked to review the need for a failsafe mechanism whereby, when there is a repeated enquiry regarding the same complaint over a child’s health within a period of time, there is a rapid assessment to determine whether or not that call requires urgent escalation to a review by an appropriate clinician and, where appropriate, a face to face meeting between the patient and an appropriate clinician.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a failsafe mechanism for rapid assessment and escalation after repeated enquiries about the same child health complaint
Wider context from the report “Following the inquest I received submissions that without changes in the NHS Pathways the 111 call handlers will not be adequately assisted by the Pathways to recognise the acutely unwell child, in particular:
i at the conclusion of the inquest there was no question within the NHS Pathways questionnaire concerning cold hands and feet for children aged over five
ii at the time of the conclusion of the inquest the question regarding green vomit, asked in respect of children over five, had an inappropriately high threshold (that is required severe pain for more than four hours before the question was engaged) and would not have been activated in Sebastian’s case
iii there has no indication NHS Pathways/NHS Digital have reviewed the support arrangements for non-clinically qualified call advisors to refer unusual cases to clinically qualified colleagues
iv at the time of the conclusion of the inquest NHS Pathways’ questions did not allow a meaningful assessment of pain in a child; that is to say questions about severity of pain and ability of a child to communicate such pain should be reviewed at national governance level
One expert at the Hearing expressed the view that three contacts with medical providers about one concern should instigate a face to face meeting between patient and clinician .
Those providing health care are asked to review the need for a failsafe mechanism whereby, when there is a repeated enquiry regarding the same complaint over a child’s health within a period of time, there is a rapid assessment to determine whether or not that call requires urgent escalation to a review by an appropriate clinician and, where appropriate, a face to face meeting between the patient and an appropriate clinician .
” 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 Analyse outcome and deployment data to evaluate the green-vomit and critical-illness changes and identify overlooked cases or further safety enhancements.
Verbatim wording from the response “Since the additional question relating to green vomit was added to the child abdominal pain pathway in Release 14, we have analysed the data available to ensure that no cases of children presenting with green vomit had been overlooked. This work identified a very low proportion of potentially critically ill children identified through an NHS Pathways triage on the basis of these changes subsequently attended the emergency department or were admitted to a hospital ward.” Source location 2019-0193-Response-by-NHS-Digital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement and deploy a green-vomit question for children aged five to sixteen in Release 14, with emergency-department referral when positive.
Verbatim wording from the response “Upon further consideration of this issue an additional question about the presence of green vomit in children aged 5 - 16 was implemented in Release 14. A positive response results in callers being referred to the emergency department within 1 hour. Widescale deployment of Release 14 to all providers of NHS111 and all ambulance services in England that use the NHS Pathways system was 2nd October 2017, with services then having an 8-week period to update their staff and deploy in their systems.” Source location 2019-0193-Response-by-NHS-Digital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish and recirculate posters and updated guidance reminding call handlers how to recognise and respond to complex calls.
Verbatim wording from the response “Actions in relation to complex calls following Sebastian’s death” Source location 2019-0193-Response-by-NHS-Digital
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 Broaden green-vomit questioning and emergency-treatment-centre referral scenarios for children over five in Release 17.
Verbatim wording from the response “As referrals to the ED are much lower than expected following the inclusion of the additional questions in Releases 14 and 15, it was identified that there was an opportunity to further enhance the interrogation of green vomit to support non-clinical call handlers without over referring children to the ED and impacting on services unnecessarily.” Source location 2019-0193-Response-by-NHS-Digital
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 Complete the formal evaluation of the cold-hands-and-feet question before considering extension to children aged five to sixteen.
Verbatim wording from the response “The question about cold hands and/or feet with the amended disposition was finalised and included in Release 14 in all illness pathways for the under 5 years age group. Widescale deployment of release 14 to all providers of NHS111 and all ambulance services in England that use the NHS Pathways system was 2nd October 2017, with services then having an 8 week period to update their staff and deploy in their systems. This question is undergoing a formal evaluation of impact for the under 5 years age group before extension to the 5-16 years age group. However, other markers to identify critical illness are included across the clinical content.” Source location 2019-0193-Response-by-NHS-Digital
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 Introduce a complex-calls training workshop for organisations using NHS Pathways, covering recognition, escalation and multidisciplinary support.
Verbatim wording from the response “Finally, we have developed a training session which focuses on how we can support call handlers to recognise complex calls. This was introduced to all organisations that use NHS Pathways at the Training and Quality Forum on 25th June 2019.” Source location 2019-0193-Response-by-NHS-Digital
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual providers are responsible for training and supporting call handlers and creating infrastructure and clinical capacity for clinician transfers.
Verbatim wording from the response “The training and support materials provided to sites are also under continual review as part of the NHS Pathways governance processes. Individual providers are responsible for training and supporting their staff as required by NHS Pathways and as appropriate to their local operating procedures.” Source location 2019-0193-Response-by-NHS-Digital
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 Cold hands and feet were not included for older children because evidence indicated they were an unreliable discriminator of critical illness in remote assessment.
Verbatim wording from the response “Historically, a question about whether a child has cold hands and/or feet has not been included within NHS Pathways. This was a deliberate decision not to include it after consideration of the available evidence of its accuracy as a discriminator of severe illness in a remote assessment setting. According to the National Institute for Health and Care Excellence (NICE) guideline for sepsis NG51, published in July 2016, cold hands and/or feet in the context of an unwell child is a moderate to high risk factor or an ‘amber flag’ considered during diagnosis in an unwell child with possible sepsis.” Source location 2019-0193-Response-by-NHS-Digital
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 pathway was not deficient regarding green vomit because other critical symptoms were already assessed and the existing threshold had clinical support.
Verbatim wording from the response “The question regarding the production of green vomit was not included in the abdominal pain pathway used for the over 5 years age group at the time of Sebastian's illness.” Source location 2019-0193-Response-by-NHS-Digital
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 Functional-capacity questions were considered the most meaningful available method for assessing children's pain remotely.
Verbatim wording from the response “A telephone assessment of pain in any age group is challenging as pain can be binary in nature. It is acknowledged that asking how bad the pain is will likely generate a very subjective description. Therefore, the system call handlers could undertake a ‘functional capacity’ assessment by way of the question presented.” Source location 2019-0193-Response-by-NHS-Digital
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing complex-call definitions and early-exit routes were considered sound for enabling non-clinical handlers to obtain clinical support.
Verbatim wording from the response “Actions in relation to complex calls following Sebastian’s death” Source location 2019-0193-Response-by-NHS-Digital
Open published response
Concerns raised 3 Pressure on staff to avoid hospital admission View source Failure to assess painful, swollen and hard suspected hernias for strangulation and arrange hospital transfer View source Failure to ensure paramedics are not instructed to reduce hernias outside their training 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
Mildred CLARK · 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
Mildred CLARK died in hospital on 17 December 2017 following infection and failure of a bypass graft, haemorrhage, and inadequate blood supply to the leg. The inquest found that delay in diagnosing the infection and haematoma limited the available medical intervention. A separate concern was raised about a paramedic being instructed by telephone to attempt hernia reduction despite not being trained to do so, and about possible pressure on staff to avoid hospital admission during winter pressure.
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 Pressure on staff to avoid hospital admission
Wider context from the report “Although this matter did not contribute to this death a concern was raised that a paramedic sought telephone advice from a hospital doctor by telephone on presenting symptoms and the initial diagnosis was that of a hernia were was extreme pain. The paramedic was instructed to carry out a procedure to reduce the hernia despite being informed that the paramedic was not trained to do so. The attempt caused extreme pain and failed.
(1) A senior member of ambulance crew gave evidence that reducing a hernia was not the role of a paramedic and a doctor should not instruct a paramedic to carry out this procedure particularly when they have stated they are not trained.
(2) A consultant surgeon gave evidence that:
a. a suspected hernia is not a medical emergency and there was no pressing requirement to undertake the procedure that could lead to complications if incorrectly carried out
b. where there is pain, swelling and hardness as in this case, if a hernia is suspected it would be reasonable to consider if this was a case of strangulated hernia as this could be a medical emergency and an attempt to reduce it cause significant complications and a patient should be taken to hospital
(3) There was a concern raised that staff may have felt pressured to act to avoid hospital admission during a period of winter pressure
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 painful, swollen and hard suspected hernias for strangulation and arrange hospital transfer
Wider context from the report “Although this matter did not contribute to this death a concern was raised that a paramedic sought telephone advice from a hospital doctor by telephone on presenting symptoms and the initial diagnosis was that of a hernia were was extreme pain. The paramedic was instructed to carry out a procedure to reduce the hernia despite being informed that the paramedic was not trained to do so. The attempt caused extreme pain and failed.
(1) A senior member of ambulance crew gave evidence that reducing a hernia was not the role of a paramedic and a doctor should not instruct a paramedic to carry out this procedure particularly when they have stated they are not trained.
(2) A consultant surgeon gave evidence that:
a. a suspected hernia is not a medical emergency and there was no pressing requirement to undertake the procedure that could lead to complications if incorrectly carried out
b. where there is pain, swelling and hardness as in this case, if a hernia is suspected it would be reasonable to consider if this was a case of strangulated hernia as this could be a medical emergency and an attempt to reduce it cause significant complications and a patient should be taken to hospital
(3) There was a concern raised that staff may have felt pressured to act to avoid hospital admission during a period of winter pressure
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 paramedics are not instructed to reduce hernias outside their training
Wider context from the report “Although this matter did not contribute to this death a concern was raised that a paramedic sought telephone advice from a hospital doctor by telephone on presenting symptoms and the initial diagnosis was that of a hernia were was extreme pain. The paramedic was instructed to carry out a procedure to reduce the hernia despite being informed that the paramedic was not trained to do so . The attempt caused extreme pain and failed.
(1) A senior member of ambulance crew gave evidence that reducing a hernia was not the role of a paramedic and a doctor should not instruct a paramedic to carry out this procedure particularly when they have stated they are not trained .
(2) A consultant surgeon gave evidence that:
a. a suspected hernia is not a medical emergency and there was no pressing requirement to undertake the procedure that could lead to complications if incorrectly carried out
b. where there is pain, swelling and hardness as in this case, if a hernia is suspected it would be reasonable to consider if this was a case of strangulated hernia as this could be a medical emergency and an attempt to reduce it cause significant complications and a patient should be taken to hospital
(3) There was a concern raised that staff may have felt pressured to act to avoid hospital admission during a period of winter pressure
” Open source report
2 May 2019 Alexander James Davidson · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Delays in updating electronic patient records with NHS 111 triage documents View source Failure to adapt NHS 111 telephone triage questions and wording for young and vulnerable patients View source Variation in admission for observation of paediatric patients returning to the Emergency Department View source Unclear NHS Pathways algorithm for exploring ‘soil’ or ‘coffee ground’ vomit during telephone triage View source Lack of standard lipase/amylase testing for patients under 18 with relevant abdominal symptoms View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alexander James Davidson · 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
Alexander James Davidson became suddenly unwell with abdominal pain, vomiting and diarrhoea, and died at the Queens Medical Centre on 26 February 2018 after developing an infected and necrotic pancreatic pseudocyst caused by gallstone pancreatitis. The report raised concerns about NHS 111 telephone triage for young or vulnerable patients, the clarity and transfer of triage information, testing for pancreatitis in young people, and the management of unscheduled returns to emergency departments.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in updating electronic patient records with NHS 111 triage documents
Wider context from the report “(3) The NHS 111 telephone triage service provides an electronic copy of the patient triage notes to the patient’s GP within minutes of the call ending. There was a delay of 7 days in the GP surgery uploading the 111 triage document to Alex’s patient record. This prevented Alex’s GP from reviewing the triage note prior to his consultation with the patient. There is no guidance as to expected practise with regards to the timely updating of electronic patient records, and as a result delays are all too frequent.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 adapt NHS 111 telephone triage questions and wording for young and vulnerable patients
Wider context from the report “(1) The NHS 111 telephone triage service uses the NHS Pathways computer system to triage patients via pre-determined question/answer based algorithms. The pre-determined questions are the same whether the caller is an adult or a child. Alex struggled to comprehend some of the medical terminology used during these calls. Call handlers are not permitted to deviate from the prescribed wording of the pre-determined questions, and this created confusion and inconsistency in the patient’s answers. Consideration should be given as to how young and/or vulnerable patients can be assisted to provide accurate information about their symptoms.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Variation in admission for observation of paediatric patients returning to the Emergency Department
Wider context from the report “(5) Patients who make an unscheduled return to the Emergency Department within 72 hours of discharge are required to have a review undertaken by an ED Consultant, or a ST4 trainee or above in the absence of a Consultant on the ‘shop floor’: RCEM Guidance June 2016. Some hospitals will admit returning paediatric patients for observation but practise seems to vary doctor-to-doctor and across Trusts. Consideration ought to be given to a national approach.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 NHS Pathways algorithm for exploring ‘soil’ or ‘coffee ground’ vomit during telephone triage
Wider context from the report “(2) The NHS Pathways algorithm for triaging vomiting and diarrhoea symptoms is unclear as patients may fail to understand what is meant by ‘soil’ or ‘coffee ground’ vomit . Consideration should be given to how this important diagnostic feature can be explored during telephone triage, especially when the patient is young and/or vulnerable.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 standard lipase/amylase testing for patients under 18 with relevant abdominal symptoms
Wider context from the report “(4) Adults presenting to their GP or Emergency Department with abdominal symptoms receive a lipase and/or amylase blood test as part of the standard package of blood testing. The levels of each of these enzymes can be used to diagnose pancreatitis. Patients under the age of 18 years are not offered this testing as standard , on the basis that pancreatitis is rare in paediatric patients. I heard anecdotal evidence of some doctors at Kingsmill Hospital now add this test to the standard admission bloods for older teenage patients who present with non-specific abdominal symptoms but the NICE guidance (September 2018) is not explicit in this regard . I heard evidence as to the increasing prevalence of gallstone pancreatitis in young people, in line with an increase in childhood obesity. Consideration ought to be given to a national approach for lipase/amylase testing in young people with relevant symptoms.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the vomiting question to address callers’ unfamiliarity with the term “coffee-grounds”.
Verbatim wording from the response “In 2018 NHS Pathways reviewed the question that asks about dark brown or black vomit in view of the concern that callers may not be familiar with the term ‘coffee-grounds’. Removing the 'coffee-grounds' description could result in over referral as dark/black fluid alone without texture ('bits') could be drinks (e.g. cola, coffee, Guinness) or other dietary intake that has been vomited. The reference to coffee-grounds is a texture that is reasonably specific to haematemesis and this is commonly used in health-related literature, whereas cola is not. NHS.uk also refer to coffee-ground appearance only.” Source location 2019-0149-Response-by-NHS-Digital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the gastrointestinal pathways, including diarrhoea and vomiting, clinical evidence on haematemesis, and whether user research could improve triage questions.
Verbatim wording from the response “NHS Pathways are, as part of routine review and governance procedures, conducting a review of the gastrointestinal suite of pathways (including the diarrhoea and vomiting pathways), with changes planned for Release 19 (which will be deployed May 2020). As part of this review, the clinical evidence related to haematemesis will be reviewed with consideration also given as to whether user research will be helpful in improving triage questions and the identification of haematemesis.” Source location 2019-0149-Response-by-NHS-Digital
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 Add “soil” to the supporting information for the question about vomiting blood.
Verbatim wording from the response “In 2016 NHS Pathways added reference to ‘soil’ in the ‘supporting information’ of the question asking about vomiting blood.” Source location 2019-0149-Response-by-NHS-Digital
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 Communication training, monthly audits, adaptable questioning and clinician transfer routes provide sufficient support for young or vulnerable callers.
Verbatim wording from the response “Call handlers are permitted to deviate from the exact wording presented by the system to a certain extent as each question has supplementary text called ‘supporting information’; the purpose of which is to guide the call handler to form additional probing questions or alternative ways of phrasing a question if a patient/caller might not understand what’s being asked.” Source location 2019-0149-Response-by-NHS-Digital
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 coffee-ground description is clinically specific and supported by explanatory text; removing it could cause inappropriate over-referral.
Verbatim wording from the response “The question (see example below) currently asks whether there has been ‘dark brown or black vomit, like coffee-grounds’.” Source location 2019-0149-Response-by-NHS-Digital
Open published response
Concerns raised 1 Failure to provide clearly differentiated packaging for stent sizes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ronald CLARK · 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
Ronald CLARK underwent insertion of a stent in his common hepatic duct, but an incorrectly sized stent was inserted and significantly contributed to his death at Queen Alexandra Hospital on 2 April 2018. The report raised concern that identical packaging for different stent sizes made them difficult to identify and could lead to use of the wrong-sized stent.
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 clearly differentiated packaging for stent sizes
Wider context from the report “1. I was told in evidence that the stents used at the hospital are all supplied in identical packaging with only a small label identifying the size of the stents inside . I was also told that stents in this sort of packaging are in general use in most, if not all, NHS hospitals.
2. I believe action should be taken by the purchasing agencies of the NHS to ensure that stent manufacturers should supply different sizes of stents in different coloured packaging to make it easier for them to be identified during medical procedures and to obviate the risk of the wrong-sized stent being used , as was the case with Mr Clark.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the prosthesis-verification standard to reflect developments in implant selection and verification, including potential future scanning of prostheses and implants.
Verbatim wording from the response “The NatSIPP on prosthesis verification is being updated to reflect developments in implant selection and verification processes and will include the potential for future scanning for all prostheses/implants.” Source location 2019-0151-Response-by-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 Packaging changes for different-sized stents are assigned to the Medicines and Healthcare products Regulatory Agency as the appropriate responsible body.
Verbatim wording from the response “I am grateful to you for sharing your findings from the inquest with us and highlighting that actions could prevent future deaths. The main action that you highlight relates to changes to manufacturer’s packaging so that different-sized stents are in different-coloured packaging. I note that the Regulation 28 report has also been sent to the Medicines and Healthcare products Regulatory Agency and, as changes to packaging falls within their remit, they are the more appropriate body to respond on this specific action.” Source location 2019-0151-Response-by-NHS-England
Open published response
2 Apr 2019 Tarek Mahmood CHOWDHURY · Prevention of Future Deaths report West London
View report summary
Concerns raised 4 Inadequate operation of SystmOne when new detainees arrive at IRCs View source Failure to share prisoner information between HMPPS, DEPMU and IRC staff View source Inadequate training of nurses on SystmOne and related access issues View source Failure of the process authorising IRC nurses to access former prisoners’ records View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Tarek Mahmood CHOWDHURY · 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
Tarek Mahmood CHOWDHURY was beaten to death by another detainee while detained at Heathrow Immigration Removal Centre on 1 December 2016. The report identified concerns about information sharing between prisons, the Home Office and immigration removal centres, including the availability of intelligence and other records. It also identified concerns about access to and operation of SystmOne healthcare records during the initial screening of detainees transferred from prison.
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 operation of SystmOne when new detainees arrive at IRCs
Wider context from the report “(2) That SystmOne is not operating adequately when new detainees arrive at IRCs . There are concerns both about the technology itself of SystmOne ; about the process of authorising a nurse in an IRC to see records of a former prisoner; and about whether trainers are able adequately to train nurses in respect of these issues. These concerns are addressed to NHS England, which is understood to commission and supply SystmOne; and to TPP, which is the technology company which is understood to have developed SystmOne.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 prisoner information between HMPPS, DEPMU and IRC staff
Wider context from the report “(1) That there is a failure to share information about prisoners who are to become detainees, between HMPPS and the Home Office’s DEPMU, and between HMPPS and staff in IRCs . The rolling out of Mercury intelligence to DEPMU/IRCs will not solve this problem if other information (in particular NOMIS and OASYS) is still not available to DEPMU/IRCs . This concern is addressed both to the Ministry of Justice (HMPPS) and to the Home Office (DEPMU/IRCs).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 of nurses on SystmOne and related access issues
Wider context from the report “(2) That SystmOne is not operating adequately when new detainees arrive at IRCs. There are concerns both about the technology itself of SystmOne; about the process of authorising a nurse in an IRC to see records of a former prisoner; and about whether trainers are able adequately to train nurses in respect of these issues . These concerns are addressed to NHS England, which is understood to commission and supply SystmOne; and to TPP, which is the technology company which is understood to have developed SystmOne.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 process authorising IRC nurses to access former prisoners’ records
Wider context from the report “(2) That SystmOne is not operating adequately when new detainees arrive at IRCs. There are concerns both about the technology itself of SystmOne; about the process of authorising a nurse in an IRC to see records of a former prisoner ; and about whether trainers are able adequately to train nurses in respect of these issues. These concerns are addressed to NHS England, which is understood to commission and supply SystmOne; and to TPP, which is the technology company which is understood to have developed SystmOne.
” Open source report
19 Mar 2019 Mohammed Shabol AHMED · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 2 Failure to establish whether information about olanzapine-associated drug reaction with eosinophilia and systemic symptoms is known to clinicians nationally View source Risk of adverse allergic reactions and drug reaction with eosinophilia and systemic symptoms from combined Spice use and olanzapine exposure 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
Mohammed Shabol AHMED · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mohammed Shabol Ahmed, a long-term illicit drug user with schizophrenia and a learning disability, was found deceased in his prison cell the morning after being returned from hospital following a drug-related collapse. Concerns included the possible interaction between olanzapine and Spice, failures in information-sharing between the prison, healthcare and hospital, and inadequate prison training for drug-related incidents and their aftermath.
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 establish whether information about olanzapine-associated drug reaction with eosinophilia and systemic symptoms is known to clinicians nationally
Wider context from the report “(1) The expert evidence of ████████ (Emeritus of Forensic Medicine) gave evidence that the use of Spice can prime a person for an allergic reaction. In the case of Mr Ahmed Olanzapine and Spice combined to cause an adverse allergic reaction. He had been prescribed Olanzapine throughout his imprisonment in the knowledge of Spice use.
(2) Healthcare records demonstrated that his eosinophilia count was recorded as reduced following a change in medication from Olanzapine to Risperidone.
(3) The expert evidence was that it was a very rare side effect but one which the U.S. Food and Drug Administration has warned that drug reaction with eosinophilia and systemic symptoms has been reported with olanzapine exposure.
(4) The jury was not able to find that the death was caused or contributed to by the use of Spice. It remains unclear whether the expert opinion is one which is or should be made known to clinicians 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 Risk of adverse allergic reactions and drug reaction with eosinophilia and systemic symptoms from combined Spice use and olanzapine exposure
Wider context from the report “(1) The expert evidence of ████████ (Emeritus of Forensic Medicine) gave evidence that the use of Spice can prime a person for an allergic reaction. In the case of Mr Ahmed Olanzapine and Spice combined to cause an adverse allergic reaction. He had been prescribed Olanzapine throughout his imprisonment in the knowledge of Spice use.
(2) Healthcare records demonstrated that his eosinophilia count was recorded as reduced following a change in medication from Olanzapine to Risperidone.
(3) The expert evidence was that it was a very rare side effect but one which the U.S. Food and Drug Administration has warned that drug reaction with eosinophilia and systemic symptoms has been reported with olanzapine exposure.
(4) The jury was not able to find that the death was caused or contributed to by the use of Spice. It remains unclear whether the expert opinion is one which is or should be made known to clinicians nationally.
” Open source report
14 Mar 2019 Katharine Mary DOWLING · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 5 Inconsistent availability and extent of ASD services across geographical locations View source Failure to understand and implement ASD training consistently View source Lack of ASD support beyond diagnosis View source Lack of clear and accessible guidance on ASD and co-existing mental health diagnoses View source Limited availability of ASD-appropriate inpatient environments View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Katharine Mary DOWLING · 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 Mary Dowling, who had autism spectrum disorder and co-existing mental health issues, self-ligatured while receiving care on an acute psychiatric ward and died in hospital. The concerns included inadequate integration of autism into care planning, insufficient autism training and specialist input, an inappropriate ward environment, inconsistent observations, and wider variation in national guidance and support.
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 Inconsistent availability and extent of ASD services across geographical locations
Wider context from the report “ASD support beyond diagnosis
Expert evidence adduced at this inquest indicated that, nationally, many trusts only provide a diagnostic service in respect of ASD. Consequently, it would appear that there is often no related support or assistance thereafter, including ASD specialist ‘psychology’ input.
The evidence indicated that some Trusts do provide a service beyond the purely diagnostic but the nature and extent of that service varies depending upon geographical location . Consequently it would appear that there is no consistency across the UK .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to understand and implement ASD training consistently
Wider context from the report “Training
Expert evidence at the inquest indicated that ASD training, particularly for nursing staff, is not properly understood and is not implemented consistently across the UK in accordance with appropriate national guidelines . Is there a process in place for monitoring and auditing this training?
It was the view of the expert witness that intermediate level training ought to be a mandatory requirement for all staff members involved in a clinical relationship with ASD 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 Lack of ASD support beyond diagnosis
Wider context from the report “ASD support beyond diagnosis
Expert evidence adduced at this inquest indicated that, nationally, many trusts only provide a diagnostic service in respect of ASD . Consequently, it would appear that there is often no related support or assistance thereafter, including ASD specialist ‘psychology’ input .
The evidence indicated that some Trusts do provide a service beyond the purely diagnostic but the nature and extent of that service varies depending upon geographical location. Consequently it would appear that there is no consistency across the UK.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 and accessible guidance on ASD and co-existing mental health diagnoses
Wider context from the report “Guidance
There seemed to be a paucity of clear and accessible guidance to clinicians and ward staff on the relationship between ASD and a co-existing mental health diagnosis / diagnoses . The value of such guidance is that it would signpost strategies to ensure that the ASD element will be properly integrated into a patient’s care planning and into care and treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Limited availability of ASD-appropriate inpatient environments
Wider context from the report “Environment
ASD-appropriate environments for in-patients diagnosed with ASD and who have a co-existing mental health diagnosis / diagnoses appear to be limited, nationally . If, as a consequence of that, such patients are placed on acute psychiatric wards, potentially for several months (as in this case), they may be at greater risk of suicide.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide keyworker support for autistic children and young people during and after diagnosis.
Verbatim wording from the response “• Providing keyworker support for autistic children and young people during and after diagnosis;” Source location 2019-0089-Response-by-NHS-Engalnd2
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 Expand Learning Disability Improvement Standards to better cover autism and NHS-commissioned care.
Verbatim wording from the response “Further I can confirm that the NHS Long Term Plan (‘LTP’) sets out a clear commitment on the expansion of the Learning Disability Improvement Standards to better cover Autism. In addition, it committed to covering all care commissioned by the NHS. The provision of autism specific standards would provide valuable information about services provided to autistic people across NHS funded care; and importantly, a provision of such standards would inform the development of new benchmarks.” Source location 2019-0089-Response-by-NHS-Engalnd2
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider capital funding requirements for improving therapeutic mental-health inpatient environments.
Verbatim wording from the response “The Independent Review of the Mental Health Act called on the government and the NHS to commit in the 2019 Spending Review to a major multi-year capital investment programme to modernise the NHS mental health estate and improve inpatient environments. It was identified that steps were needed to make inpatient environments more therapeutic, including co-designing wards with people with lived-in experience in line with the reasonable adjustment duty, to ensure people with learning disabilities (‘LD’), autism, or both are not unnecessarily distressed by their environment.” Source location 2019-0089-Response-by-NHS-Engalnd2
Open published response
Concerns raised 5 Lack of joint-working arrangements between the NHS and private psychiatric consultants View source Discharge of NHS patients seeking private psychiatric care View source Delays in carer assessment during the patient treatment pathway View source Lack of doctor-to-doctor communication for prescribing View source Insufficient local psychiatric beds 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.
×
AI-generated summary
Peter George Garvin · 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 George Garvin, who was under the care of a Community Mental Health Team while his medication was prescribed by his GP, entered the Regent’s Canal on 31 January 2018 with the intention of taking his own life. The report identifies concerns about communication between the CMHT and GP, insufficient local psychiatric beds, discharge from NHS care after seeking private psychiatric treatment, and the lack of an early carer’s assessment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of joint-working arrangements between the NHS and private psychiatric consultants
Wider context from the report “3. That if patients seek private psychiatric care they should not be discharged by the NHS. Instead a memorandum of understanding should be agreed between the NHS and Private psychiatric consultants to allow joint working and facilitate patient care . This should surely be possible along the lines of such agreements with GPs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Discharge of NHS patients seeking private psychiatric care
Wider context from the report “3. That if patients seek private psychiatric care they should not be discharged by the NHS . Instead a memorandum of understanding should be agreed between the NHS and Private psychiatric consultants to allow joint working and facilitate patient care. This should surely be possible along the lines of such agreements with GPs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 carer assessment during the patient treatment pathway
Wider context from the report “4. That carer’s assessment should be undertaken early in the patient treatment pathway .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 doctor-to-doctor communication for prescribing
Wider context from the report “1. That there should be a system of doctor to doctor communication to facilitate prescribing , for example through direct email contact.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 local psychiatric beds
Wider context from the report “2. That there should be sufficient local beds so that such a vulnerable person should not have to be hospitalised so very far from home.
” Open source report
Concerns raised 1 Significant reliance on locum doctors to cover clinical shifts 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
Mr Nathan Mooney · 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 Nathan Mooney died on 23 May 2017 after developing severe abdominal pain and later collapsing at home. He had previously undergone a splenectomy in which an iatrogenic diaphragmatic defect was repaired; a post-mortem examination determined that he died following colonic herniation and perforation associated with a diaphragmatic defect. The principal concern was Tameside General Hospital’s heavy reliance on locum doctors, with potential adverse effects on continuity of care and effective relationships between clinical teams.
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 Significant reliance on locum doctors to cover clinical shifts
Wider context from the report “It is apparent that at the time of Mr Mooney’s care, Tameside General Hospital was heavily reliant on locum doctors to cover shifts .
The court heard evidence of measures which have been taken locally to recruit and retain doctors to substantive posts, however significant reliance on locum doctors remains an issue . The court heard evidence from one of the Trust’s Clinical Directors that this resulted from a lack of suitably skilled doctors in the UK labour market which in turn was compounded by a high attrition rate across a number of specialties whereby doctors do not complete their post graduate speciality training within the NHS (choosing instead, for example, to work overseas).
In addition to the obvious financial consequences of significant locum use for the NHS, the court heard that it can impact adversely upon continuity of care, and militate against development of established and effective relationships between clinical teams.
The Clinical Director expressed the view that the current position would be alleviated to a certain extent by implementation of a system whereby graduates of UK medical schools were (no doubt in consideration for financial or other support during training) tied-in to a specified period of NHS work following graduation. Whilst the Clinical Director was aware of previous discussions within the NHS about such a system, she was not aware of any plans to implement such a system.
It is noted the previous Senior Coroner for this Area, John Pollard, had an exchange of correspondence with the former Under Secretary for Care Quality, Ben Gummer MP, in 2016 in which similar issues were raised.
” Open source report
21 Feb 2019 Terrence Arthur Albert Smith · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 17 Lack of call-handling provision for identifying unrecognised ED/ABD presentations View source Inconsistency between police conveyance policy and officer training View source Conveyance policy restricting timely transport of medical emergencies View source Unavailability of national guidance for out-of-hospital rapid tranquilisation View source Lack of timely escalation of serious ED/ABD safety matters to senior management View source Insufficient coverage of ED/ABD training for front-line response staff View source Contradictory ambulance call-handling instructions View source Training that conflates ED/ABD death risk with positional asphyxia View source Conveyance policy restricting timely transport of medical emergencies View source Failure of the police Mental Health Guide to separately address ED/ABD View source Police training that mischaracterises ED/ABD as controversial View source Omission of patient containment guidance from ED/ABD training View source Failure of ambulance call-triage tools to support recognition and appropriate response to ED/ABD View source Inaccurate monitoring and capture of ED/ABD incidents View source Confusing clinical-staff ED/ABD training content View source Police training that conflates ED/ABD with positional asphyxia View source Failure of call-handling guidance to capture patient restraint status View source See 14 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
Terrence Arthur Albert Smith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Terrence Smith died in hospital on 13 November 2013 after developing amphetamine-induced Excited Delirium/Acute Behavioural Disturbance, being subjected to prolonged restraint, and stopping breathing while being transported to hospital. The principal concerns included failures to recognise the condition as a medical emergency, inadequate assessment and training, excessive restraint, delayed conveyance to hospital, and deficiencies in relevant emergency response, clinical, police and custody policies and training.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of call-handling provision for identifying unrecognised ED/ABD presentations
Wider context from the report “I was told that, whilst waiting for version 17 of NHS Pathways, SECAMB has provided its call handlers with guidance (by way of a “Hot Topic”) that a call from the Police or a Health Care Professional stating that a patient is suffering ED/ABD should be given a category 2 response. I was also told, however, that SECAMB’s call handlers have no discretion when using NHS Pathways which must be followed precisely. I have three concerns about the current situation. First, there appears to be a contradiction between the call handlers being told they have no discretion when using NHS Pathways and their being given additional guidance for certain calls. This contradiction could cause confusion. Secondly, the guidance given in the “Hot Topic” is concerned only with calls from the Police or an HCP in which ED/ABD is identified. Currently, therefore, there is no provision for identifying the condition in calls from the Police or an HCP which do not expressly mention ED/ABD or in calls from the public (meaning the call from Terry’s family would still not be recognised as a call relating to ED/ABD, even today). Thirdly, the “Hot Topic” does not guide the call handlers to ask whether the patient is under restraint. If a patient suffering ED/ABD is under restraint this could add to his risk of sudden death and this information could affect the proper categorisation of the response to the call.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 between police conveyance policy and officer training
Wider context from the report “The Joint Surrey Police, Sussex Police, Kent Police and South East Coast Ambulance Service NHS Foundation Trust Conveyance Policy is currently being re-drafted but I have concerns about the current and draft proposed versions I was shown. Both versions indicate that a patient suffering ED/ABD (or other life threatening conditions) should not be conveyed to hospital by police vehicle under any circumstances or unless a series of 11 conditions are satisfied. Some of the 11 conditions could take some time to satisfy and some are dependent on the presence of SECAMB at the scene (which could be subject to delay). I have two concerns :
(a) I am concerned that the policy could prevent a patient who is suffering a medical emergency being conveyed to hospital as soon as possible, and by police vehicle if necessary, and could result in a fatal delay in the provision of life-saving treatment.
(b) I am concerned that the content of this policy is inconsistent with the training I was told is given to police officers , namely that they may convey a patient to hospital by police vehicle if the use of an ambulance is not an available or practical option , and as long as the conveyance is approved by a senior officer.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Conveyance policy restricting timely transport of medical emergencies
Wider context from the report “The Joint Surrey Police, Sussex Police, Kent Police and South East Coast Ambulance Service NHS Foundation Trust Conveyance Policy is currently being re-drafted but I have concerns about the current and draft proposed versions I was shown. Both versions indicate that a patient suffering ED/ABD (or other life threatening conditions) should not be conveyed to hospital by police vehicle under any circumstances or unless a series of 11 conditions are satisfied. Some of the 11 conditions could take some time to satisfy and some are dependent on the presence of SECAMB at the scene (which could be subject to delay). I am concerned that the policy could prevent a patient who is suffering a medical emergency being conveyed to hospital as soon as possible, and by police vehicle if necessary , and could result in a fatal delay in the provision of life-saving treatment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unavailability of national guidance for out-of-hospital rapid tranquilisation
Wider context from the report “I was told that although the London Ambulance Service has provided out of hospital rapid tranquilisation of patients (such as may well be needed by a patient suffering ED/ABD) for some years, SECAMB will not do so until a national protocol or guidance has been issued by JRCALC . In those circumstances, whilst I understand that work on the production of such guidance is being undertaken, I am nevertheless concerned that none is yet in place .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of timely escalation of serious ED/ABD safety matters to senior management
Wider context from the report “I was told by the Chief Executive Officer of SECAMB that he was not aware of Terry’s death and SECAMB’s involvement in it, nor of the issues arising at the Inquest, until very shortly before being required to give oral evidence at the Regulation 28 hearing. Given the length of the Inquest and the seriousness of the issues arising in relation to SECAMB (including their failure to recognise that Terry was suffering ED/ABD and to ensure he was treated as a medical emergency and taken to an Accident and Emergency Department), I am concerned that there is no system in place to ensure that such matters are drawn to the attention of the most senior management in a timely manner so as to ensure there is strategic planning for the prevention of other 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 Insufficient coverage of ED/ABD training for front-line response staff
Wider context from the report “I was told that in 2016/17 SECAMB sought to address the absence of training of its clinical staff by providing some “key skills” training in relation to the condition of ED/ABD and its management, but that it was only in 2018 that it introduced a specific training package on the condition. I have two concerns about this training package. First, its content is potentially confusing in that (a) it refers to the condition of ED/ABD as “controversial” (when it is not) and (b) it links ED/ABD to patients detained under section 136 of the Mental Health Act (which a patient suffering ED/ABD will not necessarily be). Secondly, to date the training has been given to only about 150 out of about 650 front-line response staff (and out of a much higher number of all employees who should be trained). I was told that there are plans to create an e-learning package to aid faster delivery, but this has not yet been created .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Contradictory ambulance call-handling instructions
Wider context from the report “I was told that, whilst waiting for version 17 of NHS Pathways, SECAMB has provided its call handlers with guidance (by way of a “Hot Topic”) that a call from the Police or a Health Care Professional stating that a patient is suffering ED/ABD should be given a category 2 response. I was also told, however, that SECAMB’s call handlers have no discretion when using NHS Pathways which must be followed precisely. I have three concerns about the current situation. First, there appears to be a contradiction between the call handlers being told they have no discretion when using NHS Pathways and their being given additional guidance for certain calls. This contradiction could cause confusion. Secondly, the guidance given in the “Hot Topic” is concerned only with calls from the Police or an HCP in which ED/ABD is identified. Currently, therefore, there is no provision for identifying the condition in calls from the Police or an HCP which do not expressly mention ED/ABD or in calls from the public (meaning the call from Terry’s family would still not be recognised as a call relating to ED/ABD, even today). Thirdly, the “Hot Topic” does not guide the call handlers to ask whether the patient is under restraint. If a patient suffering ED/ABD is under restraint this could add to his risk of sudden death and this information could affect the proper categorisation of the response to the call.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Training that conflates ED/ABD death risk with positional asphyxia
Wider context from the report “I am concerned about the following within the training materials :
(a) Under the heading “What causes Death in Excited Delirium ?” there follows a series of six slides dealing with positional asphyxia when a patient has been “hogtied”. A later slide, headed “Hypoxia The last nail in the coffin?”, suggests that hypoxia is an element in what causes death from ED/ABD. In fact, the evidence provided to me at the Inquest established that ED/ABD and positional asphyxia are two entirely separate and quite different conditions. Death from ED/ABD can result even though there is no asphyxiation or hypoxia. Whilst many patients suffering ED/ABD in a custodial setting may well be under restraint (although they will not necessarily be), it is of real importance that FMEs (and all involved) understand that there is a risk of sudden death from ED/ABD whatever the patient’s position, whether or not there is restraint, and whether or not there is hypoxia. The evidence I heard showed that it is vital that it is understood that the risk of death from ED/ABD comes from the condition itself, which can be exacerbated by restraint and resistance against the restraint, no matter what the sufferer’s position. On the basis of the current training material, students may be misled in to thinking that a patient is not at risk of death as long as the position in which he is being restrained is not causing him asphyxiation (which was the thinking of the officers restraining Terry), and that they will fail to understand that there is a risk of death from ED/ABD whatever the sufferer’s position under restraint and even if he is not being restrained at all .
(b) The material suggests that FMEs should encourage the use of minimal force and minimal restraint and the use of de-escalation techniques, but it makes no reference to encouraging the containment rather than restraint of 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 Conveyance policy restricting timely transport of medical emergencies
Wider context from the report “The Joint Surrey Police, Sussex Police, Kent Police and South East Coast Ambulance Service NHS Foundation Trust Conveyance Policy is currently being re-drafted but I have concerns about the current and draft proposed versions I was shown. Both versions indicate that a patient suffering ED/ABD (or other life threatening conditions) should not be conveyed to hospital by police vehicle under any circumstances or unless a series of 11 conditions are satisfied. Some of the 11 conditions could take some time to satisfy and some are dependent on the presence of SECAMB at the scene (which could be subject to delay). I have two concerns :
(a) I am concerned that the policy could prevent a patient who is suffering a medical emergency being conveyed to hospital as soon as possible, and by police vehicle if necessary , and could result in a fatal delay in the provision of life-saving treatment .
(b) I am concerned that the content of this policy is inconsistent with the training I was told is given to police officers, namely that they may convey a patient to hospital by police vehicle if the use of an ambulance is not an available or practical option, and as long as the conveyance is approved by a senior officer.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 police Mental Health Guide to separately address ED/ABD
Wider context from the report “Surrey Police’s Mental Health Guide addresses ED/ABD only in bullet point form alongside reference to Positional Asphyxia . The conditions are separate and different and the absence of a separate sheet addressing ED/ABD alone could mislead those reading the Guide in to thinking that the conditions are necessarily connected .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Police training that mischaracterises ED/ABD as controversial
Wider context from the report “It is clear that Surrey Police now ensure that all officers and staff receive training in relation to ED/ABD and its management, including the fact that it is a medical emergency. I was provided with a copy of the current training material and told that it was, to a very large extent, reflective the material provided by The College of Policing’s National Curriculum, Module 5. I have two concerns :
(a) I am concerned that the material includes reference to ED/ABD being “controversial” when this is not the case. A number of the officers who restrained Terry stated in evidence that they believed the condition was “controversial”. The inclusion of this reference continues the risk that trainees are misled into doubting the existence of ED/ABD and this may result in their failing to recognise or accept a presentation of ED/ABD .
(b) I am concerned that, within the training material, the guidance in relation to ED/ABD is closely linked to the guidance in relation to positional asphyxia. The evidence provided to me at the Inquest established that ED/ABD and positional asphyxia are two entirely separate and quite different conditions. Death from ED/ABD can result even though there is no asphyxia. Whilst many of those suffering ED/ABD may be under restraint (although they will not necessarily be) it is of real importance that police officers and staff understand that there is a risk of sudden death from ED/ABD whatever the sufferer’s position and whether or not he is under restraint. It is vital that it is understood that the risk of death from ED/ABD comes from the condition itself, which can be exacerbated by restraint and resistance against the restraint. On the basis of the current training material, there is a risk that students may be misled in to thinking that there is no risk of death as long as there is no positional asphyxiation (which was the thinking of the officers restraining Terry).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Omission of patient containment guidance from ED/ABD training
Wider context from the report “I am concerned about the following within the training materials :
(a) Under the heading “What causes Death in Excited Delirium ?” there follows a series of six slides dealing with positional asphyxia when a patient has been “hogtied”. A later slide, headed “Hypoxia The last nail in the coffin?”, suggests that hypoxia is an element in what causes death from ED/ABD. In fact, the evidence provided to me at the Inquest established that ED/ABD and positional asphyxia are two entirely separate and quite different conditions. Death from ED/ABD can result even though there is no asphyxiation or hypoxia. Whilst many patients suffering ED/ABD in a custodial setting may well be under restraint (although they will not necessarily be), it is of real importance that FMEs (and all involved) understand that there is a risk of sudden death from ED/ABD whatever the patient’s position, whether or not there is restraint, and whether or not there is hypoxia. The evidence I heard showed that it is vital that it is understood that the risk of death from ED/ABD comes from the condition itself, which can be exacerbated by restraint and resistance against the restraint, no matter what the sufferer’s position. On the basis of the current training material, students may be misled in to thinking that a patient is not at risk of death as long as the position in which he is being restrained is not causing him asphyxiation (which was the thinking of the officers restraining Terry), and that they will fail to understand that there is a risk of death from ED/ABD whatever the sufferer’s position under restraint and even if he is not being restrained at all.
(b) The material suggests that FMEs should encourage the use of minimal force and minimal restraint and the use of de-escalation techniques, but it makes no reference to encouraging the containment rather than restraint of 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 of ambulance call-triage tools to support recognition and appropriate response to ED/ABD
Wider context from the report “The version of NHS Pathways currently in use is version 16 which does not enable operators to recognise potential ED / ABD and respond accordingly . I was told that it is intended that version 17 will do so but this is not yet in use. My concern is that, unless and until it is in use, there will continue to be a failure by call handlers to recognise ED/ABD and respond appropriately .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 monitoring and capture of ED/ABD incidents
Wider context from the report “I am concerned that SECAMB is not currently monitoring accurately the incidence of cases of ED/ABD in the regions it covers. A witness told me that she believed there were very few incidents (under ten a year) and that they were all apparent from the data gathered. On the basis of the evidence heard at the Inquest it seems unlikely that there are very few incidents given that SECAMB cover three large counties with a total population of over 4 million people and given the much higher incidence in other areas. Further, there were at least two incidents of ED/ABD (from 2018 and 2019) referred to in evidence which had not been captured at all by SECAMB’s data gathering.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Confusing clinical-staff ED/ABD training content
Wider context from the report “I was told that in 2016/17 SECAMB sought to address the absence of training of its clinical staff by providing some “key skills” training in relation to the condition of ED/ABD and its management, but that it was only in 2018 that it introduced a specific training package on the condition. I have two concerns about this training package. First, its content is potentially confusing in that (a) it refers to the condition of ED/ABD as “controversial” (when it is not) and (b) it links ED/ABD to patients detained under section 136 of the Mental Health Act (which a patient suffering ED/ABD will not necessarily be) . Secondly, to date the training has been given to only about 150 out of about 650 front-line response staff (and out of a much higher number of all employees who should be trained). I was told that there are plans to create an e-learning package to aid faster delivery, but this has not yet been created.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Police training that conflates ED/ABD with positional asphyxia
Wider context from the report “It is clear that Surrey Police now ensure that all officers and staff receive training in relation to ED/ABD and its management, including the fact that it is a medical emergency. I was provided with a copy of the current training material and told that it was, to a very large extent, reflective the material provided by The College of Policing’s National Curriculum, Module 5. I have two concerns :
(a) I am concerned that the material includes reference to ED/ABD being “controversial” when this is not the case. A number of the officers who restrained Terry stated in evidence that they believed the condition was “controversial”. The inclusion of this reference continues the risk that trainees are misled into doubting the existence of ED/ABD and this may result in their failing to recognise or accept a presentation of ED/ABD.
(b) I am concerned that, within the training material, the guidance in relation to ED/ABD is closely linked to the guidance in relation to positional asphyxia . The evidence provided to me at the Inquest established that ED/ABD and positional asphyxia are two entirely separate and quite different conditions. Death from ED/ABD can result even though there is no asphyxia. Whilst many of those suffering ED/ABD may be under restraint (although they will not necessarily be) it is of real importance that police officers and staff understand that there is a risk of sudden death from ED/ABD whatever the sufferer’s position and whether or not he is under restraint. It is vital that it is understood that the risk of death from ED/ABD comes from the condition itself, which can be exacerbated by restraint and resistance against the restraint. On the basis of the current training material, there is a risk that students may be misled in to thinking that there is no risk of death as long as there is no positional asphyxiation (which was the thinking of the officers restraining Terry).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 call-handling guidance to capture patient restraint status
Wider context from the report “I was told that, whilst waiting for version 17 of NHS Pathways, SECAMB has provided its call handlers with guidance (by way of a “Hot Topic”) that a call from the Police or a Health Care Professional stating that a patient is suffering ED/ABD should be given a category 2 response. I was also told, however, that SECAMB’s call handlers have no discretion when using NHS Pathways which must be followed precisely. I have three concerns about the current situation. First, there appears to be a contradiction between the call handlers being told they have no discretion when using NHS Pathways and their being given additional guidance for certain calls. This contradiction could cause confusion. Secondly, the guidance given in the “Hot Topic” is concerned only with calls from the Police or an HCP in which ED/ABD is identified. Currently, therefore, there is no provision for identifying the condition in calls from the Police or an HCP which do not expressly mention ED/ABD or in calls from the public (meaning the call from Terry’s family would still not be recognised as a call relating to ED/ABD, even today). Thirdly, the “Hot Topic” does not guide the call handlers to ask whether the patient is under restraint . If a patient suffering ED/ABD is under restraint this could add to his risk of sudden death and this information could affect the proper categorisation of the response to the call .
” Open source report
12 Feb 2019 Anthony John William Watson · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Unavailability of suitably proximate out-of-area inpatient mental health beds View source Insufficient numbers of inpatient mental health beds in Birmingham and Solihull 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
Anthony John William Watson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Anthony John William Watson, who had recurrent depression and anxiety and was displaying psychosis and suicidal thoughts, died after cutting his wrists and neck and jumping from a first-floor window on 21 October 2018. He sustained an unsurvivable head injury and died in hospital the following day. The principal concern was that no inpatient mental health bed was available locally despite the need for immediate admission, while out-of-area beds were considered too distant, particularly for older patients and their families.
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 suitably proximate out-of-area inpatient mental health beds
Wider context from the report “1. Mr Watson was aged 72. The Community Mental Health Team advised on 18/10/18 that he required an immediate admission for inpatient mental health treatment for his own safety. However, this could not happen as no bed was available within the area. Three days later there was still no bed available. Mr Watson was not offered a bed out-of-area.
2. This report has similar themes to the 7 reports issued by the Birmingham and Solihull Coroners on 4/10/18.
3. However, the impact of Mr Watson’s age is a new issue.
4. I heard evidence that:
a. Younger and older adults will not normally be admitted as inpatients on mixed units. Beds on young adult units may have been available on 18-22 October 2018 but these were not considered.
b. Beds in neighbouring areas are unavailable because of contractual issues. The closest out of area option is at least 70 miles away. Although Mr Watson was not offered an out of area bed, his wife was confident that had one been offered he would have declined because 70 miles was so far away. Whilst this distance is likely to deter a patient of any age from accepting the offer, it is particularly problematic for elderly patients and their families.
c. Whilst remedial action is underway in response to the concerns raised in the 7 reports issued on 4/10/18, currently it still remains the position that at least one patient every day in Birmingham and Solihull is advised they require an immediate admission for inpatient mental health treatment but no bed is available within the area.
5. The lack of inpatient beds is a resource issue. My ongoing concerns are that (a) there are insufficient numbers of beds in Birmingham and Solihull, and (b) out-of-area beds are too far 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 Insufficient numbers of inpatient mental health beds in Birmingham and Solihull
Wider context from the report “1. Mr Watson was aged 72. The Community Mental Health Team advised on 18/10/18 that he required an immediate admission for inpatient mental health treatment for his own safety. However, this could not happen as no bed was available within the area . Three days later there was still no bed available . Mr Watson was not offered a bed out-of-area.
2. This report has similar themes to the 7 reports issued by the Birmingham and Solihull Coroners on 4/10/18.
3. However, the impact of Mr Watson’s age is a new issue.
4. I heard evidence that:
a. Younger and older adults will not normally be admitted as inpatients on mixed units. Beds on young adult units may have been available on 18-22 October 2018 but these were not considered.
b. Beds in neighbouring areas are unavailable because of contractual issues. The closest out of area option is at least 70 miles away. Although Mr Watson was not offered an out of area bed, his wife was confident that had one been offered he would have declined because 70 miles was so far away. Whilst this distance is likely to deter a patient of any age from accepting the offer, it is particularly problematic for elderly patients and their families.
c. Whilst remedial action is underway in response to the concerns raised in the 7 reports issued on 4/10/18, currently it still remains the position that at least one patient every day in Birmingham and Solihull is advised they require an immediate admission for inpatient mental health treatment but no bed is available within the area .
5. The lack of inpatient beds is a resource issue. My ongoing concerns are that (a) there are insufficient numbers of beds in Birmingham and Solihull , and (b) out-of-area beds are too far away.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide clinically led support, including local workshops, to help systems safely and sustainably reduce out-of-area placements.
Verbatim wording from the response “The reduction of out of area placements (OAPs) is a high priority both nationally and locally and I can confirm as part of the 2019/20 NHS Operational Planning and Contracting Guidance all Sustainability and Transformation Partnerships (STPs) are reviewing their plans and trajectories for reducing these placements. Over the last year we have been working jointly with NHS Improvement to provide a clinically-led support offer to assist areas in their work to reduce OAPs. This has involved local workshops run by clinical experts with the necessary experience of leading complex system change, which is required to enable the safe and sustainable reduction of OAPs. Birmingham and Solihull STP are engaged with this support offer and participated in a bespoke clinically-led workshop in March 2019.” Source location 2019-0044-Response-by-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 Eliminate out-of-area placements for non-specialist acute inpatient care caused by local bed pressures by 2021.
Verbatim wording from the response “In recognition of the importance of continuity of care and the proximity to existing support networks, NHS England has committed to eliminating the practice of sending people out of area for non-specialist acute inpatient care due to local bed pressures by 2021. This applies to older adult beds, as well as general adult and psychiatric intensive care units (PICUs) and is underpinned by the expectation that there is always local capacity to meet the needs of individuals requiring this type of support.” Source location 2019-0044-Response-by-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 Bed availability is not simply determined by the number of locally commissioned beds, but largely by whole-system pathway management and community-service investment.
Verbatim wording from the response “I can confirm that evidence from those areas which maintain local bed availability suggests that this is not simply down to the number of locally commissioned beds, but largely related to the effective management of the whole system pathway and investment in local services, in particular community alternatives. As such, I also wanted to reassure you about the specific steps we are taking to improve access to, and quality of, crisis and community mental health care as part of the NHS Long Term Plan, which includes a specific focus on provision for older adults:” Source location 2019-0044-Response-by-NHS-England
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations