1 Apr 2026 Colin Foley · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 1 Life-threatening complications associated with intravenous access devices View source
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AI-generated summary
Colin Foley · 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
Colin Foley, aged 84, was admitted with decompensated cardiac failure and treated with intravenous frusemide. After an intravenous cannula became painful, failed and was removed, it became infected, leading to cellulitis, sepsis, multiorgan failure and his death. The concerns relate to meticulous insertion, maintenance and documentation of intravenous access devices, and awareness of potentially life-threatening complications.
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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 Life-threatening complications associated with intravenous access devices
Wider context from the report “Evidence was heard at inquest that the insertion of intravenous access devices are frequently performed procedures in clinical practice which require meticulous attention to detail, not only in their insertion and maintenance, but also in the documentation surrounding them, as well as awareness of associated complications, some of which may be life threatening, that may occur . Whilst the Hull University Teaching Hospitals have instituted on-going training which will continue in perpetuity, I believe that the NHS at large should be aware of issues that relate to these commonly performed procedures.
” Open source report
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PFD Monitor interpretation Support NHS organisations to embed vascular-access safety principles and audit compliance to reduce avoidable harm.
Verbatim wording from the response “The concerns raised in Mr Foley’s case reinforce the importance of a continued national focus on vascular access safety, including education, training, and the consistent application of existing guidance. Work will continue across the NHS to support organisations in embedding these principles and auditing compliance to reduce avoidable harm associated with these commonly performed procedures.” Source location Response from NHS England
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PFD Monitor interpretation Existing national guidance, infection prevention standards and training resources already address vascular-access safety across the NHS.
Verbatim wording from the response “At a national level, established guidance already supports safe and standardised practice. The UK Vessel Health and Preservation (VHP) Framework (2020) promotes a proactive, evidence-based approach to vascular access. This includes early assessment of patients, appropriate device selection using the “Right Line” approach, daily review of device necessity, and prompt recognition and management of complications. The Framework also emphasises consideration of alternative routes of treatment where clinically appropriate.” Source location Response from NHS England
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30 Mar 2026 Ethan Michael Hanson · Prevention of Future Deaths report Warwickshire
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Concerns raised 8 Lack of practical mechanisms for communicating with neurodivergent parents View source Failure of the paediatric abdominal pain pathway to align with GIRFT structure and escalation principles View source Lack of structured local support for interpreting neurodivergent parental communication View source Lack of practical mechanisms for adapting assessment of neurodivergent children View source Lack of structured local prompts for recognising neurodivergent symptom expression View source Failure to carry critical GP information into hospital assessment View source Lack of GP awareness of referral-route implications for local hospital triage and assessment View source Absence of computerised safeguards for complete and accurate observations before pathway selection or discharge View source See 5 more concerns
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Ethan Michael Hanson · Prevention of Future Deaths report
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Report summary
Ethan was assessed by his GP and then at hospital for abdominal pain, vomiting and concern about appendicitis, but was discharged without senior review after abnormal observations and the GP’s concerns were not transferred to the hospital assessment. He later collapsed, suffered cardiac arrest, and died after imaging confirmed perforated appendicitis, peritonitis and sepsis. The principal concerns include inaccurate or incomplete observations and pain assessment, pathway and escalation arrangements that did not align with guidance, inadequate support for assessing neurodivergent children and parents, and loss of critical information during transfer from primary to hospital care.
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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 Lack of practical mechanisms for communicating with neurodivergent parents
Wider context from the report “GIRFT guidance lacks practical mechanisms for assessing neurodivergent children and parents
The GIRFT guidance recognises that neurodivergent children may be more difficult to assess or diagnose, but it does not provide practical mechanisms for clinicians to adapt history-taking, pain assessment or communication. The guidance does not consider the risk that a neurodivergent parent may struggle to convey concern, may appear reassured when they are frightened, or may find questions and instructions confusing or intimidating. The absence of such mechanisms risks misunderstanding children’s symptoms and misinterpreting parental reassurance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 paediatric abdominal pain pathway to align with GIRFT structure and escalation principles
Wider context from the report “Pathway design not fully aligned with national GIRFT guidance
The Trust is developing a triage model for paediatric abdominal pain. Evidence heard at inquest showed that the pathway options do not mirror the structure or escalation principles contained in the national GIRFT guidance for paediatric abdominal pain and appendicitis. This carries a risk that children with time-critical surgical conditions may not be escalated promptly or placed on an appropriate 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 structured local support for interpreting neurodivergent parental communication
Wider context from the report “Local processes provide no structured support for neurodivergent children or parents
Local assessment processes do not contain structured prompts or guidance for recognising how neurodivergence may affect symptom expression or parental communication. Without a structured approach there is a risk that important clinical information will not be elicited or understood, and that apparent agreement with a discharge plan may be misinterpreted.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 practical mechanisms for adapting assessment of neurodivergent children
Wider context from the report “GIRFT guidance lacks practical mechanisms for assessing neurodivergent children and parents
The GIRFT guidance recognises that neurodivergent children may be more difficult to assess or diagnose, but it does not provide practical mechanisms for clinicians to adapt history-taking, pain assessment or communication. The guidance does not consider the risk that a neurodivergent parent may struggle to convey concern, may appear reassured when they are frightened, or may find questions and instructions confusing or intimidating. The absence of such mechanisms risks misunderstanding children’s symptoms and misinterpreting parental reassurance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 structured local prompts for recognising neurodivergent symptom expression
Wider context from the report “Local processes provide no structured support for neurodivergent children or parents
Local assessment processes do not contain structured prompts or guidance for recognising how neurodivergence may affect symptom expression or parental communication. Without a structured approach there is a risk that important clinical information will not be elicited or understood , and that apparent agreement with a discharge plan may be misinterpreted.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 critical GP information into hospital assessment
Wider context from the report “Critical GP information not carried forward into the hospital assessment
The GP identified the possibility of appendicitis or another serious underlying cause and recorded abnormal observations. The absence of an ambulance conveyance or written referral letter meant this information was not transferred to the hospital. As a result, Ethan entered a different clinical pathway, and the assessing clinician was unaware of the GP’s concerns. There is a wider risk that GPs may not be aware of the implications of referral route on triage and assessment in local hospitals, and that critical deterioration indicators can be lost at the point of transfer.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of GP awareness of referral-route implications for local hospital triage and assessment
Wider context from the report “Critical GP information not carried forward into the hospital assessment
The GP identified the possibility of appendicitis or another serious underlying cause and recorded abnormal observations. The absence of an ambulance conveyance or written referral letter meant this information was not transferred to the hospital. As a result, Ethan entered a different clinical pathway, and the assessing clinician was unaware of the GP’s concerns. There is a wider risk that GPs may not be aware of the implications of referral route on triage and assessment in local hospitals , and that critical deterioration indicators can be lost at the point of transfer.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Absence of computerised safeguards for complete and accurate observations before pathway selection or discharge
Wider context from the report “Absence of computerised mandatory-field safeguards
There is no electronic system with mandatory fields or hard-stops to prevent incorrect or incomplete recording of observations or pain scores. A transposition error between oxygen saturation and temperature occurred. The absence of automated safeguards requiring complete and accurate observations before pathway selection or discharge creates a risk that clinically significant information may be overlooked. Although there is an intention to develop such a system, it is not currently in place.
” Open source report
23 Mar 2026 Peter COATES · Prevention of Future Deaths report Teesside and Hartlepool
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Concerns raised 1 Lack of an immediate-response category for patients who require urgent ambulance attendance but do not meet Category 1 criteria View source
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Peter COATES · Prevention of Future Deaths report
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Report summary
Peter Coates, who had very severe COPD and relied on mains-powered respiratory equipment, died at home after an unplanned electrical power failure stopped that equipment. The report identifies delays in ambulance attendance and a concern that the ambulance response categories have a gap for patients who are not in cardiac or respiratory arrest but require an immediate response, particularly when alone and unable to update the ambulance service.
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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 Lack of an immediate-response category for patients who require urgent ambulance attendance but do not meet Category 1 criteria
Wider context from the report “In respect of the National Ambulance Response Programme, I understand from the evidence that:
- Category 1 is an immediate response to a life-threatening condition. It should only be used for a patient who requires resuscitation or emergency intervention from the ambulance service, for example, a patient who is in cardiac or respiratory arrest. Mortality rates are high where a difference of one minute in response time is likely to affect outcome and there is evidence to support the fastest response. The national standard is for 90% of Category 1 patients to have received a response within 15 minutes; and for the overall average response time to be within 7 minutes.
- Category 2 is for serious conditions, for example stroke or chest pain, that may require rapid assessment and/or urgent transport. Mortality rates are lower; a difference of an extra 15 minutes’ response time is unlikely to affect outcome and there is evidence to support an early dispatch. The national standard is for 90% of patients to have received a response within 40 minutes; and for the overall average response time to be within 18 minutes.
My concern is that there are circumstances in which a patient is not, at the time a 999 call is made to request an Ambulance, in a condition such as cardiac or respiratory arrest; but where an immediate response is still required on the basis that delay in ambulance attendance could pose a risk to their life . That is, I am concerned that there is a category of patients who do not meet the criteria for a category 1 response, but who do nonetheless require an immediate response, and that there is, therefore, a “gap” between categories 1 and 2 . This includes for patients who are alone at the time of calling 999 and who are therefore unable to update the Ambulance Service should they progress to cardiac or respiratory arrest.
” 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 ambulance response standards to prioritise the sickest patients and provide appropriate responses.
Verbatim wording from the response “In 2017, following the largest clinical ambulance trials in the world, NHS England implemented new ambulance standards across the country. This was to ensure that the sickest patients get the fastest response and that all patients get the right response first time.” Source location Response from NHSE
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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 Whether call handlers stay on the line with deteriorating patients is an operational decision for each ambulance service.
Verbatim wording from the response “In cases where there is risk of a patient’s condition deteriorating whilst waiting for an ambulance to arrive, the call handler could stay on the line with the patient; this is an operational decision to be made by each ambulance service. Moreover, the provision of instructions or actions to be taken in the case of worsening patients is a standard component of call exit scripts, whereby patients are advised that if their condition worsens, they should call 999 back. This provides an opportunity for a call to be re-triaged and potentially upgraded to a higher category response if this is clinically indicated.” Source location Response from NHSE
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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 Development of 999 triage question sets and instructions is assigned to the approved triage system provider.
Verbatim wording from the response “The primary purpose of triage is to quickly identify priority symptoms (e.g. unconsciousness, difficulty breathing, chest pain) and to assign an appropriate response priority. The outcome (disposition) reached based on the information provided by the caller is mapped to one of the five national categories (Categories 1 – 5) set out within the NHS Constitution and Ambulance Service 999 contracts. The development of triage question sets and instructions lies within the remit of the triage system provider.” Source location Response from NHSE
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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 Existing Category 1 and 2 ambulance categorisations are sufficient for effective triage and timely intervention for life-threatening and emergency conditions.
Verbatim wording from the response “The current ambulance categorisations ensure that all emergency responses are prioritised appropriately; Category 1 covers the most urgent, life-threatening cases, while Category 2 addresses emergency but less critical incidents. These two categories are sufficient for effective triage and timely intervention for life threatening and emergency conditions.” Source location Response from NHSE
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16 Mar 2026 JARDINE WILLIAMS · Prevention of Future Deaths report Cumbria
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Concerns raised 1 Absence of pathway questions addressing the immediacy of a stated suicide plan View source
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AI-generated summary
JARDINE WILLIAMS · 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
Jardine Williams, a mental health nurse experiencing worsening mental ill health, made a 999 call on 24 March 2025 stating that she had suicidal thoughts, a plan and an intention to carry it out. An ambulance arrived later that evening and found that she had died as a result of a deliberate act; the cause of death was recorded as hanging. The principal concern was that the emergency call pathway did not ask about the immediacy of the stated plan, which may have limited the clarity of the information available to the call handler.
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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 Absence of pathway questions addressing the immediacy of a stated suicide plan
Wider context from the report “As outlined above, I heard evidence that Miss Williams had made a 999 call which had been answered the Northwest Ambulance Service who, in taking information from Miss Williams, followed the pathway questions prescribed by NHS England.
In the 999 call, Miss Williams had stated that she had a plan to take her own life, and an intent to do so. I was informed that there was no question in the pathway that sought to address the immediacy of that plan that was being stated . I noted that the absence of this information, and an absence of this question from the pathway , may not have assisted the call handler in compiling as clear a picture as possible about the case they were receiving .
” Open source report
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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 Review NWAS operational practice for overdose and suicidal-ideation incidents against national guidance.
Verbatim wording from the response “NHS England’s Emergency Call Prioritisation Advisory Group (ECPAG) wrote to all ambulance trusts asking them to confirm compliance with all aspects of the NHS England guidance on ‘999 overdose and suicidal ideation calls’. NWAS confirmed that appropriate measures were in place as per NHS England guidance. To ensure this remains the case, NHS England will review NWAS’ current operational practise in relation to overdose and suicidal ideation incidents to ensure alignment with national guidance.” 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 Issue and update guidance to ambulance services on overdose and suicidal-ideation calls, including clinical review requirements.
Verbatim wording from the response “In April 2021, NHS England issued guidance to ambulance services relating to overdoses taken with suicidal intent. This was further updated in November 2023 to include callers who reach a Category 5 disposition (hear and treat). The guidance highlights the critical importance of clinical oversight and review and sets out that:” 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 The NHS Pathways system includes an immediacy question and, in this case, elicited information triggering the correct approved ambulance response.
Verbatim wording from the response “In this particular case, it appears from your report that the NHS Pathways triage system did elicit the correct information from the patient which triggered the correct nationally approved ambulance response.” 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 No further NHS Pathways system change is currently planned because substantial national changes, discussions and mandates have already addressed suicide-risk management.
Verbatim wording from the response “significant consideration nationally of the management of callers at risk of suicide in recent years, and the fact that this has resulted in system changes, national discussions and mandates, NHS England is not considering a further system change to NHS Pathways at this time, but (as with all clinical content). This will remain under review as and when new evidence or guidance emerges.” Source location Response from NHS England
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4 Mar 2026 Roman Louie BARR · Prevention of Future Deaths report Coventry
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Concerns raised 6 Risk to critically unwell patients and families when families transport patients to hospital during time-critical emergencies View source Delays in ambulance handover reducing emergency ambulance availability View source Failure to reliably identify excessive or repeated requests for salbutamol inhalers View source Lack of a consistent follow-up process for salbutamol overuse patterns View source Limited awareness of the significance of salbutamol overuse in patients and families View source Failure of NHS Pathways triage wording to be readily understood by callers in distress View source See 3 more concerns
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AI-generated summary
Roman Louie BARR · 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
Roman Louie Barr suffered an asthma attack on 14 December 2023 and died after no ambulance was available for several hours, leading his family to transport him to hospital. The principal concerns were limited awareness and follow-up of excessive salbutamol use, ambulance handover delays affecting emergency availability, risks to families transporting critically unwell patients, and unclear NHS Pathways triage wording.
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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 Risk to critically unwell patients and families when families transport patients to hospital during time-critical emergencies
Wider context from the report “4. Risks when families transport critically unwell patients
The absence of an available ambulance for several hours resulted in the family transporting Roman to hospital themselves, exposing both him and his family to significant risk during a time-critical medical emergency .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance handover reducing emergency ambulance availability
Wider context from the report “3. Ambulance handover delays affecting emergency availability
Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought , reducing emergency response capacity during periods of high demand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 reliably identify excessive or repeated requests for salbutamol inhalers
Wider context from the report “2. Identification and follow-up of reliever overuse
Evidence showed that excessive or repeated requests for salbutamol inhalers may not be reliably identified within existing systems , and there may be no consistent process for follow-up when such patterns occur, meaning deteriorating asthma may go unrecognised.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 consistent follow-up process for salbutamol overuse patterns
Wider context from the report “2. Identification and follow-up of reliever overuse
Evidence showed that excessive or repeated requests for salbutamol inhalers may not be reliably identified within existing systems, and there may be no consistent process for follow-up when such patterns occur , meaning deteriorating asthma may go unrecognised.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 awareness of the significance of salbutamol overuse in patients and families
Wider context from the report “1. Limited awareness of salbutamol overuse
Evidence showed that patients and families may not appreciate the clinical significance of increased use of the blue (salbutamol) inhaler or its association with poorly controlled asthma .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of NHS Pathways triage wording to be readily understood by callers in distress
Wider context from the report “5. Clarity of NHS Pathways triage wording
Evidence showed that a key NHS Pathways question used during triage was not understood by the caller and did not elicit clinically significant information . This raises a concern that, given the reliance on scripted triage systems, such scripts may not always use wording that is easily understood by lay callers in distress .
” Open source report
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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 Implement the Release to Rescue programme and work with regional partners to reduce ambulance handover delays to a 45-minute maximum.
Verbatim wording from the response “To ensure timely patient care and release of ambulances back into the community, the 2025/26 Urgent and Emergency Care Plan mandates the “Release to Rescue” approach. The “Release to Rescue” approach will be triggered once a handover reaches 30 minutes and means that all ambulances must complete their handover and leave the hospital site at 45 minutes. NHS England continues to work with ICBs, acute trusts, and ambulance services to deliver the 45-minute maximum handover requirement, strengthen urgent community care, and improve hospital flow and discharge. Risks associated with long community waits for ambulances are regularly discussed at national forums to support shared understanding and coordinated action across the urgent and emergency care system.” 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 Publish urgent and emergency care and long-term health plans prioritising shorter ambulance responses, reduced handover delays, improved flow and expanded urgent-care access.
Verbatim wording from the response “NHS England recognises the ongoing pressures across urgent and emergency care, including ambulance services. To improve the quality and timeliness of patient care, the Department of Health and Social Care and NHS England published the 2025/26 Urgent and Emergency Care Plan (June 2025) and the 10-Year Health Plan for England: Fit for the Future (July 2025). These plans set out key system priorities: reducing ambulance response times, eliminating handover delays over 45 minutes, ending corridor care, improving hospital flow and discharge and expanding urgent care access across primary, community, and mental health settings. Over £370 million in national capital funding supports these improvements. The plans also commit to shifting focus from treatment to prevention, reducing pressure on urgent and emergency care.” 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 Update NHS Pathways wording and supporting information to improve recognition of clinical shock across different skin tones.
Verbatim wording from the response “The question of concern “is the patient a deathly colour”, is the question used to identify symptoms of clinical shock within the CDSS. It has been been utilised in triage prior to 2005. Questions within the system often have supporting information that helps the health advisor probe when necessary, as this one does. All supporting information utilises common style and design but, as with all content, can be subject to iterative review based upon feedback from providers. For example, if a provider identifies a question that health advisors are finding difficult to answer then they can raise this as a clinical enquiry to NHS Pathways for review.” 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 Advance risk-based asthma identification and consistent adoption through the Respiratory Transformation Partnership.
Verbatim wording from the response “High or early repeat SABA prescribing is recognised nationally as a marker of risk and sub-optimal disease control, rather than an issue that can be addressed through prescribing controls alone. NHS England’s approach focuses on using prescribing data to support risk-based clinical review and pathway-level action, recognising that meaningful improvement requires coordinated clinical responses rather than isolated system interventions.” 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 Add and maintain mandatory training on recognising skin-colour changes and using probing questions for patients with different skin colours.
Verbatim wording from the response “In September 2021, a unit was added to NHS Pathways Core Module 1 mandatory training materials to give health advisors and clinicians more detailed guidance on identifying skin colour changes in patients with different skin colours. This training includes guidance on how to use the existing supporting information to form probing questions to help the caller understand what is being asked, and where on the body to best check for any change in skin colour. The module includes an interactive PowerPoint session explaining the challenges faced by those of non-white skin colours, as well as practice case studies and scenarios to help put this information into practice. It has formed a part of NHS Pathways Core Module 1 training since it’s initial inclusion in 2021.” 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 Clinicians, not non-clinical call handlers, are responsible for deciding whether higher-category patients may travel to hospital independently.
Verbatim wording from the response “For higher-category patients, the arrangement of an ambulance remains the standard response and priority. Only in exceptional circumstances, after a remote clinical assessment has been completed, which determines that it is clinically appropriate, and that a timely resource is not available, may a clinician advise a higher-category patient to make their own way to hospital. This decision must be recorded on the electronic patient record. Clinicians should use Service Finder (directory of services) to identify the most appropriate service and communicate this to the patient. Non-clinical call handlers must not make this decision, although they may record when a caller chooses to make their own way to hospital.” Source location Response from NHS England
Open published response
4 Mar 2026 Roman Louie BARR · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 6 Limited awareness of salbutamol overuse and its association with poorly controlled asthma View source Delays in ambulance handover at local hospitals View source Failure to reliably identify excessive or repeated requests for salbutamol inhalers View source Failure of NHS Pathways triage wording to be readily understood by callers in distress View source Risk to critically unwell patients and families when no ambulance is available and families transport patients themselves View source Lack of a consistent follow-up process for salbutamol overuse patterns View source See 3 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
Roman Louie BARR · 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
Roman Louie Barr suffered an asthma attack on 14 December 2023 and died after information indicating the need for an urgent ambulance response was not obtained, no ambulance was available for several hours, and his family transported him to hospital. The principal concerns included limited awareness and monitoring of excessive salbutamol use, ambulance handover delays affecting emergency availability, risks when families transport critically unwell patients, and unclear NHS Pathways triage wording.
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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 Limited awareness of salbutamol overuse and its association with poorly controlled asthma
Wider context from the report “1. Limited awareness of salbutamol overuse
Evidence showed that patients and families may not appreciate the clinical significance of increased use of the blue (salbutamol) inhaler or its association with poorly controlled asthma .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance handover at local hospitals
Wider context from the report “3. Ambulance handover delays affecting emergency availability
Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 reliably identify excessive or repeated requests for salbutamol inhalers
Wider context from the report “2. Identification and follow-up of reliever overuse
Evidence showed that excessive or repeated requests for salbutamol inhalers may not be reliably identified within existing systems , and there may be no consistent process for follow-up when such patterns occur, meaning deteriorating asthma may go unrecognised.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of NHS Pathways triage wording to be readily understood by callers in distress
Wider context from the report “5. Clarity of NHS Pathways triage wording
Evidence showed that a key NHS Pathways question used during triage was not understood by the caller and did not elicit clinically significant information . This raises a concern that, given the reliance on scripted triage systems, such scripts may not always use wording that is easily understood by lay callers in distress .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 to critically unwell patients and families when no ambulance is available and families transport patients themselves
Wider context from the report “4. Risks when families transport critically unwell patients
The absence of an available ambulance for several hours resulted in the family transporting Roman to hospital themselves, exposing both him and his family to significant risk during a time-critical medical emergency .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 consistent follow-up process for salbutamol overuse patterns
Wider context from the report “2. Identification and follow-up of reliever overuse
Evidence showed that excessive or repeated requests for salbutamol inhalers may not be reliably identified within existing systems, and there may be no consistent process for follow-up when such patterns occur , meaning deteriorating asthma may go unrecognised.
” Open source report
27 Feb 2026 Louis Robert SAUNDERS · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 1 Failure to coordinate ADHD prescribing between private providers and NHS GPs 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
Louis Robert SAUNDERS · 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
Louis Robert Saunders, who had been diagnosed with ADHD and experienced suicidal ideation as a side effect of medication, travelled to the East Sussex coast on 9 October 2024 and was found dead at the base of a cliff the following morning. The principal concern was insufficient communication and continuity of care between the private ADHD clinic and NHS GP, resulting in concurrent prescribing of different ADHD medications and a risk of duplicate prescriptions or confusion about treatment.
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 coordinate ADHD prescribing between private providers and NHS GPs
Wider context from the report “Whilst it is understood that Louis had stopped taking his medication due to a perceived increase in suicidal ideation, and no medication was found in his system following his death, the evidence identified that he was being prescribed ADHD medication by both his NHS GP and the private ADHD clinic. Neither organisation was aware of the other’s ongoing prescribing until the time of the inquest.
After Louis’ ADHD treatment was transferred to his GP, the plan was for the surgery to continue issuing his medication. Accordingly, on 6 November 2023, the surgery issued a prescription for lisdexamfetamine ([REDACTED]). However, Louis had attended an appointment at the ADHD clinic the previous day, on 5 November 2023, and the clinic’s notes record that he was to continue on Dexamphetamine ([REDACTED]). Although the medications have similar names, they are distinct drugs with different dosing requirements. Effective management and titration are understood to be essential to ensure therapeutic benefit and limit adverse effects.
The concern that has arisen relates to continuity of care between private providers and the NHS once a patient has been diagnosed with ADHD, commenced on medication, and subsequently transferred to GP care. In Louis’ case, communication between the private sector and the NHS was insufficiently clear , and the situation became more complex when he continued to be seen by both the ADHD clinic and his GP. This created opportunities for key information to be missed.
Although medication was not directly implicated in Louis’ death, there remains a risk that a patient may inadvertently obtain duplicate prescriptions or become confused about which medication to take. Such scenarios may pose a risk of future deaths. As increasing numbers of patients are receiving ADHD diagnoses and commencing treatment in the private sector due to long NHS waiting times, I am concerned about the robustness of current processes to ensure safe and continuous care following transfer to a GP.
” 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 Highlight duplicate-prescription, medication-confusion, continuity-of-care and treatment-change communication risks to ADHD specialists and primary-care prescribers through ongoing programme work.
Verbatim wording from the response “I have fed your concerns back to NHS England’s National ADHD Programme and Primary Care Teams, who will ensure that the risks you have raised of duplicate prescriptions and confusion between current and previous medication regimes, and actions you have identified, including the need for continuity of care and timely and effective communication of treatment changes, are highlighted to both specialist providers and primary care prescribers wherever possible in their ongoing work.” Source location 2026-0130 - Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish non-mandatory ADHD assessment and treatment guide prices and commissioning guidance setting expectations for assessment, data quality, governance, shared care and follow-up.
Verbatim wording from the response “NHS England is committed to working with system partners, including commissioners and providers of ADHD support, to improve health-related experience and outcomes for those with ADHD. We recently published non-mandatory guide prices for ADHD assessments and treatment pathways, alongside detailed commissioning guidance, that will set clear expectations for assessment standards, data quality, clinical governance, shared care and follow-up.” Source location 2026-0130 - Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The private ADHD provider considered its existing systems sufficient to ensure continuity of care and safer prescribing, requiring no process changes.
Verbatim wording from the response “The Region have liaised with the private ADHD clinic who have advised that they have held a formal preventing future deaths review meeting for this case. The result of the review was that they did not identify any deficiencies in their processes, nor any changes required to their current clinical practice. They highlighted their current systems ensure continuity of care and safer prescribing which included that following every clinical interaction, including titration, medication reviews, and shared care reviews, detailed written correspondence is issued to the patient’s GP to ensure continuity, transparency, and clarity of care. They clarified that they do not initiate medication without first obtaining a Summary Care Record or equivalent clinical information from the patient’s GP.” Source location 2026-0130 - Response from NHS England
Open published response
19 Feb 2026 Rajwinder Singh · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 3 Lack of training in the principles of risk formulation during ACCT induction View source Lack of mandatory procedures ensuring ACCT training equivalence for agency healthcare staff before deployment View source Lack of mandatory ACCT refresher training for prison officers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rajwinder Singh · 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
Rajwinder Singh was imprisoned after being sentenced at Southwark Crown Court and was identified as at risk of self-harm and suicide. He was transferred to St George’s Hospital after failures including unanswered cell bells and inadequate observations, and died there on 25th June 2026. The principal concerns included inadequate risk assessment and record keeping, failures in observations and handovers, and insufficient mandatory ACCT training for prison and agency healthcare staff.
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 training in the principles of risk formulation during ACCT induction
Wider context from the report “(3) When Prison Officers and/or Healthcare staff are given ACCT induction training at HMP Wandsworth, there is no training in the principles of risk formulation
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory procedures ensuring ACCT training equivalence for agency healthcare staff before deployment
Wider context from the report “(2) There are no mandatory procedures to ensure that, before they are deployed in the prison setting, Oxleas agency staff have the same mandatory ACCT training as that provided to permanent healthcare staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory ACCT refresher training for prison officers
Wider context from the report “(1) There is no mandatory ACCT refresher training for prison officer at HMP Wandsworth ;
” 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 Requested regional commissioning teams to confirm timely access to required joint training, including ACCT, for prison healthcare staff.
Verbatim wording from the response “In response to the findings of that report and to support national learning, the National Director for Health and Justice requested that regional commissioning teams confirm that there are appropriate arrangements in place to ensure that all staff, including agency and bank staff, have timely access to all joint training, including ACCT, that is necessary for them to undertake their role effectively within the prison environment. Therefore, regional commissioners gained assurance from healthcare providers operating across London prisons, that there were arrangements in place whereby ACCT training was in place for temporary staff working in prison settings.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conducted a quality assurance visit verifying ACCT training arrangements and temporary staff completion at HMP Wandsworth.
Verbatim wording from the response “NHS England undertook a quality assurance visit to the healthcare team at HMP Wandsworth on the 19th March 2026. At that visit, the process was verified and it was confirmed that all temporary staff had undertaken ACCT training, with the exception of two. It was confirmed that the two outstanding members of temporary staff were booked onto ACCT refresher training.” 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 Obtained assurance from London prison healthcare providers that temporary staff had access to ACCT training arrangements.
Verbatim wording from the response “In response to the findings of that report and to support national learning, the National Director for Health and Justice requested that regional commissioning teams confirm that there are appropriate arrangements in place to ensure that all staff, including agency and bank staff, have timely access to all joint training, including ACCT, that is necessary for them to undertake their role effectively within the prison environment. Therefore, regional commissioners gained assurance from healthcare providers operating across London prisons, that there were arrangements in place whereby ACCT training was in place for temporary staff working in prison settings.” 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 Obtained further assurance from London prison health providers that systems ensure all staff access required training, including ACCT.
Verbatim wording from the response “Further assurances were gained by NHS England (London Region) from regional prison health providers in March/April 2026 that there continue to be suitable systems and processes in place to ensure that all staff, including bank and agency staff, have accessed the required training, including ACCT training, to undertake their roles.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing processes are considered sufficient to ensure temporary prison healthcare staff access required ACCT training.
Verbatim wording from the response “NHS England’s London regional colleagues have advised that Oxleas NHS Foundation Trust now have a process in HMP Wandsworth to ensure that all staff, permanent and temporary (including agency), have undertaken mandatory ACCT training. At the time of Mr Singh’s death, access to ACCT training was sporadic, due to a shortage of Safer Custody staff available to lead in training. This has since been resolved, with Safer Custody staff now available to deliver ACCT training for healthcare staff on two dates per month. In addition, all members of temporary staff receive an induction before working at HMP Wandsworth.” Source location Response from NHS England
Open published response
19 Feb 2026 Jane Ann FENWICK · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 3 Failure to refer people at risk of choking to Speech and Language Therapy for support and intervention View source Delays in access to Speech and Language Therapy support View source Failure to supervise people while eating in accordance with care plans View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jane Ann FENWICK · 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
Jane Ann Fenwick died on 21 August 2025 at Kettering General Hospital after choking on a piece of beef at her care home. She had no teeth, did not wear dentures, tended to rush and overfill her mouth, preferred softer food, and had a care plan identifying a choking risk. The principal concerns were the threshold for Speech and Language Therapy intervention and support, and the waiting time for that support, despite her identified risks and lack of supervision while eating.
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 refer people at risk of choking to Speech and Language Therapy for support and intervention
Wider context from the report “Mrs Fenwick:-
a) had no teeth
b) did not wear her dentures
c) had a tendency to rush her food
d) had a tendency to put too much in her mouth
e) had poor posture and generally did not sit at a table to eat
f) did not sit still
g) was generally not supervised whilst eating (despite the care plan recommending she be observed while eating)
h) had a preference for softer food
i) had a care plan which identified a risk of choking
Despite the above, Mrs Fenwick had not been referred to Speech and Language Therapy (SALT). The care home’s evidence was that even if Mrs Fenwick had been referred to SALT, she would not have met their threshold for support and intervention on the basis that there had been no previous episodes of choking .
The care home also said in evidence that the average wait for SALT support is 13 weeks.
I have concerns regarding the threshold for intervention/support and the current waiting lists.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in access to Speech and Language Therapy support
Wider context from the report “Mrs Fenwick:-
a) had no teeth
b) did not wear her dentures
c) had a tendency to rush her food
d) had a tendency to put too much in her mouth
e) had poor posture and generally did not sit at a table to eat
f) did not sit still
g) was generally not supervised whilst eating (despite the care plan recommending she be observed while eating)
h) had a preference for softer food
i) had a care plan which identified a risk of choking
Despite the above, Mrs Fenwick had not been referred to Speech and Language Therapy (SALT). The care home’s evidence was that even if Mrs Fenwick had been referred to SALT, she would not have met their threshold for support and intervention on the basis that there had been no previous episodes of choking.
The care home also said in evidence that the average wait for SALT support is 13 weeks.
I have concerns regarding the threshold for intervention/support and the current waiting lists.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to supervise people while eating in accordance with care plans
Wider context from the report “Mrs Fenwick:-
a) had no teeth
b) did not wear her dentures
c) had a tendency to rush her food
d) had a tendency to put too much in her mouth
e) had poor posture and generally did not sit at a table to eat
f) did not sit still
g) was generally not supervised whilst eating (despite the care plan recommending she be observed while eating)
h) had a preference for softer food
i) had a care plan which identified a risk of choking
Despite the above, Mrs Fenwick had not been referred to Speech and Language Therapy (SALT). The care home’s evidence was that even if Mrs Fenwick had been referred to SALT, she would not have met their threshold for support and intervention on the basis that there had been no previous episodes of choking.
The care home also said in evidence that the average wait for SALT support is 13 weeks.
I have concerns regarding the threshold for intervention/support and the current waiting lists.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish guidance outlining recommended actions to reduce community health service waiting times.
Verbatim wording from the response “The recently published NHS England » Community health services waiting times: actions to meet Medium term planning framework targets guidance outlines recommended actions to support achievement of the Medium-Term Planning” Source location 2026-0104 - Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local services determine SALT referral criteria and make referral decisions according to individual patient need.
Verbatim wording from the response “The referral criteria for SALT is agreed locally, aligned to commissioning and service models but referral decisions should be based on an individual’s need. Not having a previous choking episode should not prevent a referral if the wider clinical history and risk of choking are recognised and included in the referral.” Source location 2026-0104 - Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Integrated Care Boards are responsible for increasing community SALT capacity and managing waiting times under national planning requirements.
Verbatim wording from the response “The Medium-Term Planning Framework states that in 2026/27, Integrated Care Boards are required to:” Source location 2026-0104 - Response from NHS England
Open published response
Concerns raised 3 Failure to ensure consistent application of the Sepsis Screening Tool between Paediatric Emergency and paediatric inpatient units View source Absence of a validated and sufficiently discriminating sepsis screening tool for Paediatric Emergency Departments View source Failure to deploy the Sepsis Screening Tool in Paediatric Emergency Department assessments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Edward Richard Jones · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Edward Richard Jones died from invasive Group A Streptococcus sepsis after presenting to the Paediatric Emergency Department with abdominal and leg pain, diarrhoea, previous vomiting and dehydration. The substantive concerns included failure to repeat a venous blood gas showing raised lactate, non-use of the trust’s Sepsis Screening Tool, delayed recognition and treatment of sepsis, and delays associated with communication, staffing and bed pressures.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure consistent application of the Sepsis Screening Tool between Paediatric Emergency and paediatric inpatient units
Wider context from the report “Acknowledging that the trust’s SST had not been deployed in any assessment of Edward that was undertaken in the LGI PED, a trust witness told the inquest that work was ongoing to ensure a consistent application of the SST as between the PED and the paediatric in-patient units at the Leeds Children’s Hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Absence of a validated and sufficiently discriminating sepsis screening tool for Paediatric Emergency Departments
Wider context from the report “The inquest was told it is acknowledged nationally that there is no Sepsis Screening Tool which is validated for use in Paediatric Emergency Departments or has a sensitivity or specificity which makes it a useful tool for escalation within a Paediatric Emergency Department .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 deploy the Sepsis Screening Tool in Paediatric Emergency Department assessments
Wider context from the report “Acknowledging that the trust’s SST had not been deployed in any assessment of Edward that was undertaken in the LGI PED , a trust witness told the inquest that work was ongoing to ensure a consistent application of the SST as between the PED and the paediatric in-patient units at the Leeds Children’s Hospital.
” 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 Trial an Emergency Department version of the National Paediatric Early Warning System.
Verbatim wording from the response “The RCPH and NHS England are currently trialling an Emergency Department (ED) NPEWS, and this should be published this year. Both RCPCH and Royal College of Emergency Medicine (RCEM) fully support the introduction of ED NPEWS.” Source location 2026-0096 - Response from Medical Director 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 Roll out the National Paediatric Early Warning System with an integrated sepsis trigger for recognising deterioration in hospitalised children.
Verbatim wording from the response “NHS England rolled out the National Paediatric Early Warning System (NPEWS) in November 2023. The NPEWS is a national standardised approach of tracking the deterioration of children in hospital. The aim of the NPEWS is to allow for consistency in how deterioration in children is recognised. The NPEWS incorporates a sepsis trigger which encompasses the Academy of Medical Royal Colleges guidance. A sepsis trigger is a set of criteria, in this case the NPEWS ‘score’, which is used to trigger a review of a patient.” Source location 2026-0096 - Response from Medical Director 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 England relies on NPEWS, including its sepsis trigger, rather than introducing a separate national paediatric emergency department sepsis screening tool.
Verbatim wording from the response “Your Report raises concerns that nationally there is no sepsis screening tool which is validated for use in Paediatric Emergency Departments. You highlighted that Leeds Teaching Hospital Trust have developed a local sepsis screening tool.” Source location 2026-0096 - Response from Medical Director NHS England
Open published response
9 Feb 2026 Josh Yemi TARRANT · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 2 Lack of ABD training for prison healthcare staff View source Failure of prison nurses to recognise ABD and treat it as a medical emergency View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Josh Yemi TARRANT · 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
Josh Yemi Tarrant died at HMP Elmley on 1 November 2023 after cocaine intoxication and exertion during a lengthy and challenging restraint. The principal concern was that acute behavioural disturbance was not recognised by healthcare staff, who lacked relevant training, and that an ambulance was not called at the earliest appropriate opportunity.
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 ABD training for prison healthcare staff
Wider context from the report “I am concerned that:
(a) No training is provided to prison healthcare staff in relation to ABD (despite the clear advice of PSO 1600).
(b) If prison nurses remain unaware of ABD and the need to treat it as a medical emergency, then further deaths are likely in future.
Accordingly, this situation should be reviewed and consideration given as to whether any steps should be taken to reduce the risk of death by from ABD. In particular, training of prison clinicians should be carefully reviewed at a national level.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of prison nurses to recognise ABD and treat it as a medical emergency
Wider context from the report “I am concerned that:
(a) No training is provided to prison healthcare staff in relation to ABD (despite the clear advice of PSO 1600).
(b) If prison nurses remain unaware of ABD and the need to treat it as a medical emergency , then further deaths are likely in future.
Accordingly, this situation should be reviewed and consideration given as to whether any steps should be taken to reduce the risk of death by from ABD. In particular, training of prison clinicians should be carefully reviewed at a national level.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and communicate a national framework defining healthcare roles and responsibilities for use-of-force incidents and ABD warning signs.
Verbatim wording from the response “In 2025 NHS England developed a framework for healthcare roles and responsibilities for planned and unplanned use of force in adult prisons and immigration removal centres which was communicated to all healthcare providers in August 2025. This framework supports HMPPS and Home Office policy documents and makes clear healthcare requirement to attend all planned, and where possible, unplanned use of force incidents.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure establishments include clear ABD red-flag criteria and emergency escalation pathways in healthcare training and operational briefings, with governance review of incidents.
Verbatim wording from the response “We will be sharing the details of this report with all prison and Immigration Removal Centre healthcare providers with an action to ensure all establishments have a clear red flag criteria and emergency escalation pathway within existing healthcare training structures and operation briefings. This should include a focus on early recognition of deterioration, prompt ambulance activation where indicated, minimising restraint duration and maintaining continuous observation until handover, with routine governance review of such incidents.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The available reviews do not identify ABD or excited delirium, suggesting the presentation was related to cocaine use and an undiagnosed heart condition.
Verbatim wording from the response “South East Regional Colleagues have shared reports around the Trust’s PSII and PPOs independent review. South East Regional Colleagues have advised that both sets of reports identify that clinical staff should receive training in managing violence, aggression and mental health crises, as well as the fact some actions taken by staff, particularly around restraint, were not with current guidance and policy. Neither report shared mentions ABD or ‘Excited Delirium’, suggesting that Mr Tarrant’s presentation” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prison healthcare staff cannot reasonably be expected to diagnose ABD reliably; safety depends on recognising severe agitation, physiological red flags and emergency escalation.
Verbatim wording from the response “Given the rarity and complexity of ABD and the operational realities of prisons, it is not reasonable to expect prison healthcare staff to diagnose ABD reliably. The critical safety issue is recognition of severe agitation accompanied by physiological red flags and escalation as a medical emergency.” Source location Response from NHS England
Open published response
9 Feb 2026 Ellen Victoria Floyd Taylor · Prevention of Future Deaths report Northumberland
View report summary
Concerns raised 4 Failure to routinely recognise previous gastric surgery during nasogastric tube insertion View source Lack of guidelines for nasogastric tube insertion after previous gastric surgery View source Failure to make previous altered gastric anatomy apparent in clinical notes View source Failure to consider altered gastric anatomy and investigate potential perforation when complications arise View source See 1 more concern
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
Ellen Victoria Floyd Taylor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ellen Victoria Floyd Taylor, aged 69, died on 1 July 2025 after a nasogastric tube perforated her small intestine, resulting in acute peritonitis. Her previous gastric bypass surgery and altered anatomy were not known to treating professionals, and the report raises concerns about the lack of guidance and wider NHS risk regarding nasogastric tube insertion in patients with previous gastric surgery.
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 routinely recognise previous gastric surgery during nasogastric tube insertion
Wider context from the report “(1) Ms Taylor underwent gastric/bariatric surgery in 2009. As a result of this her oesophagus was not attached to her stomach but instead attached to her small bowel.
On 25th June 2025 she was admitted to hospital having suffered a stroke and was deemed to require a nasogastric tube.
The fact that she has previous surgery and her anatomy was therefore altered was not obvious from her notes. As such when complications began this was not something that was considered and investigations about potential perforation were not undertaken initially.
(2) I heard evidence that the time there were no guidelines about insertion of nasogastric tubes in circumstances where someone had had previous gastric surgery.
The Northumbria Healthcare NHS Foundation Trust identified areas of learning as a result of the circumstances of Ms Taylor’s death. The key finding from the After Action Review was that the previous gastric surgery was not recognised at the time of the nasogastric tube insertion.
Previous surgery was not a routine consideration and not included within the nasogastric tube guideline. Local guidelines have now changed and consultation with on-call surgical team for guidance about insertion of the tube in these circumstances is now included in the process. Training has taken place and a clinical safety message circulated to increase awareness.
Whilst the local NHS Traut have taken and implemented these steps my concern is that there is a wider risk, and these are circumstances that are relevant to every NHS Trust nationally and there is a risk future deaths will occur unless action is taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidelines for nasogastric tube insertion after previous gastric surgery
Wider context from the report “(1) Ms Taylor underwent gastric/bariatric surgery in 2009. As a result of this her oesophagus was not attached to her stomach but instead attached to her small bowel.
On 25th June 2025 she was admitted to hospital having suffered a stroke and was deemed to require a nasogastric tube.
The fact that she has previous surgery and her anatomy was therefore altered was not obvious from her notes. As such when complications began this was not something that was considered and investigations about potential perforation were not undertaken initially.
(2) I heard evidence that the time there were no guidelines about insertion of nasogastric tubes in circumstances where someone had had previous gastric surgery .
The Northumbria Healthcare NHS Foundation Trust identified areas of learning as a result of the circumstances of Ms Taylor’s death. The key finding from the After Action Review was that the previous gastric surgery was not recognised at the time of the nasogastric tube insertion.
Previous surgery was not a routine consideration and not included within the nasogastric tube guideline . Local guidelines have now changed and consultation with on-call surgical team for guidance about insertion of the tube in these circumstances is now included in the process. Training has taken place and a clinical safety message circulated to increase awareness.
Whilst the local NHS Traut have taken and implemented these steps my concern is that there is a wider risk, and these are circumstances that are relevant to every NHS Trust nationally and there is a risk future deaths will occur unless action is taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to make previous altered gastric anatomy apparent in clinical notes
Wider context from the report “(1) Ms Taylor underwent gastric/bariatric surgery in 2009. As a result of this her oesophagus was not attached to her stomach but instead attached to her small bowel.
On 25th June 2025 she was admitted to hospital having suffered a stroke and was deemed to require a nasogastric tube.
The fact that she has previous surgery and her anatomy was therefore altered was not obvious from her notes. As such when complications began this was not something that was considered and investigations about potential perforation were not undertaken initially.
(2) I heard evidence that the time there were no guidelines about insertion of nasogastric tubes in circumstances where someone had had previous gastric surgery.
The Northumbria Healthcare NHS Foundation Trust identified areas of learning as a result of the circumstances of Ms Taylor’s death. The key finding from the After Action Review was that the previous gastric surgery was not recognised at the time of the nasogastric tube insertion.
Previous surgery was not a routine consideration and not included within the nasogastric tube guideline. Local guidelines have now changed and consultation with on-call surgical team for guidance about insertion of the tube in these circumstances is now included in the process. Training has taken place and a clinical safety message circulated to increase awareness.
Whilst the local NHS Traut have taken and implemented these steps my concern is that there is a wider risk, and these are circumstances that are relevant to every NHS Trust nationally and there is a risk future deaths will occur unless action is taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 altered gastric anatomy and investigate potential perforation when complications arise
Wider context from the report “(1) Ms Taylor underwent gastric/bariatric surgery in 2009. As a result of this her oesophagus was not attached to her stomach but instead attached to her small bowel.
On 25th June 2025 she was admitted to hospital having suffered a stroke and was deemed to require a nasogastric tube.
The fact that she has previous surgery and her anatomy was therefore altered was not obvious from her notes. As such when complications began this was not something that was considered and investigations about potential perforation were not undertaken initially .
(2) I heard evidence that the time there were no guidelines about insertion of nasogastric tubes in circumstances where someone had had previous gastric surgery.
The Northumbria Healthcare NHS Foundation Trust identified areas of learning as a result of the circumstances of Ms Taylor’s death. The key finding from the After Action Review was that the previous gastric surgery was not recognised at the time of the nasogastric tube insertion.
Previous surgery was not a routine consideration and not included within the nasogastric tube guideline. Local guidelines have now changed and consultation with on-call surgical team for guidance about insertion of the tube in these circumstances is now included in the process. Training has taken place and a clinical safety message circulated to increase awareness.
Whilst the local NHS Traut have taken and implemented these steps my concern is that there is a wider risk, and these are circumstances that are relevant to every NHS Trust nationally and there is a risk future deaths will occur unless action is taken.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the Shared Care Records Programme to support wider access to relevant patient information.
Verbatim wording from the response “NHS England is aware of the challenge in sharing medical records and results within organisations and recognises the variability between areas using different technologies. The FD programme continues to work across the health and care system to support greater integration and awareness of record sharing between providers. NHS England is also working with the Shared Care Records Programme which supports wider access to relevant patient information.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a ten-year healthcare plan committing to a single, secure and authoritative patient record.
Verbatim wording from the response “Developing this further NHS England and the Department of Health and Social Care published the Fit for the future: 10 Year Plan for England, which sets out the government’s plan for healthcare in England over the next 10 years. It also sets out a commitment to give patients ‘a single, secure and authoritative account of their data – a single patient record – to enable more coordinated, personalised and predictive care.’” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support provider organisations to adopt and safely implement electronic patient records, including improved interoperability and information sharing.
Verbatim wording from the response “NHS England has developed and led for the last 5 years a Frontline Digitisation (FD) Programme, which has supported provider organisations across England to adopt Electronic Patient Record (EPR) systems which support increased consistency in digital maturity but also improve information sharing within and between organisations.” 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 clinical guidance on nasogastric tube insertion sits with NICE, which should address concerns about national guidance.
Verbatim wording from the response “The responsibility for clinical guidance sits with the National Institute for Health and Care Excellence (NICE). We would advise the Coroner to contact NICE directly to address concerns regarding the guidance.” Source location Response from NHS England
Open published response
9 Feb 2026 Ellen Victoria Floyd Taylor · Prevention of Future Deaths report Northumberland
View report summary
Concerns raised 4 Failure to make previous gastric surgery and altered anatomy apparent in clinical notes View source Failure to routinely recognise and consider previous gastric surgery during nasogastric tube insertion and subsequent complications View source Lack of nasogastric tube insertion guidelines for patients with previous gastric surgery View source Delays in investigating potential perforation after nasogastric tube complications View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ellen Victoria Floyd Taylor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ellen Victoria Floyd Taylor, aged 69, died on 1 July 2025 after a nasogastric tube perforated her small intestine, leading to acute peritonitis. Her previous gastric bypass surgery and altered anatomy were not known to treating professionals, and the perforation was not initially recognised. The report identifies concerns about the absence of guidance for inserting nasogastric tubes in patients with previous gastric surgery and a wider risk to patients nationally.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to make previous gastric surgery and altered anatomy apparent in clinical notes
Wider context from the report “(1) Ms Taylor underwent gastric/bariatric surgery in 2009. As a result of this her oesophagus was not attached to her stomach but instead attached to her small bowel.
On 25th June 2025 she was admitted to hospital having suffered a stroke and was deemed to require a nasogastric tube.
The fact that she has previous surgery and her anatomy was therefore altered was not obvious from her notes. As such when complications began this was not something that was considered and investigations about potential perforation were not undertaken initially.
(2) I heard evidence that the time there were no guidelines about insertion of nasogastric tubes in circumstances where someone had had previous gastric surgery.
The Northumbria Healthcare NHS Foundation Trust identified areas of learning as a result of the circumstances of Ms Taylor’s death. The key finding from the After Action Review was that the previous gastric surgery was not recognised at the time of the nasogastric tube insertion.
Previous surgery was not a routine consideration and not included within the nasogastric tube guideline. Local guidelines have now changed and consultation with on-call surgical team for guidance about insertion of the tube in these circumstances is now included in the process. Training has taken place and a clinical safety message circulated to increase awareness.
Whilst the local NHS Traut have taken and implemented these steps my concern is that there is a wider risk, and these are circumstances that are relevant to every NHS trust nationally and there is a risk future deaths will occur unless action is taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 routinely recognise and consider previous gastric surgery during nasogastric tube insertion and subsequent complications
Wider context from the report “(1) Ms Taylor underwent gastric/bariatric surgery in 2009. As a result of this her oesophagus was not attached to her stomach but instead attached to her small bowel.
On 25th June 2025 she was admitted to hospital having suffered a stroke and was deemed to require a nasogastric tube.
The fact that she has previous surgery and her anatomy was therefore altered was not obvious from her notes. As such when complications began this was not something that was considered and investigations about potential perforation were not undertaken initially.
(2) I heard evidence that the time there were no guidelines about insertion of nasogastric tubes in circumstances where someone had had previous gastric surgery.
The Northumbria Healthcare NHS Foundation Trust identified areas of learning as a result of the circumstances of Ms Taylor’s death. The key finding from the After Action Review was that the previous gastric surgery was not recognised at the time of the nasogastric tube insertion .
Previous surgery was not a routine consideration and not included within the nasogastric tube guideline. Local guidelines have now changed and consultation with on-call surgical team for guidance about insertion of the tube in these circumstances is now included in the process. Training has taken place and a clinical safety message circulated to increase awareness.
Whilst the local NHS Traut have taken and implemented these steps my concern is that there is a wider risk, and these are circumstances that are relevant to every NHS trust nationally and there is a risk future deaths will occur unless action is taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 nasogastric tube insertion guidelines for patients with previous gastric surgery
Wider context from the report “(1) Ms Taylor underwent gastric/bariatric surgery in 2009. As a result of this her oesophagus was not attached to her stomach but instead attached to her small bowel.
On 25th June 2025 she was admitted to hospital having suffered a stroke and was deemed to require a nasogastric tube.
The fact that she has previous surgery and her anatomy was therefore altered was not obvious from her notes. As such when complications began this was not something that was considered and investigations about potential perforation were not undertaken initially.
(2) I heard evidence that the time there were no guidelines about insertion of nasogastric tubes in circumstances where someone had had previous gastric surgery .
The Northumbria Healthcare NHS Foundation Trust identified areas of learning as a result of the circumstances of Ms Taylor’s death. The key finding from the After Action Review was that the previous gastric surgery was not recognised at the time of the nasogastric tube insertion.
Previous surgery was not a routine consideration and not included within the nasogastric tube guideline . Local guidelines have now changed and consultation with on-call surgical team for guidance about insertion of the tube in these circumstances is now included in the process. Training has taken place and a clinical safety message circulated to increase awareness.
Whilst the local NHS Traut have taken and implemented these steps my concern is that there is a wider risk, and these are circumstances that are relevant to every NHS trust nationally and there is a risk future deaths will occur unless action is taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 potential perforation after nasogastric tube complications
Wider context from the report “(1) Ms Taylor underwent gastric/bariatric surgery in 2009. As a result of this her oesophagus was not attached to her stomach but instead attached to her small bowel.
On 25th June 2025 she was admitted to hospital having suffered a stroke and was deemed to require a nasogastric tube.
The fact that she has previous surgery and her anatomy was therefore altered was not obvious from her notes. As such when complications began this was not something that was considered and investigations about potential perforation were not undertaken initially .
(2) I heard evidence that the time there were no guidelines about insertion of nasogastric tubes in circumstances where someone had had previous gastric surgery.
The Northumbria Healthcare NHS Foundation Trust identified areas of learning as a result of the circumstances of Ms Taylor’s death. The key finding from the After Action Review was that the previous gastric surgery was not recognised at the time of the nasogastric tube insertion.
Previous surgery was not a routine consideration and not included within the nasogastric tube guideline. Local guidelines have now changed and consultation with on-call surgical team for guidance about insertion of the tube in these circumstances is now included in the process. Training has taken place and a clinical safety message circulated to increase awareness.
Whilst the local NHS Traut have taken and implemented these steps my concern is that there is a wider risk, and these are circumstances that are relevant to every NHS trust nationally and there is a risk future deaths will occur unless action is taken.
” 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 Lead the Frontline Digitisation Programme to support provider adoption and implementation of electronic patient record systems that improve information sharing.
Verbatim wording from the response “NHS England has developed and led for the last 5 years a Frontline Digitisation (FD) Programme, which has supported provider organisations across England to adopt Electronic Patient Record (EPR) systems which support increased consistency in digital maturity but also improve information sharing within and between organisations.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working across the health and care system and with the Shared Care Records Programme to support greater integration and access to relevant patient information.
Verbatim wording from the response “NHS England is aware of the challenge in sharing medical records and results within organisations and recognises the variability between areas using different technologies. The FD programme continues to work across the health and care system to support greater integration and awareness of record sharing between providers. NHS England is also working with the Shared Care Records Programme which supports wider access to relevant patient information.” 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 clinical guidance lies with NICE, so concerns about national nasogastric tube guidance should be directed to NICE.
Verbatim wording from the response “The responsibility for clinical guidance sits with the National Institute for Health and Care Excellence (NICE). We would advise the Coroner to contact NICE directly to address concerns regarding the guidance.” Source location Response from NHS England
Open published response
8 Feb 2026 Luke John ABRAHAMS · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 1 Failure of NHS website information to explain necrotising fasciitis presentations without wounds or noticeable skin changes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Luke John ABRAHAMS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Luke Abrahams developed a sore throat followed by severe leg pain, necrotising fasciitis and septic shock, and died after cardiac arrest on 23 January 2023 despite emergency surgery and resuscitation. The principal concern was that NHS website information about necrotising fasciitis focused on wounds and did not clearly explain that it can present with intense or disproportionate pain without noticeable skin changes or a wound.
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 NHS website information to explain necrotising fasciitis presentations without wounds or noticeable skin changes
Wider context from the report “During the inquest the court heard evidence regarding the difficulties in diagnosing necrotising fasciitis by medical practitioners and a general lack of awareness amongst the public about the condition and how it can present. The court was directed to the NHS website which sets out that "Necrotising fasciitis...can happen if a wound get infected". The symptoms listed all relate to a cut or wound. In Luke's case there was no wound and the website entry does not make it clear that the condition can present as intense / disproportionate pain without any noticeable skin changes or wound. This gives rise to a concern as the website is frequently used by member of the public and is often shared by healthcare professionals when providing advice to patients .
” 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 and publish clinically assured NHS website content explaining that necrotising fasciitis can occur without visible skin damage and may cause disproportionately intense pain.
Verbatim wording from the response “The Necrotising Fasciitis topic was picked up as part of our regular review of NHS Website content in January 2026. As there had been changes in clinical evidence, an updated version was designed, clinically-assured and published on the 2nd February 2026. The updated content contains a reference to new evidence which supports that in 20% of Necrotising Fasciitis cases there is no primary infection site. It now emphasises that ‘infection usually happens near a cut or wound, but sometimes there may be no obvious damage to your skin in the affected area’ and references the” Source location 2026-0201 - Response from NHS England
Open published response
6 Feb 2026 Mr Stephen Martin Rhodes · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 2 Failure to adequately scrutinise laboratory blood test results View source Failure to prominently flag abnormal laboratory results View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Stephen Martin Rhodes · 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 Stephen Martin Rhodes, who had progressive shortness of breath, had a markedly raised NT-proBNP result that was filed in the mistaken belief that there was no abnormal finding. He collapsed and died after developing a cardiac arrest while working as a delivery driver on 11 March 2025. The principal concern was that the blood test result was not adequately scrutinised and the recommended specialist referral and echocardiography within two weeks did not occur; the inquest conclusion was narrative, with natural causes contributed to by neglect.
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 adequately scrutinise laboratory blood test results
Wider context from the report “2. My concern is that the blood test results from the laboratory were not adequately scrutinised by the GP . The blood test results reported on the 17 September 2024 showed normal renal function, normal liver function and bone metabolism. However, the NT-Brain Natriuretic Peptide results which are a marker of increased left atrial pressure and screen for heart failure was markedly raised at 3473 (normal expected for this age group < 400). This was reported to the practice and noted in the practice record with the advice from the laboratory to “refer for specialist assessment and transthoracic echocardiography within 2 weeks”.
3. The GP giving evidence, described that the Practice could have up to several hundred reports a day. They could not adequately explain how the error occurred. However, one suggestion was that the abnormal results were not found on the top page of the report or highlighted in red.
4. I also heard, evidence that since this incident the laboratory involved has now updated their reporting to ensure that abnormal results are flagged on the first page of the report.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 prominently flag abnormal laboratory results
Wider context from the report “2. My concern is that the blood test results from the laboratory were not adequately scrutinised by the GP. The blood test results reported on the 17 September 2024 showed normal renal function, normal liver function and bone metabolism. However, the NT-Brain Natriuretic Peptide results which are a marker of increased left atrial pressure and screen for heart failure was markedly raised at 3473 (normal expected for this age group < 400). This was reported to the practice and noted in the practice record with the advice from the laboratory to “refer for specialist assessment and transthoracic echocardiography within 2 weeks”.
3. The GP giving evidence, described that the Practice could have up to several hundred reports a day. They could not adequately explain how the error occurred. However, one suggestion was that the abnormal results were not found on the top page of the report or highlighted in red .
4. I also heard, evidence that since this incident the laboratory involved has now updated their reporting to ensure that abnormal results are flagged on the first page of the report.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish guidance and resources supporting safe clinical messaging, test-result handling, clinical decision support and digital clinical safety.
Verbatim wording from the response “While operational arrangements are managed at individual practice level, NHS England has published several resources available to support safe systems of work, including:” Source location 2026-0083 - 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 Pilot safe transmission and ingestion of DAPB4101 pathology reports between laboratories and GP practices.
Verbatim wording from the response “A pilot is underway to establish and prove how a DAPB4101 pathology report can be sent from labs and ingested by GP practices safely. This will involve working with the GP system supplier, and the three pathology middleware suppliers that enable national coverage for lab to GP reporting as well as with Berkshire & Surrey NHS Pathology Services. Once the pilot has completed, implementing DAPB4101 will then go onto NHS England's GP system suppliers’ managed roadmap of development work, leading to national roll-out.” Source location 2026-0083 - 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 Promote wider standardisation of pathology result-flagging conventions.
Verbatim wording from the response “The Pathology Transformation and Interoperability Programme in NHS England is currently undertaking the opportunity to promote:” Source location 2026-0083 - 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 Laboratory and GP system suppliers are primarily responsible for pathology result formatting, structure, presentation and display of abnormal results.
Verbatim wording from the response “The responsibility for the formatting, structure and presentation of pathology results sits primarily with:” Source location 2026-0083 - Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual GP practices manage operational arrangements for reviewing, assigning and acting on pathology results.
Verbatim wording from the response “NHS England recognises the need for robust result review processes are needed at pace in busy practices and the ability to correctly assign and act on results.” Source location 2026-0083 - Response from NHS England
Open published response
Concerns raised 2 Lack of national guidance for clinicians on how to diagnose Autoimmune Encephalitis View source Lack of national guidance for clinicians on when to consider Autoimmune Encephalitis View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mia Maisie Lucas · 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
Mia Maisie Lucas, aged 12, was admitted to hospital after experiencing hallucinations, extreme changes in behaviour and suicidal thoughts. She was later found unresponsive with a bedsheet around her neck and died on 30 January 2024. The inquest identified autoimmune encephalitis and acute psychosis, and raised concerns about the absence of national guidance for recognising and diagnosing autoimmune encephalitis and the failure to undertake a lumbar puncture, which possibly contributed to her death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for clinicians on how to diagnose Autoimmune Encephalitis
Wider context from the report “The Court heard there is no national guidance for clinicians on when to consider, and how to diagnose, Autoimmune Encephalitis . Without this I am of the view there is a risk the condition will not be identified which gives rise to a risk that deaths will occur in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for clinicians on when to consider Autoimmune Encephalitis
Wider context from the report “The Court heard there is no national guidance for clinicians on when to consider , and how to diagnose, Autoimmune Encephalitis. Without this I am of the view there is a risk the condition will not be identified which gives rise to a risk that deaths will occur in the future.
” 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 national encephalitis guidelines with expanded guidance on managing Autoimmune Encephalitis.
Verbatim wording from the response “Your Report raised concern that there is no national guidance for clinicians on when to consider, and how to diagnose, Autoimmune Encephalitis.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National encephalitis guidelines already include guidance on autoimmune encephalitis, although they are currently being updated.
Verbatim wording from the response “Your Report raised concern that there is no national guidance for clinicians on when to consider, and how to diagnose, Autoimmune Encephalitis.” Source location Response from NHS England
Open published response
Concerns raised 5 Failure of the acute paediatric ward to provide a secure, suitable setting for children and young people with mental health concerns View source Failure of staff to provide required mental health care in the acute paediatric ward View source Insufficient availability of Tier 4 paediatric mental health beds View source Lack of community care packages for children and young people without acute physical medical needs View source Unavailability of Tier 4 paediatric mental health beds for children and young people remaining on acute paediatric wards 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
Ellame FORD-DUNN · 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
Ellame FORD-DUNN, aged 16, was detained on an acute paediatric ward because no Tier 4 Paediatric Mental Health bed was available. She absconded from the ward during a toilet visit and died following her absconding. The principal concerns included insufficient Tier 4 beds, inadequate security and risk management, inconsistent handovers and unclear procedures for responding to absconsion, and poor coordination between agencies.
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 acute paediatric ward to provide a secure, suitable setting for children and young people with mental health concerns
Wider context from the report “3. I heard that at Worthing Hospital the Acute Paediatric Ward has been altered since Ellame’s death but due to fire regulations cannot be locked in the same way as a Tier 4 Paediatric Mental Health Unit would be and is not designed for the admission and treatment of children and young people with mental health concerns . I heard that the staff are not able to provide the mental health care that these patients are considered to require in their setting.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 staff to provide required mental health care in the acute paediatric ward
Wider context from the report “3. I heard that at Worthing Hospital the Acute Paediatric Ward has been altered since Ellame’s death but due to fire regulations cannot be locked in the same way as a Tier 4 Paediatric Mental Health Unit would be and is not designed for the admission and treatment of children and young people with mental health concerns. I heard that the staff are not able to provide the mental health care that these patients are considered to require in their setting .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of Tier 4 paediatric mental health beds
Wider context from the report “1. I heard that there are insufficient numbers of Tier 4 Paediatric Mental Health beds available for the children and young people who have been assessed as requiring this level of admission . I heard that the waiting time for a bed for those who are under the Kent and Sussex Child and Adolescent Mental Health Services (CAMHS) Inpatient Provider Collaborative is, on average, 8 days .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 community care packages for children and young people without acute physical medical needs
Wider context from the report “2. I heard from clinicians at University Hospitals Sussex NHS Foundation Trust that they continued to have on acute paediatric wards a number of children and young people who have no physical medical needs for which they requirement treatment in an acute hospital but do not have packages of care in the community in place or a Tier 4 Paediatric Mental Health bed available to be admitted to.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 Tier 4 paediatric mental health beds for children and young people remaining on acute paediatric wards
Wider context from the report “2. I heard from clinicians at University Hospitals Sussex NHS Foundation Trust that they continued to have on acute paediatric wards a number of children and young people who have no physical medical needs for which they requirement treatment in an acute hospital but do not have packages of care in the community in place or a Tier 4 Paediatric Mental Health bed available to be admitted to .
” 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 additional paediatric ward support workers and nurses and provide regional mental health training, including Oliver McGowan training.
Verbatim wording from the response “• During the surge in referrals in 2021/22 and the post-COVID increase in demand, NHS England and the Provider Collaboratives also funded additional support workers and nurses in paediatric wards, along with regional mental health training, such as the Oliver McGowan training in the recognition of the needs of young people with Autism and/or ADHD in healthcare settings.” 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 Establish intensive home treatment services across Sussex as an alternative to hospital admission where safe.
Verbatim wording from the response “From a regional perspective, there has been substantial investment in Intensive Home Treatment Services (COAST) in Sussex, either directly via NHS England funded schemes or directly via the Lead Provider Trust and/or Sussex ICB and Sussex Partnership NHS Foundation Trust. These services have been co-produced with young people with lived experience and their parents, families and carers. These services, now established across all counties in the Sussex Integrated Care System (ICS) geography, currently provide:” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide specialist advice, guidance and support to acute paediatric teams managing young people with mental health needs.
Verbatim wording from the response “From a regional perspective, there has been substantial investment in Intensive Home Treatment Services (COAST) in Sussex, either directly via NHS England funded schemes or directly via the Lead Provider Trust and/or Sussex ICB and Sussex Partnership NHS Foundation Trust. These services have been co-produced with young people with lived experience and their parents, families and carers. These services, now established across all counties in the Sussex Integrated Care System (ICS) geography, currently provide:” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish implementation guidance defining a comprehensive 24/7 urgent and emergency mental health offer for children and young people.
Verbatim wording from the response “In 2024, NHS England published updated implementation guidance on urgent and emergency mental health care for children and young people, which set out the components of a comprehensive 24/7 offer that must be available to all children and young people experiencing mental health crisis. As well as a single point of access through NHS 111, the offer should include brief interventions in the community and intensive home treatment, avoiding admissions to hospital where these are not necessary and helping to ensure that beds are available for those who do need them.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop an NHS Estates Technical Bulletin on therapeutic paediatric ward design, incorporating safety investigation findings and wider evidence.
Verbatim wording from the response “• Led by clinical advisors, policy teams are currently working with NHSE’s Estates team to produce an NHS Estates Technical Bulletin (NETB) on the design of the paediatric ward. This will incorporate recommendations from the Health Services Safety Investigations Body (HSSIB) and wider evidence on the importance of a therapeutic environment for children and young people with a mental health need.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide early discharge planning through intensive home treatment services to reduce prolonged hospital stays and dependence on inpatient admission.
Verbatim wording from the response “From a regional perspective, there has been substantial investment in Intensive Home Treatment Services (COAST) in Sussex, either directly via NHS England funded schemes or directly via the Lead Provider Trust and/or Sussex ICB and Sussex Partnership NHS Foundation Trust. These services have been co-produced with young people with lived experience and their parents, families and carers. These services, now established across all counties in the Sussex Integrated Care System (ICS) geography, currently provide:” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a framework for integrated, holistic care in acute paediatric settings for children and young people with mental health needs.
Verbatim wording from the response “• In November 2022, NHSE published a framework for systems to support acute paediatric settings to provide holistic, appropriate care for children and young people with a mental health need, through integrated working with system partners (including community mental health, inpatient services and Voluntary, Community, and Social Enterprise organisations (VCSEs)) and the involvement of children, young people and their families. The framework also emphasises the importance of education and training for the paediatric workforce so that they have the skills and confidence to support children and young people with a mental health need.” Source location Response from NHS England
Open published response
Concerns raised 3 Limited access for community pharmacists to patients’ drug histories and recent test results View source Confusion among community pharmacists about reconciling safe dispensing with patient confidentiality when medication is collected by another person View source Confusion and variation among community pharmacists about the duty to perform clinical checks for safe prescribing View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Lyn Maher · 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
Lyn Maher, aged 79, was prescribed clarithromycin while taking simvastatin and was not advised to stop the statin. She was admitted to hospital, where the contraindicated co-ingestion was not identified, the statin continued, and rhabdomyolysis was missed; she died following cardiac arrest due to hyperkalaemia on 23 January 2024. The concerns included confusion among community pharmacists about clinical checks and confidentiality, and their limited access in Wales to relevant drug history and test results.
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 Limited access for community pharmacists to patients’ drug histories and recent test results
Wider context from the report “(3) I am concerned that community pharmacists in Wales only have very limited access to the Welsh Clinical Portal , where they can see relevant drug history and recent test results , which would enable them to properly and safely counsel patients to stop contraindicated drugs (here simvastatin with clarithromycin) but applicable more widely. I heard evidence that access to such information is available routinely in English pharmacies, but only in exceptional circumstances in Wales. I have no understanding of why this is the case.
(4) Here, had either community pharmacist had access to Lyn’s drug history, they would have noted the contraindication and either told Lyn, her representative or written on the pharmacy bag that she was to stop the simvastatin. This likely would have changed the outcome for Lyn.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Confusion among community pharmacists about reconciling safe dispensing with patient confidentiality when medication is collected by another person
Wider context from the report “(2) I am concerned that there is confusion amongst community pharmacists in Wales around the conflict between the expectation of safe prescribing/dispensing and patient confidentiality (when someone other than the patient collects the medication) .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Confusion and variation among community pharmacists about the duty to perform clinical checks for safe prescribing
Wider context from the report “(1) Evidence was heard that 2 separate community pharmacists did not tell Lyn, (nor pass a message via her family who collected the tablets), that she must stop taking simvastatin during the course of the clarithromycin, required for her chest infection. The pharmacists did not know she was taking simvastatin. I am concerned that there is confusion and a variety of opinion amongst community pharmacists around the extent of the expectation or duty to perform ‘clinical checks’ to enable safe prescribing and what that practically entails .
” Open source report
1 Feb 2026 Simon Moss · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Failure to use EPCR narrative in mental health risk assessments View source Failure to obtain and use family contact details in mental health assessment and discharge risk mitigation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Simon Moss · 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
Simon Moss was discovered on the roof of his family home on 14 February 2024 after recently developing paranoid thinking, becoming extremely anxious and appearing to be considering suicide. After ambulance attendance and a mental health assessment that did not use detailed information in the ambulance record or contact his wife for collateral information, he was discharged and deliberately fell from a nearby building to his death later that day. The concern was that gaps in training, practice, policy or procedures could result in important risk information and family contact details not being used, undermining the assessment and mitigation of risk to patients presenting with potential risk to self.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to use EPCR narrative in mental health risk assessments
Wider context from the report “The EPRC contained a detailed account of the reasons for which the ambulance paramedics considered the patient at risk to self. It provided a record of details and issues that would have been important to explore in a mental health assessment, including indicators that the patient’s own account could not be relied on.
However, the evidence was that in his subsequent mental health assessment only the triage referral note made by the triage nurse in A&E was relied on, together with the patient’s account . That triage note was necessarily brief and so the detail in the EPCR was lost . Furthermore, the Manchester Triage System only provided the option of “suicidal ideation” or “self-harm” whereas there was evidence in the EPCR of planning and intent.
Further, neither the referral, nor broader medical records contained the contact information of his wife who had called the emergency services. Her mobile number was on the EPCR. Trust policy was that she should have been called as part of his assessment. She was not as the patient would not disclose her number and the EPRC was not consulted.
The evidence was that across several experienced mental health nurses present – who had worked across many roles and mental health trusts – none knew of, or thought to look for the EPCR for further collateral or to seek next of kin details through this or other means. The EPCR was accessible on systems available to the mental health nurse however.
While remedied at the relevant trust, given the evidence of broader practice among mental health nurses I am concerned that there remains a gap in training, practice, policy and/or procedural frameworks for mental health assessments leading to an important source of significant information (EPCR narrative and family contact details) not being known of or used , which could otherwise:
(a) inform an accurate evaluation of the risk to self of patients presenting with mental health illness via ambulance services (i.e. this was not an isolated incident of the EPCR not being known of or used by the specific mental health nurse making the assessment) by (i) providing an independent and detailed account of recent patient history and (ii) contact details for family/friends/individuals who can provide further collateral on their recent presentation, and
(b) allow better mitigation of residual risks at the point of discharge (e.g. through engagement with family and ensuring the patient is collected).
I am concerned that this may undermine the evaluation and mitigation of risk in patients presenting with potential risk-to-self and so represents a risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and use family contact details in mental health assessment and discharge risk mitigation
Wider context from the report “The EPRC contained a detailed account of the reasons for which the ambulance paramedics considered the patient at risk to self. It provided a record of details and issues that would have been important to explore in a mental health assessment, including indicators that the patient’s own account could not be relied on.
However, the evidence was that in his subsequent mental health assessment only the triage referral note made by the triage nurse in A&E was relied on, together with the patient’s account. That triage note was necessarily brief and so the detail in the EPCR was lost. Furthermore, the Manchester Triage System only provided the option of “suicidal ideation” or “self-harm” whereas there was evidence in the EPCR of planning and intent.
Further, neither the referral, nor broader medical records contained the contact information of his wife who had called the emergency services . Her mobile number was on the EPCR. Trust policy was that she should have been called as part of his assessment. She was not as the patient would not disclose her number and the EPRC was not consulted.
The evidence was that across several experienced mental health nurses present – who had worked across many roles and mental health trusts – none knew of, or thought to look for the EPCR for further collateral or to seek next of kin details through this or other means . The EPCR was accessible on systems available to the mental health nurse however.
While remedied at the relevant trust, given the evidence of broader practice among mental health nurses I am concerned that there remains a gap in training, practice, policy and/or procedural frameworks for mental health assessments leading to an important source of significant information (EPCR narrative and family contact details) not being known of or used , which could otherwise:
(a) inform an accurate evaluation of the risk to self of patients presenting with mental health illness via ambulance services (i.e. this was not an isolated incident of the EPCR not being known of or used by the specific mental health nurse making the assessment) by (i) providing an independent and detailed account of recent patient history and (ii) contact details for family/friends/individuals who can provide further collateral on their recent presentation , and
(b) allow better mitigation of residual risks at the point of discharge (e.g. through engagement with family and ensuring the patient is collected) .
I am concerned that this may undermine the evaluation and mitigation of risk in patients presenting with potential risk-to-self and so represents a risk of future deaths.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure next-of-kin details are added to patient information during triage at University Hospital London.
Verbatim wording from the response “The NHS England London Region Team have liaised with South East London Integrated Care Board (ICB) about the concerns you have raised. They have advised that the University Hospital London now ensures that next of kin details are added to patient information during the triage process. They are also ensuring that information from the London Ambulance Service is added to their Emergency Department (iCare) system. They advised that South London and Maudsley Mental Health Trust has introduced a new induction form to be completed by all new bank and locum staff which provides details on how to access the electronic patient record and London care record systems. There is now greater awareness amongst staff of the valuable information relevant to mental health assessments that may be on the electronic patient care system.” Source location 2026-0052 - 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 Introduce an induction form for new bank and locum staff covering access to electronic patient and London care record systems.
Verbatim wording from the response “The NHS England London Region Team have liaised with South East London Integrated Care Board (ICB) about the concerns you have raised. They have advised that the University Hospital London now ensures that next of kin details are added to patient information during the triage process. They are also ensuring that information from the London Ambulance Service is added to their Emergency Department (iCare) system. They advised that South London and Maudsley Mental Health Trust has introduced a new induction form to be completed by all new bank and locum staff which provides details on how to access the electronic patient record and London care record systems. There is now greater awareness amongst staff of the valuable information relevant to mental health assessments that may be on the electronic patient care system.” Source location 2026-0052 - 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 Ensure London Ambulance Service information is added to the Emergency Department iCare system.
Verbatim wording from the response “The NHS England London Region Team have liaised with South East London Integrated Care Board (ICB) about the concerns you have raised. They have advised that the University Hospital London now ensures that next of kin details are added to patient information during the triage process. They are also ensuring that information from the London Ambulance Service is added to their Emergency Department (iCare) system. They advised that South London and Maudsley Mental Health Trust has introduced a new induction form to be completed by all new bank and locum staff which provides details on how to access the electronic patient record and London care record systems. There is now greater awareness amongst staff of the valuable information relevant to mental health assessments that may be on the electronic patient care system.” Source location 2026-0052 - Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish and implement national Staying safe from suicide guidance promoting holistic assessments, family involvement and safety planning.
Verbatim wording from the response “The recently launched NHS England Staying safe from suicide guidance was co-produced by mental health nurses and published by NHS England in June 2025. Its aim is to address issues in terms of mental health assessments both in a crisis situation and when mental health nurses are undertaking detailed mental health assessments in mental health and acute physical health trusts. This guidance supports the government’s work to reduce suicide and improve mental health services. It promotes a shift towards a more holistic, person-centred approach rather than relying on risk prediction, which is unreliable because suicidal thoughts can change quickly. Instead, it recommends using a method based on understanding each person’s situation and managing the safety. It highlights the importance of bringing in families/carers in gaining an overall understanding and need for safety planning.” Source location 2026-0052 - Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support mental health trusts through the Culture of Care programme to strengthen clinical information use and relational approaches to care.
Verbatim wording from the response “Through the Culture of Care national programme, NHS England is supporting mental health trusts to strengthen both the effective use of clinical information and relational approaches to care, in inpatient settings. This includes supporting mental health staff to know the person, understand their history, and engage with family, friends and carers to better recognise and respond to risk. Trusts are beginning to apply these principles more broadly across community services.” Source location 2026-0052 - Response from NHS England
Open published response
29 Jan 2026 Antonio Galisi-Swallow · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1 Lack of national guidance for propofol use for short-term sedation in children and young people on PICUs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Antonio Galisi-Swallow · 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
Antonio Galisi-Swallow died in hospital on 7 October 2021 after developing Propofol-Related Infusion Syndrome following continuous propofol sedation after cardiac surgery. The inquest heard that there was no national guidance for short-term propofol sedation in children and young people on PICUs, and an expert witness supported a guideline subsequently developed by Leeds Teaching Hospitals Trust.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for propofol use for short-term sedation in children and young people on PICUs
Wider context from the report “During the inquest, the court was told that there is no national guidance for the use of propofol for short term sedation in children and young people on PICU’s .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support development and implementation of the position statement and standards actions so paediatric intensive care units establish safe propofol-use arrangements.
Verbatim wording from the response “NHS England will support with the development and implementation of the actions to ensure all PICUs have appropriate arrangements in place for the safe use of propofol. Action 2 allows engagement with the relevant professional groups (anaesthetists and pharmacy) and is a formal communication to ensure units take swift action without waiting for the longer-term action of the overall standards re-write (Action 3 listed above).” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add a requirement to the next PCCS standards that every paediatric intensive care unit have a local propofol-use guideline.
Verbatim wording from the response “3. The next iteration of the PCCS standards (Version 7 is currently under development) will include a specific requirement that all PCC units must have a local guideline for the use of propofol in PICU. (Expected completion date: end of 2026)” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual PICU services are responsible for developing local propofol guidance under professional and commissioning standards.
Verbatim wording from the response “NHS England commission PICU services in line with Paediatric Critical Care Society (PCCS) standards. Standard L3-505 lists clinical guidance that each PICU should have in use and these include ‘Drug administration and medicines management’ and ‘Procedural sedation and analgesia’. PICU services are responsible for developing their own local guidelines as a requirement of PCCS standards.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing mandated local PICU protocols are considered sufficient because they can address patient selection, contraindications, prescribing and monitoring requirements.
Verbatim wording from the response “We have had sight of Professor ████████ response to your Report and concur with him that the above does not mean that propofol cannot be used in clinical practice as many drugs are not licensed for use in children due to a lack of specific paediatric research evidence. However, use of these types of drugs should be supported by strong local protocols. Such protocols should include patient selection, contraindications, cautions, and local prescribing issues (such as who can prescribe, review and monitoring details, and limitations on use).” Source location Response from NHS England
Open published response
28 Jan 2026 Akhona MOYO · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 1 Lack of hospital doctors’ electronic access to detailed primary care medical notes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Akhona MOYO · 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
Akhona Moyo, aged 4, died on 26 November 2022 at Queens Medical Centre, Nottingham, from a brain tumour. The principal concern was that hospital doctors lacked electronic access to detailed primary care records, which the evidence indicated would assist in delivering better treatment and care, particularly for patients who are autistic and non-verbal.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of hospital doctors’ electronic access to detailed primary care medical notes
Wider context from the report “Hospital doctors, including in the Emergency Department and Paediatrics, do not have electronic access to primary care medical notes e.g. GP notes, community mental health notes etc. At Northampton General Hospital, a new electronic system known as “Nerve Centre” contains only hospital notes . Hospital doctors also have access to the “Northamptonshire Care Record” which contains basic lists of GP visits and medication, but no detailed entries .
All the doctors that gave evidence to the Inquest stated that access to primary care records would undoubtedly assist them in delivering better patient treatment and care. It was felt that access to such information was particularly important in cases such as the present when a patient is autistic and non-verbal. There may be a multitude of other reasons why a patient or their family may not be able to relay to doctors a full and accurate medical history. Access may also enable doctors to have a more global view of a patient’s medical condition rather than, as it was put at Inquest, “working in silos”.
” 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 Implement the Frontline Productivity Programme to improve access to patient information and develop digital workflow capabilities.
Verbatim wording from the response “Further digital investment has been confirmed for the Frontline Productivity (FP) Programme, a four-year initiative which is beginning in April 2026. The programme aims to help NHS organisations realise the full benefits of digitised patient information by developing the capabilities enabled through EPR systems, building on the successful implementation funding provided through the FD Programme.” Source location 2026-0045 - 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 Work across the health system to support greater integration and awareness of medical-record sharing between providers.
Verbatim wording from the response “NHS England is aware of the challenge in sharing medical records between providers and the variability between areas using different technologies. We are also aware that use of the SCR is variable across different care settings. We are therefore working across the health system to support greater integration and awareness of record sharing between providers. We are also working with the SCR Programme to support wider access to relevant patient information.” Source location 2026-0045 - 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 Lead the Frontline Digitisation Programme to support adoption and safe deployment of electronic patient record systems.
Verbatim wording from the response “NHS England recognises that limited information sharing between care settings can contribute to delays in discharge, incomplete handovers and less effective continuity of care, particularly when patients receive support across organisational or geographical boundaries. NHS England has developed and led the Frontline Digitisation (FD) Programme, which has supported provider organisations to adopt Electronic Patient Record (EPR) systems which support increased consistency in digital maturity but also improve information sharing within and between organisations.” Source location 2026-0045 - 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 Work with the Summary Care Record Programme to support wider access to relevant patient information.
Verbatim wording from the response “NHS England is aware of the challenge in sharing medical records between providers and the variability between areas using different technologies. We are also aware that use of the SCR is variable across different care settings. We are therefore working across the health system to support greater integration and awareness of record sharing between providers. We are also working with the SCR Programme to support wider access to relevant patient information.” Source location 2026-0045 - 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 Access to the Northamptonshire Care Record is determined locally and falls outside NHS England’s remit to comment on.
Verbatim wording from the response “Access and information contained within the local ‘Northamptonshire Care Record’ is determined by local policy and procedures and therefore falls outside of NHS England’s remit to comment upon.” Source location 2026-0045 - NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust is responsible for, and better placed to answer, questions about local EPR integration and hospital information access.
Verbatim wording from the response “As part of the FD Programme, Northampton General Hospital secured funding and went live with the Nervecentre Electronic Patient Record (EPR) on 27 June 2025. Prior to adoption, patient information was recorded through a range of non-standardised processes rather than a single integrated EPR. NHS England are unable to state the ability of Nervecentre to integrate or view GP primary care records as this would be dependant on the local trust and organisation. We would suggest that the Coroner directs this query to the Trust.” Source location 2026-0045 - NHS England
Open published response
28 Jan 2026 Mrs Patricia Irene Walker · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 1 Failure to maintain adequate staffing for TAG nursing care 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
Mrs Patricia Irene Walker · 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
Patricia Irene Walker suffered a fractured neck of femur after a fall, followed by further falls in hospital, including a fall that resulted in an acute bilateral subdural haematoma. She was later discharged to a care home on a fast-track basis and died after poor nutritional intake, medication refusal and worsening confusion; the report raised concerns about suboptimal staffing on Ward 90 and increased falls risk.
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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 maintain adequate staffing for TAG nursing care
Wider context from the report “(1) Staffing was sub optimal and remain sub optimal on Ward 90 as recruitment is difficult which means that TAG nursing care is not always possible , and patients are at an increased risk of falls.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The staffing and TAG nursing concerns fall outside NHS England’s usual role and remit.
Verbatim wording from the response “We note that your Report has also been sent to Hull University Teaching Hospitals NHS Trust, who would be best placed to respond to your concerns from a local perspective. NHS England has endeavoured to address your concerns as far as we are able to, but consider the issues in this case to fall outside of our usual role and remit.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hull University Teaching Hospitals NHS Trust is responsible for its own recruitment and should address related queries.
Verbatim wording from the response “NHS provider organisations have a statutory duty to ensure that services are staffed safely and appropriately to meet the clinical needs of patients. Each Trust or NHS organisation is responsible for its own recruitment and therefore any future queries in this regard will be best addressed by Hull University Teaching Hospitals NHS Trust.” Source location Response from NHS England
Open published response
27 Jan 2026 Pippa Isobel Waller GILLIBRAND · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 9 Lack of national or local home birth data collection View source Lack of guidance on the threshold for transfer from home birth to hospital View source Lack of guidance on midwife training for competent home birth management View source Lack of guidance on information for expectant parents about home birth risks and team experience View source Lack of guidance on midwife experience requirements for home birth management View source Lack of guidance on backup arrangements for electronic system failure during home births View source Lack of guidance on safe home birth staffing and equipment levels View source Lack of guidance on supervision during home births View source Lack of national guidance on the home birth model of care View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Pippa Isobel Waller GILLIBRAND · 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
Pippa Isobel Waller Gillibrand was delivered by forceps in poor condition after a home birth was continued despite staffing, equipment and fetal heart-rate monitoring issues, and she later died in hospital from a severe irreversible brain injury. The report identified concerns about the lack of guidance on home-birth staffing, midwife competence, transfer thresholds, equipment, supervision, electronic-recording failures and information for parents, as well as the absence of national or local home-birth outcome data.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of national or local home birth data collection
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on the threshold for transfer from home birth to hospital
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on midwife training for competent home birth management
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth , given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on information for expectant parents about home birth risks and team experience
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on midwife experience requirements for home birth management
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on backup arrangements for electronic system failure during home births
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on safe home birth staffing and equipment levels
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on supervision during home births
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on the home birth model of care
Wider context from the report “1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on:
a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency.
b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills.
c. The threshold for transfer to hospital.
d. Safe staffing and equipment levels, without which the service should be suspended.
e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes.
f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine.
g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice.
2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop national resources with partner organisations to address gaps in homebirth guidance and safety practice.
Verbatim wording from the response “We acknowledge that the current intrapartum care guidance does not provide sufficient clarity to women, staff and services as to how to safely support requests for and the provision of homebirth services. NHS England will continue working with partners including NICE, the Royal College of Midwives, the Royal College of Obstetrics and Gynaecology, the Nursing & Midwifery Council, Maternity & Newborn Safety Investigations, the Care Quality Commission, and the General Medical Council to develop further resources that enable services to consistently support commissioners, providers and women and families.” Source location 2026-0042 - Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with other organisations to ensure multidisciplinary emergency simulation includes a scenario beginning in a community or homebirth setting.
Verbatim wording from the response “Midwives providing care at home must be able to respond to developing emergencies on their own, sometimes without the support of multi-disciplinary teams and immediate access to hospital facilities, until additional assistance is provided from the ambulance service. Such midwives are expected to undergo regular training in this. NHS England will work with other organisations to ensure that multi-disciplinary team training simulation for obstetric emergencies includes at least one scenario starting in a community/homebirth setting, in addition to the yearly training competency required by all NHS midwives within the NHS England » Core competency framework version two (2023).” Source location 2026-0042 - 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 Write to NHS maternity providers urging urgent review of homebirth service safety and quality.
Verbatim wording from the response “On 26 November 2025, NHS England wrote to all NHS maternity providers in England asking them to urgently review the safety and quality of their homebirth services. In particular, we urged them to consider the following issues:” Source location 2026-0042 - Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the NMC to consider post-registration standards specifically focused on homebirths.
Verbatim wording from the response “The NMC also maintains standards of proficiency for all midwives, which represent the skills, knowledge and attributes they must demonstrate. While the number of births attended is not alone a reliable indicator of a midwife’s fitness to practice intrapartum care, we will work with the NMC to consider the requirements for post-registration standards, that have a specific focus on homebirths, as part of the development of resources mentioned above.” Source location 2026-0042 - 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 Ask NHS Trusts to implement risk assessment at each pregnancy contact, including ongoing review of intended place of birth.
Verbatim wording from the response “For all women, communication around risk should be personalised. Donna Ockenden, in her review of the maternity services at Shrewsbury and Telford Hospital NHS Trust, made it clear that staff must ensure that women undergo a risk assessment at each contact throughout the pregnancy pathway and that “risk assessment must include ongoing review of the intended place of birth.” NHS England asked Trusts to implement this at the time. All pregnant women should also be offered a personalised care and support plan where such information is recorded, alongside the decisions they make about their care.” Source location 2026-0042 - 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 Explore updating existing data systems to provide regular reporting on homebirth outcomes.
Verbatim wording from the response “We acknowledge that this does not provide evidence of the number of women who have been transferred from home to hospital during labour or after birth, or of their and their baby’s outcomes. We will explore whether existing data gathering systems can be updated to provide regular reporting on outcomes associated with homebirths and will go out to tender to develop a longer-term solution to this evidence gap.” Source location 2026-0042 - 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 Go out to tender for a longer-term solution to the homebirth evidence gap.
Verbatim wording from the response “We acknowledge that this does not provide evidence of the number of women who have been transferred from home to hospital during labour or after birth, or of their and their baby’s outcomes. We will explore whether existing data gathering systems can be updated to provide regular reporting on outcomes associated with homebirths and will go out to tender to develop a longer-term solution to this evidence gap.” Source location 2026-0042 - 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 Employing NHS Trusts are responsible for ensuring midwives and obstetricians practise in line with informed-decision-making and maternity-care guidance.
Verbatim wording from the response “The Royal College of Midwives (RCM) has separately issued guidance around informed decision making and care outside of guidance. The Nursing & Midwifery Council (NMC) has also issued principles for supporting women's choices in maternity care. Employing Trusts are responsible for ensuring that their midwives and obstetricians practise in line with this guidance.” Source location 2026-0042 - Response from NHS England
Open published response
Concerns raised 1 Failure to use the specialist National Early Warning Score matrix for prenatal women throughout the hospital View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mrs Dhananji Denawawake Dona · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Dhananji Denawawake Dona attended hospital while pregnant, experiencing bleeding, abdominal pain, sepsis and a miscarriage. There was a delay in her assessment, and the sepsis screening tool and specialist National Early Warning Score matrix for prenatal women were not used in the A&E department. She deteriorated and died on 2 October 2024; the principal concern was that the specialist warning-score matrix was not used throughout the hospital and there were no plans to introduce it within a reasonable timescale.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to use the specialist National Early Warning Score matrix for prenatal women throughout the hospital
Wider context from the report “1. That although the specialist National Early Warning Score matrix for prenatal women, should be used within the whole of the hospital , it still was not , and there were no plans to introduce this within a reasonable timescale .
” 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 Disseminate draft MEWS digital specifications to suppliers through the NHS Futures platform ahead of formal publication.
Verbatim wording from the response “Draft versions of the specifications have already been circulated to digital suppliers via the NHS Futures platform ahead of their planned formal publication in Spring 2026. This early dissemination aims to enable suppliers and organisations to begin aligning or configuring their systems in preparation for national rollout, thereby supporting safer and more consistent digital recognition of deterioration in pregnant and recently pregnant women across all care settings.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the Maternal Care Bundle setting national maternity safety standards, including MEWS implementation across relevant care settings.
Verbatim wording from the response “Further to this, NHS England published the Maternal Care Bundle (MCB) in January 2026. This sets out evidence-based standards across five key clinical areas to be implemented nationally by March 2027. MEWS is an essential component of Element 2: Pre-hospital and Acute Care.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop national digital specifications supporting consistent implementation of MEWS across maternity and non-maternity electronic patient record systems.
Verbatim wording from the response “NHS England has developed national digital specifications to support the implementation of the national MEWS across both maternity and non-maternity clinical environments. These specifications are designed to ensure consistency and interoperability across electronic patient record (EPR) systems, reducing variation in how deterioration is recognised, recorded, and escalated.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the final MEWS digital specifications in Spring 2026.
Verbatim wording from the response “Draft versions of the specifications have already been circulated to digital suppliers via the NHS Futures platform ahead of their planned formal publication in Spring 2026. This early dissemination aims to enable suppliers and organisations to begin aligning or configuring their systems in preparation for national rollout, thereby supporting safer and more consistent digital recognition of deterioration in pregnant and recently pregnant women across all care settings.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop the national Maternity Early Warning Score using pregnancy-specific thresholds for deterioration recognition and escalation.
Verbatim wording from the response “To address this, NHS England has developed MEWS as a separate scoring tool using evidence-based, pregnancy-specific thresholds, which more accurately reflect physiological changes from conception to four weeks postpartum. This ensures deterioration can be recognised and escalated appropriately and consistently.” Source location Response from NHS England
Open published response
19 Jan 2026 Martin Douglas Bryant · Prevention of Future Deaths report Essex
View report summary
Concerns raised 3 Inadequate capacity for suitable waiting accommodation within the MHUCD View source Reliance on an open reception area for people in mental health crisis while medical authority or beds are secured View source Lack of locally and nationally available beds for mental health admissions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Martin Douglas Bryant · 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 Douglas Bryant died by suicide on 19 January 2025 after presenting to the Mental Health Urgent Care Department following a suicide attempt. While awaiting informal admission and a bed, he was asked to wait in an open reception area from which he was free to come and go, and he subsequently left and did not return. The substantive concerns related to reliance on this waiting arrangement, the suitability of the waiting area, and shortages of mental health admission beds resulting in prolonged waits.
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 capacity for suitable waiting accommodation within the MHUCD
Wider context from the report “2. EPUT’s ability to accommodate improvement to where people wait within the MHUCD , particularly in light of the evidence given by nursing staff and the indication that rooms will always need to be kept vacant for patients requiring triage or assessment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Reliance on an open reception area for people in mental health crisis while medical authority or beds are secured
Wider context from the report “1. The reliance by EPUT that those suffering a mental health crisis will wait in the MHUCD’s open reception area , from which they are free to come and go as desired , whilst medical authority and/or beds are secured for them .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of locally and nationally available beds for mental health admissions
Wider context from the report “3. The lack of beds, locally and nationally, for mental health admissions and the suggestion given in evidence that patients can be waiting in the open reception area for days or sometimes weeks for a bed .
” 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 Reduce and eliminate the use of out-of-area placements.
Verbatim wording from the response “If local beds are not available, Out of Area Placements are currently used to ensure patient care is delivered in an inpatient setting if needed. However, NHS England plans to reduce and eliminate the use of Out of Area Placements as they can result in poorer outcomes for patients and provide additional risk to patient safety.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue operational planning guidance directing systems to reduce average adult acute mental health ward length of stay and improve access to local beds.
Verbatim wording from the response “NHS England’s 2025/26 priorities and operational planning guidance reinforces this focus on improving patient flow as a key priority – with systems directed to reduce the average length of stay in adult acute mental health wards in order to deliver more timely access to local beds. NHS England is taking steps to address current operational pressures driving these issues.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider providing more mental health beds within a whole-system transformation approach.
Verbatim wording from the response “Given increasing lengths of stay and the increased number of patients clinically ready for discharge, providing more beds will be considered as part of a whole system transformation approach. This was supported by the NHS Long Term Plan (LTP), which saw an additional £2.3 billion funding invested in mental health services from 2019/20 – 2023/24, around £1.3 billion of which was for adult community, crisis and acute mental health services to help people get quicker access to the care they need and prevent avoidable deterioration and hospital admission.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £75 million in additional capital for local systems to improve bed capacity and reduce out-of-area placements.
Verbatim wording from the response “NHS England is aware of the issues in some healthcare systems around high bed occupancy and limited local bed availability. This is related to long lengths of stay and high numbers of patients clinically ready for discharge but unable to be discharged, leading to flow pressures across systems. To improve this, in 2025/26, NHS England made £75 million of additional capital available for local systems to invest in improving local bed capacity and reduce the use of Out of Area Placements.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out 24/7 neighbourhood mental health centres, specialist mental health emergency departments and 24/7 psychiatric liaison teams.
Verbatim wording from the response “In relation to concern 3 above and the issue of bed availability, NHS England is currently rolling out dedicated 24/7 neighbourhood mental health centres to better support the community, including opening more specialist Mental Health Emergency Departments alongside general Emergency Departments and having a 24/7 psychiatric liaison team available. A pilot programme for these centres started in October 2025 and will run until July 2026. This will be followed by an Implementation Support Programme which will roll out to sites from March 2026.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation EPUT is best placed to comment on evidence that patients may wait in the open reception area for days or weeks for a bed.
Verbatim wording from the response “3. The lack of beds, locally and nationally, for mental health admissions and the suggestion given in evidence that patients can be waiting in the open reception area for days or sometimes weeks for a bed.” 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 EPUT is best placed to address concerns about the MHUCD waiting area and accommodation for people awaiting triage, assessment or beds.
Verbatim wording from the response “1. The reliance by Essex Partnership University NHS Foundation Trust (EPUT) that those suffering a mental health crisis will wait in the open reception area of the Mental Health Urgent Care Department (MHUCD), from which they are free to come and go as desired, whilst medical authority and/or beds are secured for them.” Source location Response from NHS England
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations