23 May 2014 Samarjit Natasha SINGH · Prevention of Future Deaths report The Wirral
View report summary
Concerns raised 3 Lack of a Mother and Baby Perinatal Mental Health inpatient unit in the Liverpool City Region View source Lack of a Specialist Community Perinatal Mental Health Service in the Wirral View source Sub-optimal treatment for perinatal mental health issues 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
Samarjit Natasha 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
Samarjit Natasha Singh developed postnatal depression after giving birth to her son and had acts of deliberate self-harm and a threat of self-harm. On 4 December 2012, she was found in cardiac arrest following hanging and sustained an irreversible hypoxic brain injury; she died the following day. The report identified concerns about the absence of a Specialist Community Perinatal Mental Health Service and a Mother and Baby Perinatal Mental Health inpatient unit in the Liverpool City Region.
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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 a Mother and Baby Perinatal Mental Health inpatient unit in the Liverpool City Region
Wider context from the report “Mrs Singh suffered from severe postnatal depression following the birth of her son. Clearly she needed to be with her son whilst she was being treated for her perinatal mental health issues, given his needs.
1. There was no Specialist Community Perinatal Mental Health Service in the Wirral to meet both her son’s and her needs. The treatment that was available was sub-optimal.
2. There is not a Mother and Baby Perinatal Mental health—in-patient Unit in the Liverpool City Region serving the needs of Lancashire, Merseyside and East Cheshire . 50% of referrals from this area to the Manchester Unit decline because it is too far from family and support networks but more relevantly from older sibling children who remain in the family home
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 Specialist Community Perinatal Mental Health Service in the Wirral
Wider context from the report “Mrs Singh suffered from severe postnatal depression following the birth of her son. Clearly she needed to be with her son whilst she was being treated for her perinatal mental health issues, given his needs.
1. There was no Specialist Community Perinatal Mental Health Service in the Wirral to meet both her son’s and her needs . The treatment that was available was sub-optimal.
2. There is not a Mother and Baby Perinatal Mental health—in-patient Unit in the Liverpool City Region serving the needs of Lancashire, Merseyside and East Cheshire. 50% of referrals from this area to the Manchester Unit decline because it is too far from family and support networks but more relevantly from older sibling children who remain in the family home
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Sub-optimal treatment for perinatal mental health issues
Wider context from the report “Mrs Singh suffered from severe postnatal depression following the birth of her son. Clearly she needed to be with her son whilst she was being treated for her perinatal mental health issues, given his needs.
1. There was no Specialist Community Perinatal Mental Health Service in the Wirral to meet both her son’s and her needs. The treatment that was available was sub-optimal .
2. There is not a Mother and Baby Perinatal Mental health—in-patient Unit in the Liverpool City Region serving the needs of Lancashire, Merseyside and East Cheshire. 50% of referrals from this area to the Manchester Unit decline because it is too far from family and support networks but more relevantly from older sibling children who remain in the family home
” Open source report
Concerns raised 2 Failure of two-way communication about prescribing between primary and secondary care View source Lack of access to each other's clinical documentation between primary and secondary care 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
Denise Sharon Parramore · 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
Denise Sharon Parramore, who had a lengthy history of mental ill health and previous self-harm, died from respiratory depression after taking Tramadol in excess of the prescribed level in combination with other medication. The concerns were that psychiatric services were unaware of the Tramadol prescription and that primary and secondary care should have open two-way communication and access to each other's documentation.
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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 of two-way communication about prescribing between primary and secondary care
Wider context from the report “(1) The Psychiatric Services, and in particular her Consultant Psychiatrist, was not aware, prior to Denise Parramore's death, of her being prescribed Tramadol by her General Practitioner. Concerns would have been raised, and action likely taken, if she had been aware. The Consultant Psychiatrist was not informed either by Mrs Parramore herself, nor the General Practitioner of the prescribing of the Tramadol. My concern is that there should be open, and constant two-way communication between those in primary care and secondary care such as in these circumstances.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of access to each other's clinical documentation between primary and secondary care
Wider context from the report “(2) For the same reasons as given above, will it be possible for those in primary and secondary care access each other's documentation , which would likely have revealed the prescribing .
” Open source report
12 May 2014 Keiran Michael John Toman · Prevention of Future Deaths report Inner West London
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Concerns raised 5 Isolation of vulnerable patients and increased risk of deterioration and death from lack of family contact View source Insufficient review of patient decisions about permission to contact next of kin or family View source Failure to appropriately challenge decisions by patients with insufficient insight not to share information with families View source Insufficient training of psychiatric staff to assess patients’ capacity to decline contact with next of kin View source Failure to contact family or next of kin when a patient who previously declined contact disengages from psychiatric services View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Keiran Michael John Toman · 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
Keiran Michael John Toman had fixed delusions, withdrew from social and psychiatric support, and subsequently starved himself to death due to paranoia before being found deceased in a hotel. The report raised concerns that psychiatric services did not maintain contact with his family despite his lack of insight and capacity, potentially leaving him isolated and increasing the risk of deterioration and death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Isolation of vulnerable patients and increased risk of deterioration and death from lack of family contact
Wider context from the report “(2) That the lack of contact with families in such circumstances may leave vulnerable patients isolated and increase their risk of deterioration and death , as occurred in this case and in others that I have investigated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 review of patient decisions about permission to contact next of kin or family
Wider context from the report “(5) That permission to contact next of kin/ family decisions taken by patients may not be reviewed often enough by those providing psychiatric care , such that information in relation to changes in treatment, mental state, discharge, provider of care etc may not be being appropriately communicated to the detriment of patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately challenge decisions by patients with insufficient insight not to share information with families
Wider context from the report “(1) That some psychiatric staff and services may effectively collude with patients by acquiescing to requests not to pass on information to their families , when these decisions are taken by patients who have insufficient insight to make 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 Insufficient training of psychiatric staff to assess patients’ capacity to decline contact with next of kin
Wider context from the report “(3) That some psychiatric staff may be insufficiently trained to assess the capacity of patients to decline contact with next of kin and thus the best interest of such patients is compromised.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 contact family or next of kin when a patient who previously declined contact disengages from psychiatric services
Wider context from the report “(4) That where decisions are taken by psychiatric staff not to contact family in line with a patients wishes in order to try and keep that patient engaged with services, that contact is still not made to the family or next of kin even when such a patient disengages from the psychiatric services .
” Open source report
9 May 2014 Lisa Webb · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 5 Failure to use pulse oximetry in respiratory assessment View source Failure to measure and record peak flow rate View source Failure to enquire about asthma and inhaler use before diagnosing anxiety-related hyperventilation View source Failure to record respiratory and pulse rates View source Failure to avoid prescribing Diazepam for anxiety in sleep apnoea or respiratory distress View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Lisa Webb · 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
Lisa Webb died suddenly and unexpectedly at home on 10 March 2012, aged 44. The inquest recorded natural causes, including adult respiratory distress syndrome and lower respiratory tract infection, with sleep apnoea and chronic asthma noted. Expert evidence raised concerns about the general practitioner's assessment and management of her asthma and respiratory symptoms, including the prescription of Diazepam.
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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 use pulse oximetry in respiratory assessment
Wider context from the report “Expert evidence was heard that:
(1) The management of asthma by the general practitioner on 9th March 2012, when she presented post-operatively with fast breathing and anxiety, was sub-optimal and creates potential risks for other patients.
a) Enquiries about her asthma and use of inhalers were not made, before a diagnosis was made of anxiety related hyperventilation (which was not in previous medical history)
b) Fast breathing was observed and recorded (sic hyperventilating and mild wheeze, but the respiratory rate not recorded, nor was her pulse rate.
c) Her peak flow rate was not recorded. There was only one record of its being measured in the years of general practice care and that was in 2008, when she was given a steroid inhaler.
d) Pulse oximetry was not used
(2) The prescription of Diazepam, although it did no harm in this instance, was poor treatment for anxiety, it should not be prescribed in sleep apnoea; and ideally should be avoided in respiratory distress. The GP said that he would not have given it in an asthmatic unless she had it before (of which there was no record) and that he was unaware of the diagnosis of sleep apnoea (of which diagnosis there was also no medical record).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 measure and record peak flow rate
Wider context from the report “Expert evidence was heard that:
(1) The management of asthma by the general practitioner on 9th March 2012, when she presented post-operatively with fast breathing and anxiety, was sub-optimal and creates potential risks for other patients.
a) Enquiries about her asthma and use of inhalers were not made, before a diagnosis was made of anxiety related hyperventilation (which was not in previous medical history)
b) Fast breathing was observed and recorded (sic hyperventilating and mild wheeze, but the respiratory rate not recorded, nor was her pulse rate.
c) Her peak flow rate was not recorded . There was only one record of its being measured in the years of general practice care and that was in 2008, when she was given a steroid inhaler.
d) Pulse oximetry was not used
(2) The prescription of Diazepam, although it did no harm in this instance, was poor treatment for anxiety, it should not be prescribed in sleep apnoea; and ideally should be avoided in respiratory distress. The GP said that he would not have given it in an asthmatic unless she had it before (of which there was no record) and that he was unaware of the diagnosis of sleep apnoea (of which diagnosis there was also no medical record).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 enquire about asthma and inhaler use before diagnosing anxiety-related hyperventilation
Wider context from the report “Expert evidence was heard that:
(1) The management of asthma by the general practitioner on 9th March 2012, when she presented post-operatively with fast breathing and anxiety, was sub-optimal and creates potential risks for other patients.
a) Enquiries about her asthma and use of inhalers were not made, before a diagnosis was made of anxiety related hyperventilation (which was not in previous medical history)
b) Fast breathing was observed and recorded (sic hyperventilating and mild wheeze, but the respiratory rate not recorded, nor was her pulse rate.
c) Her peak flow rate was not recorded. There was only one record of its being measured in the years of general practice care and that was in 2008, when she was given a steroid inhaler.
d) Pulse oximetry was not used
(2) The prescription of Diazepam, although it did no harm in this instance, was poor treatment for anxiety, it should not be prescribed in sleep apnoea; and ideally should be avoided in respiratory distress. The GP said that he would not have given it in an asthmatic unless she had it before (of which there was no record) and that he was unaware of the diagnosis of sleep apnoea (of which diagnosis there was also no medical record).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to record respiratory and pulse rates
Wider context from the report “Expert evidence was heard that:
(1) The management of asthma by the general practitioner on 9th March 2012, when she presented post-operatively with fast breathing and anxiety, was sub-optimal and creates potential risks for other patients.
a) Enquiries about her asthma and use of inhalers were not made, before a diagnosis was made of anxiety related hyperventilation (which was not in previous medical history)
b) Fast breathing was observed and recorded (sic hyperventilating and mild wheeze, but the respiratory rate not recorded, nor was her pulse rate .
c) Her peak flow rate was not recorded. There was only one record of its being measured in the years of general practice care and that was in 2008, when she was given a steroid inhaler.
d) Pulse oximetry was not used
(2) The prescription of Diazepam, although it did no harm in this instance, was poor treatment for anxiety, it should not be prescribed in sleep apnoea; and ideally should be avoided in respiratory distress. The GP said that he would not have given it in an asthmatic unless she had it before (of which there was no record) and that he was unaware of the diagnosis of sleep apnoea (of which diagnosis there was also no medical record).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to avoid prescribing Diazepam for anxiety in sleep apnoea or respiratory distress
Wider context from the report “Expert evidence was heard that:
(1) The management of asthma by the general practitioner on 9th March 2012, when she presented post-operatively with fast breathing and anxiety, was sub-optimal and creates potential risks for other patients.
a) Enquiries about her asthma and use of inhalers were not made, before a diagnosis was made of anxiety related hyperventilation (which was not in previous medical history)
b) Fast breathing was observed and recorded (sic hyperventilating and mild wheeze, but the respiratory rate not recorded, nor was her pulse rate.
c) Her peak flow rate was not recorded. There was only one record of its being measured in the years of general practice care and that was in 2008, when she was given a steroid inhaler.
d) Pulse oximetry was not used
(2) The prescription of Diazepam , although it did no harm in this instance, was poor treatment for anxiety , it should not be prescribed in sleep apnoea; and ideally should be avoided in respiratory distress . The GP said that he would not have given it in an asthmatic unless she had it before (of which there was no record) and that he was unaware of the diagnosis of sleep apnoea (of which diagnosis there was also no medical record).
” Open source report
15 Apr 2014 Desiree Harmony Falvo · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 2 Failure of airway-management training to ensure clinicians have the skills and confidence to perform emergency surgical tracheotomy View source Insufficient A&E cover by clinicians able to secure airways via emergency surgical tracheotomy 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
Desiree Harmony Falvo · 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
Desiree Harmony Falvo developed severe breathing difficulties after a procedure and was transferred to hospital in extremis. Difficulties securing her airway led to cardiac arrest and hypoxic brain injury, and she subsequently died in intensive care. The concerns were insufficient on-site emergency surgical tracheotomy expertise in some A&E departments and the adequacy of training and confidence of clinicians expected to secure airways.
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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 of airway-management training to ensure clinicians have the skills and confidence to perform emergency surgical tracheotomy
Wider context from the report “(2) That the training planned and provided to those expected to manage and secure airways including the use as appropriate of surgical tracheotomy , is reviewed and upgraded such that those clinicians have both the skills and confidence to perform such procedures in an emergency situation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 A&E cover by clinicians able to secure airways via emergency surgical tracheotomy
Wider context from the report “(1) That A&E departments have insufficient cover to ensure that they have on site clinicians able to secure airways via emergency surgical tracheotomy ,
” 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 increased senior doctor presence in A&E departments, including 24/7 consultant cover in Major Trauma units and extended consultant or senior trainee cover elsewhere.
Verbatim wording from the response “Across London there has been a review of Emergency Departments and the availability of senior staff with these skills as part of a wider review of Quality Standards in Acute Trusts. It is clear that provision has varied, and a standard has been agreed whereby all Major Trauma units have consultants on site 24/7 and all A&Es will have increased consultant presence over 16 hours with senior training doctors (ST4s) on site and available for the other time. This is a substantial challenge as there is a shortage of A&E doctors, but already many Trusts have made strides to meet these standards and this has also been a drive behind the reconfiguration of some A&Es.” Source location 2014-0171-Response-by-NHS-England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review Emergency Departments and senior-staff availability for emergency airway skills across London.
Verbatim wording from the response “Across London there has been a review of Emergency Departments and the availability of senior staff with these skills as part of a wider review of Quality Standards in Acute Trusts. It is clear that provision has varied, and a standard has been agreed whereby all Major Trauma units have consultants on site 24/7 and all A&Es will have increased consultant presence over 16 hours with senior training doctors (ST4s) on site and available for the other time. This is a substantial challenge as there is a shortage of A&E doctors, but already many Trusts have made strides to meet these standards and this has also been a drive behind the reconfiguration of some A&Es.” Source location 2014-0171-Response-by-NHS-England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide and periodically repeat advanced airway training, including emergency tracheotomy and needle cricothyroidotomy, with practical training for relevant clinicians.
Verbatim wording from the response “There are insufficient experienced ENT surgeons to provide immediately available resident cover in all A&E departments at all times, and to do so would be impractical. Acute Trusts responsible for the provision of A&E are expected to recognise and manage this risk by ensuring that general training is available to the initial receiving staff in A&E, and that specialist expertise can be accessed in a timely way. A&E senior staff are trained as part of Advanced Trauma Life Support (ATLS) in both tracheotomies and needle cricothyroidotomy. This is repeated at least every four years to ensure skills and confidence are maintained.” Source location 2014-0171-Response-by-NHS-England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Acute Trusts providing A&E are responsible for managing airway-cover risks through general training and timely access to specialist expertise.
Verbatim wording from the response “There are insufficient experienced ENT surgeons to provide immediately available resident cover in all A&E departments at all times, and to do so would be impractical. Acute Trusts responsible for the provision of A&E are expected to recognise and manage this risk by ensuring that general training is available to the initial receiving staff in A&E, and that specialist expertise can be accessed in a timely way. A&E senior staff are trained as part of Advanced Trauma Life Support (ATLS) in both tracheotomies and needle cricothyroidotomy. This is repeated at least every four years to ensure skills and confidence are maintained.” Source location 2014-0171-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Immediate resident ENT surgeon cover in every A&E is impractical because there are insufficient experienced ENT surgeons.
Verbatim wording from the response “There are insufficient experienced ENT surgeons to provide immediately available resident cover in all A&E departments at all times, and to do so would be impractical. Acute Trusts responsible for the provision of A&E are expected to recognise and manage this risk by ensuring that general training is available to the initial receiving staff in A&E, and that specialist expertise can be accessed in a timely way. A&E senior staff are trained as part of Advanced Trauma Life Support (ATLS) in both tracheotomies and needle cricothyroidotomy. This is repeated at least every four years to ensure skills and confidence are maintained.” Source location 2014-0171-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing airway training, recurring skills maintenance, guidelines and practical courses are considered sufficient for clinicians managing emergency airways.
Verbatim wording from the response “There are insufficient experienced ENT surgeons to provide immediately available resident cover in all A&E departments at all times, and to do so would be impractical. Acute Trusts responsible for the provision of A&E are expected to recognise and manage this risk by ensuring that general training is available to the initial receiving staff in A&E, and that specialist expertise can be accessed in a timely way. A&E senior staff are trained as part of Advanced Trauma Life Support (ATLS) in both tracheotomies and needle cricothyroidotomy. This is repeated at least every four years to ensure skills and confidence are maintained.” Source location 2014-0171-Response-by-NHS-England
Open published response
Concerns raised 1 Lack of mandatory formal paediatric training for GPs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Oliver George Hiscutt · 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
Oliver George Hiscutt developed a Group A beta-haemolytic streptococcal infection with a retropharyngeal abscess, followed by catastrophic haemorrhage and cardiac arrests; he died on 7 October 2012. The report raised concern that formal paediatric or child-health training is not mandatory for GPs and that exposure to acute paediatrics during GP training is limited.
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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 mandatory formal paediatric training for GPs
Wider context from the report “Currently it is not mandatory for GPs to undertake formal paediatric / child health training. Facing the Future (2011) states that there are currently 10 000 GP trainees in the country and less than 25% of them will undertake any paediatric placement during their training. GP trainees who do undertake a paediatric placement during their training gain a range of educational benefits such as the development of skills in spotting the sick child, specialist management of children with long term conditions and multi disciplinary team working.
The Royal College of General Practitioners and the Royal College of Paediatrics and Child Health strongly support all GPs having exposure to acute paediatrics as part of their vocational training. Offering every GP trainee a hospital post in paediatrics within the current 3 year specialty training programme is undeliverable. The Royal College of General Practitioners makes the case that there should be an enhanced 4 year programme of GP training and that all GPs should undertake specialist led paediatric training. Specialist led paediatric training will ensure that future GPs have the skills and experience they need to assess and respond effectively and safely to sick children, to better co-ordinate the care of children with long term conditions and to safeguard those at risk.
” Open source report
Concerns raised 1 Potential worsening of depression following antidepressant medication 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
Susan Edea Poore · 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
Susan Edea Poore was fatally injured after being struck by a train on 3 May 2012, after she was seen standing on the railway line near Thains Lane, East Runton. The report raised concerns about her depression deteriorating after prescribed antidepressant medication and whether the medication warning about worsening depression was sufficient.
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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 Potential worsening of depression following antidepressant medication
Wider context from the report “(1) Shortly before her death, Mrs Poore had been prescribed anti-depressant medication (Mirtazapine 29.03.2012 changed to Fluoxetine 23.04.2012)
(2) The evidence is that her depression deteriorated following her taking the anti-depressant medication and the mode of death was out of character for Mrs Poore
(3) Although the medication did contain a message warning of the potential side-effect of worsening depression , this did not prevent Mrs Poore’s death
” Open source report
18 Mar 2014 Matthew David James Simmonds · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 1 Failure to share commissioning plans for complex care pathway discharges with Clinical Commissioning Groups outside the county 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
Matthew David James Simmonds · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Matthew Simmonds, who was dependent on invasive ventilation, died after assisted ventilation ceased during a change of ventilators because the replacement ventilator was not switched to a functioning mode. The principal concern was that a locally developed care-planning system for complex community discharges, particularly ventilated patients, had not been shared with Clinical Commissioning Groups outside the county.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to share commissioning plans for complex care pathway discharges with Clinical Commissioning Groups outside the county
Wider context from the report “(1) Hampshire Primary Care Trust (then responsible for commissioning services) carried out a Serious Incident Review as a result of this death and have since put into effect an action plan for commissioning services in the case of complex care pathways for discharges to the community particularly in the case of ventilated patients.
(2) I heard evidence that Hampshire Clinical Commissioning Groups successors to the Primary Care Trust have adopted this plan and that it is working satisfactorily.
(3) The plan was prepared locally and has not been shared with CCG's outside the County. My concern is that to prevent deaths in other parts of the country all Clinical Commissioning Groups should adopt the plan.
” Open source report
13 Feb 2014 Lisa Marie Inkin · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 10 Failure to record calls taken from patients by the ward View source Insufficient staffing to answer patients’ phone calls View source Failure to promptly escalate information about patients’ suicidal intent View source Lack of training or experience to recognise the importance of information about patients’ suicidal intention View source Lack of overnight supervision for patients being treated for eating disorders View source Transport difficulties disrupting access to eating disorder therapy View source Lack of local inpatient specialist eating disorder beds View source Shortage of local general adult psychiatric inpatient beds View source Lack of training or experience on when and how to escalate information about patients’ suicidal intent View source Failures in communication between local services and out-of-area psychiatric care providers View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Lisa Marie Inkin · 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
Lisa Marie Inkin, who had severe anorexia nervosa and was on home leave from an eating disorders unit, took her own life by diving in front of a train at Victoria Station on 9 April 2013. The report raised concerns about the lack of local specialist inpatient eating disorder services, communication between local and out-of-area providers, inadequate escalation of information about suicidal intent, possible failures to record or answer calls, and the proposed lack of overnight supervision and transport difficulties in Kent.
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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 record calls taken from patients by the ward
Wider context from the report “7. Potential failures either to record calls taken from patients by the ward or insufficient staff on duty to answer the phone to patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing to answer patients’ phone calls
Wider context from the report “7. Potential failures either to record calls taken from patients by the ward or insufficient staff on duty to answer the phone to patients .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly escalate information about patients’ suicidal intent
Wider context from the report “6. The failure on the part of the ward staff at Cygnet to appropriately escalate the information that they received about suicidal intent on Lisa’s part until the day after the information was received and it was too late for any preventative action to be 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 training or experience to recognise the importance of information about patients’ suicidal intention
Wider context from the report “8. Possible lack of training or experience on the part of Cygnet ward staff to understand the importance of receiving information about suicidal intention of one of their patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of overnight supervision for patients being treated for eating disorders
Wider context from the report “4. The lack of overnight supervision of patients being treated for eating disorders in Kent .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Transport difficulties disrupting access to eating disorder therapy
Wider context from the report “5. The possibility of transport difficulties with potential problems on pick up such as refusal to leave the home address, not being ready at the appointed time etcetera , spending more time in transport than in therapy .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of local inpatient specialist eating disorder beds
Wider context from the report “2. The complete lack of any local in-patient specialist eating disorder beds .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Shortage of local general adult psychiatric inpatient beds
Wider context from the report “1. The shortage of local General Adult Psychiatric in-patient beds .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 or experience on when and how to escalate information about patients’ suicidal intent
Wider context from the report “9. Possible lack of training or experience on the part of ward staff at Cygnet as to when and how to escalate information about suicidal intent expressed by a patient .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failures in communication between local services and out-of-area psychiatric care providers
Wider context from the report “3. The communication between local services and out of area providers of psychiatric care .
” Open source report
27 Jan 2014 Judith Lesley Marshall · Prevention of Future Deaths report York City
View report summary
Concerns raised 7 Uncertainty about availability of prescription-reading software alerts for drug identity or amount errors View source Absence of a central database of prescription errors View source Failure of colleague checking to prevent dispensing medication errors View source Lack of mandatory end-of-day reconciliation of prescription-only drugs dispensed against prescriptions View source Lack of policing of internal pharmacy error records View source Lack of mandatory read-back procedures for dispensing details View source Lack of central monitoring and trend analysis of prescription errors View source See 4 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
Judith Lesley Marshall · 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
Judith Lesley Marshall was prescribed morphine sulphate 10mg twice daily, but a pharmacy dispensed 60mg capsules. She took the capsules as prescribed and was found dead on 30 September 2009; the inquest recorded bronchopneumonia and the effects of morphine, with a conclusion of accidental death. The principal concerns were pharmacy dispensing errors, the adequacy of checking and monitoring systems, and the absence of central monitoring of prescription errors.
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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 Uncertainty about availability of prescription-reading software alerts for drug identity or amount errors
Wider context from the report “(3) It is not clear whether there is any software , obtainable from the Department of Health or elsewhere, that could read prescriptions and raise an alert if the label sought to be created or if the drug sought to be dispensed is wrong in identity or amount . This would be of particular significance when a high risk drug is dispensed or when a drug is dispensed in an unusual quantity, dosage or form.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 central database of prescription errors
Wider context from the report “(6) There is evidently no central database of all prescription errors so there can be no central monitoring of such errors and no means of determining trends or particular repeat errors.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 colleague checking to prevent dispensing medication errors
Wider context from the report “(2) Despite a system of checking by a colleague it is apparent that there can be a mistake in dispensing medication which in this case was a controlled opiate drug. The consequences were fatal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 end-of-day reconciliation of prescription-only drugs dispensed against prescriptions
Wider context from the report “(5) A mandatory check, by a suitably qualified pharmacist or by a third party, at the end of the day after cashing up on the till, of records of each (prescription only) drug dispensed against the prescription would be a further precaution against a repetition of these circumstances.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of policing of internal pharmacy error records
Wider context from the report “(1) The Pharmacy’s Errors Book shows a number of drug errors (including higher or lower dose tablets and three wrong drugs) over a number of years. It is not clear whether and to what extent such internal records are policed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 read-back procedures for dispensing details
Wider context from the report “(4) Mandatory procedures requiring a ‘read-back’ of the drug, its dosage, its frequency of administration and its total quantity may prevent such dispensing errors . In so far as the error in this case can be attributable to ‘Human Error’ it is concluded that the dispensing pharmacist focused on the figure of 60 and incorrectly attributed that to the dosage as well as to the number of capsules.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 central monitoring and trend analysis of prescription errors
Wider context from the report “(6) There is evidently no central database of all prescription errors so there can be no central monitoring of such errors and no means of determining trends or particular repeat errors .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review community-pharmacy incident data and relevant research, and engage stakeholders to develop safer-practice guidance on dispensing medicines, technology and checking systems.
Verbatim wording from the response “Unfortunately, there is little use of bar codes in the dispensing process in community pharmacy at present. Greater use of this technology in dispensaries could improve patient safety. The Safe Medication Practice Team in NHS England, plan to undertake a review of community pharmacy incident data, together with relevant research and engage with stakeholders to prepare a Patient Safety Alert for possible publication in 2014. The proposed Alert would better describe the risks arising from dispensing medicines and safer practices to further minimise these risks, including better use of technology and checking systems. This guidance will help inform health care commissioners, providers and regulators of actions that they can take to further minimise risks arising from dispensing medicines.” Source location 2014-0039-Response-by-NHS-England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Negotiate the 2014/15 community pharmacy contract to specify minimum patient-safety incident reporting rates and highlight prescribing-error reporting.
Verbatim wording from the response “a) NHS England is in the final stages of negotiating the community pharmacy Contract for 2014/15 and are planning to emphasise the requirement on community pharmacy to report patient safety incidents to the NRLS. We will look to achieve this by stipulating the minimum expected reporting rate and highlighting the requirement for prescribing error.” Source location 2014-0039-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a National Medication Safety Network and identify medication safety officers in large healthcare provider organisations, including community pharmacy companies.
Verbatim wording from the response “b) NHS England is preparing to publish a Patient Safety Alert on March 2014 to improve reporting and learning of medication errors from all sectors including community pharmacy. This will include the establishment of a National Medication Safety Network, the identification of medication safety officers in large healthcare provider organisations including community pharmacy companies and other measures into to increase the number, quality, timeliness and learning of medication error incident reports.” Source location 2014-0039-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prepare and publish a Patient Safety Alert to improve medication-error reporting and learning across healthcare sectors, including community pharmacy.
Verbatim wording from the response “b) NHS England is preparing to publish a Patient Safety Alert on March 2014 to improve reporting and learning of medication errors from all sectors including community pharmacy. This will include the establishment of a National Medication Safety Network, the identification of medication safety officers in large healthcare provider organisations including community pharmacy companies and other measures into to increase the number, quality, timeliness and learning of medication error incident reports.” Source location 2014-0039-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mandatory read-back procedures are not introduced because definitive evidence that they reduce dispensing errors is lacking.
Verbatim wording from the response “4) Mandatory procedures requiring a ‘read-back’ of the drug, its dosage, its frequency of administration and its total quantity may prevent such dispensing errors. In so far as the error in this case can be attributable to ‘Human Error’ it is concluded that the dispensing pharmacist correctly had the figure of 60 and incorrectly attributed that to the dosage as well as to the number of capsules.” Source location 2014-0039-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The National Reporting and Learning System is a central database for prescription errors, although community pharmacies underreport incidents.
Verbatim wording from the response “6) There is evidently no central database of all prescription errors so there can be no central monitoring of such errors and no means of determining trends or particular repeat errors.” Source location 2014-0039-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Community pharmacists, pharmacy staff and General Pharmaceutical Council inspectors are responsible for reviewing pharmacy incidents and addressing identified risks.
Verbatim wording from the response “Community pharmacies are required to record patient safety incidents that caused harm or have the potential to cause harm in a pharmacy errors log. They should also report these incidents to the National Reporting and Learning System (NRLS). The aim of recording and reporting incidents is to identify risks to patient safety and ensure that they are addressed both locally and nationally. Community pharmacists and their staff have responsibility to reflect on patient safety incidents that occur and identify safer practice to address these risks. Health care teams and governance systems should be in place to ensure this occurs. In a community pharmacy the responsible pharmacist and superintendent pharmacist have a particular responsibilities in this regard.” Source location 2014-0039-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mandatory end-of-day prescription reconciliation is not introduced because evidence that it reduces dispensing errors is required.
Verbatim wording from the response “5) A mandatory check, by a suitably qualified pharmacist or by a third party, at the end of the day after cashing up on the till, of records of each (prescription only) drug dispensed against the prescription would be a further precaution against a repetition of these circumstances.” Source location 2014-0039-Response-by-NHS-England
Open published response
20 Dec 2013 Adrian Johnson · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 10 Failure to secure complete health care information for ACCT reviews View source Lack of health care staff training to manage tobacco withdrawal View source Inconsistent requests for members to attend ACCT reviews View source Failure to establish individual learning from ACCT review involvement View source Unclear responsibility for tobacco-withdrawal screening and management View source Failure to ensure fully informed decisions on reducing observations for vulnerable prisoners in the Segregation Unit View source Lack of health care staff training to conduct tobacco-withdrawal screening View source Failure to routinely screen and enquire into tobacco withdrawal during prison reception screening View source Inconsistent case management for prisoners moving to the Segregation Unit View source Inadequate caremap planning View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Adrian Johnson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Adrian Johnson died by an act of accidental hanging between 12.50 and 13.55 on 13 May 2010 in the Segregation Unit of HMP Belmarsh. The report identified failures in initial screening and ACCT review processes, including inadequate attention to mental health assessment, medication needs, nicotine dependency, clinical information and protection measures. Concerns remained about prison screening for tobacco withdrawal and the consistency and adequacy of ACCT case management and observation decisions for vulnerable prisoners.
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 secure complete health care information for ACCT reviews
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews , but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered . It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 health care staff training to manage tobacco withdrawal
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal , nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inconsistent requests for members to attend ACCT reviews
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend , nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to establish individual learning from ACCT review involvement
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved . It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibility for tobacco-withdrawal screening and management
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be .
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 fully informed decisions on reducing observations for vulnerable prisoners in the Segregation Unit
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit . Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 health care staff training to conduct tobacco-withdrawal screening
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening , nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 screen and enquire into tobacco withdrawal during prison reception screening
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inconsistent case management for prisoners moving to the Segregation Unit
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit , nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 caremap planning
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning . The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report
16 Dec 2013 Cynthia Fretwell · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Delays in consultation and responses to telephone referrals View source Inability of reception staff to interrupt GPs to alert and inform them of changes in a patient’s condition following telephone referrals View source Failure to fully and properly document discussions with patients or their families View source Failure to determine an adequate threshold for telephone versus home consultation View source Failure to fully assess patients’ mental capacity when they refuse medical treatment or hospital admission View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Cynthia Fretwell · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Cynthia Fretwell, aged 84, was admitted to hospital with abdominal pain, obstructive jaundice and suspected gallbladder inflammation, but was discharged after treatment with antibiotics. She later became unwell at home, was not admitted to hospital after GP contacts including a telephone consultation, and died that evening from peritonitis resulting from an infected gall bladder that had not responded to antibiotics. Concerns included telephone referral systems and responses, the threshold for telephone versus home consultations, assessment of mental capacity when refusing treatment or admission, and documentation of discussions.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in consultation and responses to telephone referrals
Wider context from the report “(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects:
(a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral.
(b) Timely consultation and timely responses to telephone referrals from patients and their families.
(c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken.
(2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital.
(3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inability of reception staff to interrupt GPs to alert and inform them of changes in a patient’s condition following telephone referrals
Wider context from the report “(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects:
(a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral.
(b) Timely consultation and timely responses to telephone referrals from patients and their families.
(c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken.
(2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital.
(3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to fully and properly document discussions with patients or their families
Wider context from the report “(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects:
(a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral.
(b) Timely consultation and timely responses to telephone referrals from patients and their families.
(c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken.
(2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital.
(3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to determine an adequate threshold for telephone versus home consultation
Wider context from the report “(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects:
(a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral.
(b) Timely consultation and timely responses to telephone referrals from patients and their families.
(c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken.
(2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital.
(3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to fully assess patients’ mental capacity when they refuse medical treatment or hospital admission
Wider context from the report “(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects:
(a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral.
(b) Timely consultation and timely responses to telephone referrals from patients and their families.
(c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken.
(2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital.
(3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances.
” Open source report
13 Dec 2013 STEPHANIE DANIELS · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 9 Failure to complete and record patient observations View source Lack of nurse review of recent records during admission or transfer handover View source Delays in admission to an appropriate mental health bed View source Failure to properly clerk in mental health patients View source Failure to implement handover policies in practice View source Lack of clinical supervision and guidance for junior medical staff View source Failure to conduct prompt, thorough and independent investigations of serious patient deaths View source Failure of junior medical staff to review clinical records and history before prescribing medication View source Lack of a reliable method for notifying the responsible Consultant of patient admission View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
STEPHANIE DANIELS · 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
Stephanie Daniels, who had a history of serious mental health problems and repeated self-harm, was admitted to the Safire unit on 22 March 2012 after a delay in securing an inpatient bed. She died there on 24 March 2012 after being found unconscious with a ligature around her neck. The principal concerns included inadequate observation and handover, failure to clerk her in, medication-recording and supervision problems, failures in the emergency response, and deficiencies in the subsequent internal investigation.
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 complete and record patient observations
Wider context from the report “8. Performing and recording observations on other patients
I was concerned about the discovery of incomplete written observations for another patient where there are significant gaps in the records and may illustrate a systemic problem because the patient was transferred to a different ward. This was only discovered during the course of the inquest and was brought to the attention of MHSC so that they could carry out their own investigations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 nurse review of recent records during admission or transfer handover
Wider context from the report “2. Handover
All the evidence showed that the handover of information between nursing and clinical colleagues was a vital piece in the jigsaw of care. MHSC have introduced a new policy but I have a concern that simple issues may be overlooked. For new patients being admitted or transferred, there is no requirement for the nurse in charge to review their recent records . MHSC have produced new or updated policies/protocols but experience has shown that what may be delivered on paper is not being done in practice. Consequently, I am concerned that without appropriate audit and clinical/nursing leadership this may prove to be ineffective.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 admission to an appropriate mental health bed
Wider context from the report “3. Bed Availability
MHSC say that following the death of the deceased, a new policy has been introduced so that there is no waiting time at all for the allocation of a bed in the case of a patient who is deemed clinically to require one. A bed will be found somewhere which will be appropriate to their needs. As I understood the evidence from the CCG in the case this should have occurred in any event. However, other NHS Trusts nationwide who do not have such a policy, may have patients whose delayed admission means that they are not having the appropriate nursing and clinical input, as well as medication review . In turn this means their condition may continue to deteriorate and when effective care does start, the patient may well be more ill than they should be. I am concerned that the importance of this is recognised not only by MHSC but nationally for all other NHS mental health trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to properly clerk in mental health patients
Wider context from the report “4. Clerking In
The failure to properly clerk in the patient is a matter of serious concern , especially as many such patients will have physical health problems. MHSC had clear policies requiring the clerking in of a patient, but these were simply not adhered to . It is very common for patients with mental health problems to have associated physical conditions which require appropriate monitoring and treatment. It seems that despite the existence of appropriate policies, in practice these were not being complied with . Whether or not any new or different policy or auditing of compliance is the way to achieve uniformity is a matter for MHSC. I repeat what I have said earlier. MHSC have produced new or updated policies/protocols but experience has shown that what may be delivered on paper is not being done in practice. Consequently, I am concerned that without appropriate audit and clinical/nursing leadership this may prove to be ineffective.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to implement handover policies in practice
Wider context from the report “2. Handover
All the evidence showed that the handover of information between nursing and clinical colleagues was a vital piece in the jigsaw of care. MHSC have introduced a new policy but I have a concern that simple issues may be overlooked. For new patients being admitted or transferred, there is no requirement for the nurse in charge to review their recent records. MHSC have produced new or updated policies/protocols but experience has shown that what may be delivered on paper is not being done in practice . Consequently, I am concerned that without appropriate audit and clinical/nursing leadership this may prove to be ineffective .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 clinical supervision and guidance for junior medical staff
Wider context from the report “5. Supervision of Junior Medical Staff
I am concerned about the lack of appropriate clinical supervision and guidance for junior medical staff . Two junior doctors were asked to attend the ward and made no appropriate clinical records of the reason for their attendance, reviewing the records, seeing the patient and explaining any clinical decision to prescribe medication. It is appreciated that they are busy with a number of duties but it is a matter of concern that they did not undertake basic clinical recording duties for a patient who clearly should have been seen. They did not notice that the patient had not been clerked in. Medication was being prescribed without adequate consideration of the relevant clinical history. They did not notice the named Consultant in charge of the patient was unaware of the admission. Appropriate clinical supervision would be expected to ensure an appropriate standard of performance. I understand that supervision may be delegated by the North West Deanery to the relevant NHS Trust but there has to be some basic accepted levels of interaction, communication and supervision between the junior Doctors and their Consultants to ensure an appropriate standard and continuity of care. This may be a joint responsibility between the Deanery and the NHS trust involved.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct prompt, thorough and independent investigations of serious patient deaths
Wider context from the report “1. Internal NHS SUI Investigation v Independent Investigation
I am concerned that a death such as this of either a detained or voluntary patient (where Article 2 is arguably engaged) requires a prompt, thorough and robust investigation to be completed as soon as possible. Deficiencies in systems, protocols, policies, record keeping and individual actions need to be identified quickly and remedial action taken. This cannot wait for an inquest which may not take place for many months. This was not the first case of a poor or incomplete SUI investigation. The court was aware of and invited submissions about the recent case of R (Antoniou) v Central and North West London NHS Foundation Trust and others [2013] EWHC 3055 (Admin).
In this case there were significant errors and omissions in the SUI investigation . Important witnesses were not interviewed. The delay in finding the deceased a bed was not a central issue and no specific findings were made about it. The medication recording errors had not been noted and had the deceased been injected with PRN Haloperidol for severe agitation, then she should have been subject to physical observations for a continuous period of time immediately afterwards, as well as other steps in compliance with the Trust’s Rapid Tranquilisation Policy. It is accepted that SUI investigations are important and hope to learn lessons quickly to be implemented. Whilst the current law indicated that it is not a requirement for there to be an independent investigation at that stage, it is a matter of concern that very significant failures in the investigative process have occurred. The Trust investigation did not reveal at all the allegation of the commencement of discreet continuous observations on the morning of 24th March.
This is not the first time that the Trust SUI investigations have been found to be flawed and I have experience of other Trusts’ investigations also being significantly flawed. In conclusion in this sort of case I am concerned that without appropriately speedy and thorough independent investigation commissioned by the NHS Trust involved, flawed SUI investigation reports may continue to be produced . This is a policy decision for the NHS but I strongly urge consideration of this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of junior medical staff to review clinical records and history before prescribing medication
Wider context from the report “6. Prescribing of Medication by Junior Medical Staff
I am concerned by the circumstances in this case where medication came to be prescribed. There is an overlap of my concerns about supervision and my observations at paragraph 5 above should be regarded as repeated here. Both junior doctors had no recollection of attending the ward, speaking to the staff or seeing the patient. They simply prescribed the medication. They had no recollection of reviewing the deceased’s records and understood that was essential when considering prescribing any medication, and in particular PRN rapid tranquillisation. In this case, the patient was already taking a number of drugs which had sedative effects. Two further medications were introduced that have similar properties and that also could potentially affect heart function.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 reliable method for notifying the responsible Consultant of patient admission
Wider context from the report “7. Mechanism by which the Consultant in charge of the patient would learn of the patient’s admission
It is of concern that there was apparently no simple method of ensuring that the Consultant in whose name the patient was admitted became aware of the admission and could therefore ensure appropriate clinical leadership and review was undertaken. It would seem that there could be a number of simple solutions for this problem.
” Open source report
28 Nov 2013 Doris Phoebe Miller · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 3 Unavailability of a pulse oximeter in the GP surgery View source Lack of an effective communication system between GP surgeries and district nurses View source Failure to provide the GP surgery with access to transferred patient records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Doris Phoebe Miller · 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
The circumstances of Doris Phoebe Miller’s death are not provided in the supplied text. Concerns included the GP surgery’s lack of access to her transferred medical records, ineffective communication about an urgent blood test, and the absence of a pulse oximeter at the 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 Unavailability of a pulse oximeter in the GP surgery
Wider context from the report “(3) During the inquest hearing it became apparent that the surgery at Broughton Gate did not have access to a pulse oximeter to measure Mrs Miller’s oxygenation . This is a relatively inexpensive item and should perhaps be available in every doctor’s surgery throughout the country.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective communication system between GP surgeries and district nurses
Wider context from the report “(2) On the 23rd July 2013 the GP had requested the district nurses to attend Mrs Miller to carry out an urgent blood test. The GP was dismayed to discover a week later that the call out sample had not been taken and that the results, therefore, were not available to her. There appears to be no system for effective communication between the GP surgery and the district nurses . Again this gives rise to a concern that lives may be at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the GP surgery with access to transferred patient records
Wider context from the report “(1) Mrs Miller’s notes and records were unavailable to the GP surgery at Broughton Gate despite having been transferred to the surgery , following the closure of the Willen practice in April 2013. Indeed I was informed by a GP who gave evidence before me that she was still, in November 2013, unable to access the patient records . Over 2000 patients were transferred to Broughton Gate and if the circumstance above continues there is a possibility that lives will be put at risk.
” Open source report
19 Nov 2013 Barnabas Newlyn · Prevention of Future Deaths report London Inner (North)
View report summary
Concerns raised 1 Insufficient timeliness of road transfer for time-sensitive critical care patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Barnabas Newlyn · 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
Barnabas Newlyn, a four-year-old boy being treated for Ewing’s sarcoma, suffered a large intracerebral haemorrhage after collapsing at home and died following emergency surgery. The report raised concerns that road transfer times from QEQM to specialist hospitals may not provide a realistic opportunity to save patients needing time-sensitive critical care, particularly neurosurgical emergencies.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient timeliness of road transfer for time-sensitive critical care patients
Wider context from the report “In the case of Barnabas Newlyn there were particular difficulties in arranging timely transfer, and earlier transfer would have been unlikely to affect the outcome. However, the Court heard that even without such difficulties the time taken to travel by road from QEQM to Great Ormond Street Hospital does not afford a realistic opportunity to save the life of a patient needing time sensitive critical care transfer, especially neurosurgical emergencies . This may be an issue for other similarly placed hospitals elsewhere in the country where they need to transfer patients to specialist facilities at some distance . Whilst recognising that helicopter services are not directly managed or funded by NHS England, it may be helpful and appropriate for healthcare staff needing urgent transfer to start by attempting to secure air transfer.
” 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 Mobilise commissioning arrangements to discuss and standardise neurosurgical transfer protocols between local receiving units and ambulance services.
Verbatim wording from the response “Secondly we are in the process of mobilising commissioning arrangements in particular the Paediatric Neuroscience Clinical Reference Group of NHS England and the South London and Kent Trauma Network (run from Kings College Hospital – adults only) for a more comprehensive discussion about standardising protocols between the local neurosurgical receiving units (Kings College Hospital for adults and Great Ormond Street for paediatrics). These arrangements will need to encompass at least two” Source location 2013-0382-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission a report evaluating the feasibility of integrating air ambulance services more closely into the critical care neurosurgery pathway.
Verbatim wording from the response “Finally we will commission a report that looks specifically at the feasibility of building the air ambulance service more closely into the critical care neurosurgery pathway in these circumstances.” Source location 2013-0382-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue interim guidance to acute hospitals covering equipment readiness for paediatric and adult road or air transfers.
Verbatim wording from the response “Firstly in the next month we will issue interim guidance to acute hospitals which will contain the following:” Source location 2013-0382-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a programme to provide retrieval training for critical care staff in district general hospitals.
Verbatim wording from the response “3. Training will be offered to critical care staff in all district general hospitals in retrieval. This is currently a requirement of doctors in training in critical care to receive. However it is not clear the degree to which these skills are available at all times within all of our local hospitals and a programme will be established to ensure that it is so. This programme will be established within the next month.” Source location 2013-0382-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Air ambulance integration cannot yet be specified because availability is unreliable and evidence does not establish that air transfer would be quicker.
Verbatim wording from the response “The availability of an air ambulance resource was discussed in some detail. The NHS in Kent, Surrey and Sussex does have access to an air ambulance service and recently that service received clearance to fly outside the hours of daylight. It was noted however that there are difficulties in building the air ambulance service reliably into the critical care transfer pathway. Firstly the air ambulance is tasked at present to be available to respond to severe road traffic crashes. There is a single aircraft and it cannot be relied upon to be available at all time for reasons of other operational distractions or maintenance. In addition it is not clear from the evidence or experience of senior clinicians that an air ambulance transfer to Great Ormond Street would have been quicker than the 77 minutes that the road ambulance took to transfer the patient to Great Ormond Street.” Source location 2013-0382-Response-by-NHS-England
Open published response
12 Oct 2013 Carol Ann Gibson · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 4 Lack of a robust system for posting patient safety alerts View source Lack of staff understanding and training to respond appropriately to patient safety alerts View source Failure of posted patient safety alerts to correctly and sufficiently identify the problem View source Failure to check adverse-reaction alerts before prescribing View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Carol Ann Gibson · 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
Carol Ann Gibson, aged 65, died at home on 8 August 2012 following an adverse reaction to nitrofurantoin, which had been prescribed despite an alert in her medical records about a previous adverse reaction. The concerns included failure to heed and appropriately investigate the alert, and possible weaknesses in the practice’s systems and staff understanding for managing patient safety alerts.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a robust system for posting patient safety alerts
Wider context from the report “1. ████████ ignored a warning alert in the medical records that his patient had suffered an adverse reaction to nitrofurantoin without checking the nature of the adverse reaction and issued a prescription for the drug regardless.
2. A letter dated 3rd November 2008 was sent by a consultant to ████████ at Castlefields Health Centre identifying that the interstitial lung disease from which
3. ████████ on commenting on alert warnings, said that most are “trivial, spurious, irrelevant or just wrong”, identified a phenomenon that he described as alert fatigue and further stated that colleagues within the practice had admitted that they “may well have done the same in my situation”.
I am concerned that if ████████ comments correctly describe the attitude within his medical practice to patient safety alerts this is a matter of considerable concern and warrants investigation by you to ensure first of all that the practice has a robust system in place for posting such alerts , secondly that such alerts when posted, correctly and sufficiently identify the problem and thirdly that doctors and medical staff within the practice have full understanding and training to respond to such alerts in an appropriate manner.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of staff understanding and training to respond appropriately to patient safety alerts
Wider context from the report “1. ████████ ignored a warning alert in the medical records that his patient had suffered an adverse reaction to nitrofurantoin without checking the nature of the adverse reaction and issued a prescription for the drug regardless.
2. A letter dated 3rd November 2008 was sent by a consultant to ████████ at Castlefields Health Centre identifying that the interstitial lung disease from which
3. ████████ on commenting on alert warnings, said that most are “trivial, spurious, irrelevant or just wrong”, identified a phenomenon that he described as alert fatigue and further stated that colleagues within the practice had admitted that they “may well have done the same in my situation”.
I am concerned that if ████████ comments correctly describe the attitude within his medical practice to patient safety alerts this is a matter of considerable concern and warrants investigation by you to ensure first of all that the practice has a robust system in place for posting such alerts, secondly that such alerts when posted, correctly and sufficiently identify the problem and thirdly that doctors and medical staff within the practice have full understanding and training to respond to such alerts in an appropriate manner .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 posted patient safety alerts to correctly and sufficiently identify the problem
Wider context from the report “1. ████████ ignored a warning alert in the medical records that his patient had suffered an adverse reaction to nitrofurantoin without checking the nature of the adverse reaction and issued a prescription for the drug regardless.
2. A letter dated 3rd November 2008 was sent by a consultant to ████████ at Castlefields Health Centre identifying that the interstitial lung disease from which
3. ████████ on commenting on alert warnings, said that most are “trivial, spurious, irrelevant or just wrong”, identified a phenomenon that he described as alert fatigue and further stated that colleagues within the practice had admitted that they “may well have done the same in my situation”.
I am concerned that if ████████ comments correctly describe the attitude within his medical practice to patient safety alerts this is a matter of considerable concern and warrants investigation by you to ensure first of all that the practice has a robust system in place for posting such alerts, secondly that such alerts when posted, correctly and sufficiently identify the problem and thirdly that doctors and medical staff within the practice have full understanding and training to respond to such alerts in an appropriate manner.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 check adverse-reaction alerts before prescribing
Wider context from the report “1. ████████ ignored a warning alert in the medical records that his patient had suffered an adverse reaction to nitrofurantoin without checking the nature of the adverse reaction and issued a prescription for the drug regardless .
2. A letter dated 3rd November 2008 was sent by a consultant to ████████ at Castlefields Health Centre identifying that the interstitial lung disease from which
3. ████████ on commenting on alert warnings, said that most are “trivial, spurious, irrelevant or just wrong”, identified a phenomenon that he described as alert fatigue and further stated that colleagues within the practice had admitted that they “may well have done the same in my situation”.
I am concerned that if ████████ comments correctly describe the attitude within his medical practice to patient safety alerts this is a matter of considerable concern and warrants investigation by you to ensure first of all that the practice has a robust system in place for posting such alerts, secondly that such alerts when posted, correctly and sufficiently identify the problem and thirdly that doctors and medical staff within the practice have full understanding and training to respond to such alerts in an appropriate manner.
” Open source report
Concerns raised 1 Failure to ensure dissemination of incident-specific lessons to the wider healthcare community View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
David Hackman · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Hackman took up to 32 paracetamol tablets at home and was taken to hospital. After a mental health assessment, he left the Ambulatory Care Unit unnoticed, travelled to a multi-storey car park and jumped from it, dying from multiple traumatic injuries. The concern was how the lessons from this incident had been disseminated to the wider healthcare community, including other Trusts, and whether further action was needed to prevent future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure dissemination of incident-specific lessons to the wider healthcare community
Wider context from the report “At the end of the Inquest I heard evidence as regards the concordance of voluntary arrangements that were established in 2004 and as regards the national reporting and learning service but I am concerned here as regards how this specific incident and in particular its lessons are being disseminated to the wider health care community in England & Wales and in particular other Trusts. I understand the general principle but I would be grateful if you could please specifically explain relevant to this particular incident and the learning exercise that’s been carried out as to how the lessons learned have been communicated and if they have not been communicated to review as to why no action is being taken in that respect with a view to the prevention of future deaths.
” Open source report
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