Concerns raised 2 Lack of inpatient psychiatric beds causing unacceptable A&E waits for people awaiting mental health beds View source Unsuitability of A&E as a holding environment for people awaiting mental health beds View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sapphire Kathleen BERNARD · 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
Sapphire Kathleen BERNARD was detained under the Mental Health Act and waited 19 days in an A&E department for a psychiatric bed while continuing to self-ligature. After admission to Langley Green Hospital, she self-tied a ligature while on intermittent observations and died at East Surrey Hospital on 30 October 2023. The principal concerns were the lack of psychiatric beds, the unsuitability of A&E as a holding environment for people needing mental health care, and vulnerabilities in the risk assessment and observation requirements at Langley Green Hospital.
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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 inpatient psychiatric beds causing unacceptable A&E waits for people awaiting mental health beds
Wider context from the report “1. The lack of inpatient beds leading to the unacceptable wait time in A&E for those suffering with their mental health who are awaiting a psychiatric 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 Unsuitability of A&E as a holding environment for people awaiting mental health beds
Wider context from the report “3. The unsuitability of the environment of A&E as a holding place for those in need of a mental health bed .
4. The evidence was that the environment in A&E as a holding place is not conducive for those suffering with Autism and/or who are neurodiverse . The environment in A&E can exacerbate and cause further deterioration in their mental health
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Measure response times for people presenting to urgent and emergency mental-health services to support faster access to appropriate care.
Verbatim wording from the response “NHS England’s ambition is not just to improve the access point and connection to the specialist mental health points of access, but to bring significant improvements and expansion in the mental health services that ‘sit behind’ the point of access, so that people can be facilitated to access support that meets their needs and preferences in a more timely way. To this effect, we are moving at pace and are beginning to measure response times to those presenting to urgent and emergency mental health services, either in the community and/or emergency departments, with the aim of supporting these people to access appropriate care more quickly.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor patients waiting more than 72 hours in emergency departments for mental-health placements and escalate cases nationally for executive intervention.
Verbatim wording from the response “NHS England recognises the unsuitability of emergency departments for people experiencing mental health crisis once their immediate physical health needs have been attended to. We are aware of the increasing numbers of patients waiting in emergency departments for mental health beds and, since the time of this incident, we have introduced national level monitoring of all patients in emergency departments waiting over 72 hours for mental health placements. Due to this oversight, individual patient cases are escalated at a national level and executive input is then sought to expedite care.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide trusts and systems with action cards to reduce emergency-department waiting times, including actions for people with complex learning disabilities and autism.
Verbatim wording from the response “From Winter 2024/25 we have also introduced action cards for trusts and systems, articulating key actions to be taken by trusts and systems to reduce the time patients spend in emergency departments. These include specific actions for people with complex learning disabilities and autism.” Source location Response from NHS England
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and finalise a South East standard operating procedure for managing mental-health presentations in A&E departments.
Verbatim wording from the response “NHS England’s South East region’s Mental Health, Learning Disability and Autism (MHLDA) Team are in the process of developing a Standard Operating Procedure (SOP) for managing mental health presentations with A&E departments. This has followed Quality & Safety visits to A&E departments, which have concluded that patients are safer being admitted. The SOP should be approved and finalised by April 2025 and findings are due to be shared with South East ICBs, as well as multi-disciplinary teams and the Urgent & Elective Care (UEC) Recovery Board.” Source location Response from NHS England
Open published response
Concerns raised 5 Reluctance of patients to attend the emergency department because of long waiting times View source Delays in emergency treatment caused by unavailable inpatient beds View source Unavailability of beds for emergency department patients View source Failure to free hospital beds occupied by patients medically fit for discharge View source Delays in emergency department patients being seen by a doctor View source See 2 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
Dorothy Lilian REID · 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
Dorothy Reid, a 91-year-old woman, suffered spinal fractures after a fall and later died from a pulmonary embolism on 3 April 2024. Concerns included delays and poor conditions in the emergency department, the impact of hospital bed shortages on emergency care, and patients’ reluctance to attend hospital because of long waiting times.
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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 Reluctance of patients to attend the emergency department because of long waiting times
Wider context from the report “(3) When asked about whether the delays led to a risk of deaths to others evidence was brought to the courts attention that the President of the Royal College of Emergency Medicine has published an analysis of the impact that this is having and that there are a significant number deaths associated with long waits in the emergency department. This, in conjunction with the reluctance of patients to attend the emergency department due to long waiting times clearly gives rise to a risk of future deaths unless something is done.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 emergency treatment caused by unavailable inpatient beds
Wider context from the report “(2) Both attendances at the emergency department were on busy shifts but evidence heard from staff was that this was not unusual and the reasons being that beds in the hospital are blocked by patients who are medically fit for discharge. The evidence heard was that on average around 25% of the hospital beds were filled with patients who did not need to be there which in turn leads to patients who need to be admitted not having a bed to be admitted into . This in turn leads to patients waiting in the emergency department for a bed . This places unnecessary pressure on the emergency departments and leads to delays for those seeking emergency treatment . The evidence heard suggested that this was a national not local problem.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 beds for emergency department patients
Wider context from the report “(1) During the course of the evidence it became clear that on both attendances to the emergency department at QEQM she had to wait on a chair as there were no beds . The first attendance led to such a poor experience that she chose not to go back to hospital when an ambulance was called on 31 March 2024. Had she gone to hospital on 31 March 2024 when advised to do so it is likely that her pulmonary embolus would have been diagnosed in the emergency department and treated and she would not have died when she did. Delays in being seen by a doctor at the second attendance were of concern but were found not to be causative of her death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to free hospital beds occupied by patients medically fit for discharge
Wider context from the report “(2) Both attendances at the emergency department were on busy shifts but evidence heard from staff was that this was not unusual and the reasons being that beds in the hospital are blocked by patients who are medically fit for discharge . The evidence heard was that on average around 25% of the hospital beds were filled with patients who did not need to be there which in turn leads to patients who need to be admitted not having a bed to be admitted into. This in turn leads to patients waiting in the emergency department for a bed. This places unnecessary pressure on the emergency departments and leads to delays for those seeking emergency treatment. The evidence heard suggested that this was a national not local problem.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 emergency department patients being seen by a doctor
Wider context from the report “(1) During the course of the evidence it became clear that on both attendances to the emergency department at QEQM she had to wait on a chair as there were no beds. The first attendance led to such a poor experience that she chose not to go back to hospital when an ambulance was called on 31 March 2024. Had she gone to hospital on 31 March 2024 when advised to do so it is likely that her pulmonary embolus would have been diagnosed in the emergency department and treated and she would not have died when she did. Delays in being seen by a doctor at the second attendance were of concern but were found not to be causative of her death.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen use of Discharge Ready Date and Reason for Discharge Delay data to identify and reduce discharge delays.
Verbatim wording from the response “NHS England recognises the significant impact that delayed discharges have on hospital flow, ambulance handovers and the patients affected by these delays. To address this, we are strengthening the use of Discharge Ready Date (DRD) and Reason for Discharge Delay (RfDD) data to gain a clearer understanding of discharge delays and their key contributing factors, both locally and nationally, so that measures can be taken to reduce the number of patients occupying beds who are ready for discharge.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with local areas and health, social care and local-government partners to maximise discharge-funding impact and improve timely patient discharge.
Verbatim wording from the response “Over the coming year we will be working with local areas to support them to maximise the impact of this investment, for example by providing additional or enhanced support to those areas which face particular challenges, and working with partners in local government and social care including the Local Government Association (LGA), Directors of Social Services (DASSs) and Care and Health Improvement Advisers (CHIAs) to support local systems to improve timely discharge of patients.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Collect weekly data on patients waiting over 100 days for discharge and use system leadership, coordination calls and regional engagement to enable appropriate discharge.
Verbatim wording from the response “In addition, to reduce the number of very long discharge waits, we have been collecting weekly data to identify the number of patients waiting over 100 days and will ensure actions are being taken through system leadership to enable patients to be discharged to the most appropriate setting as soon as possible. The patients identified as waiting over 100 days will be discussed at a weekly National Coordination Centre call, and themes will be tracked through weekly regional engagement meetings.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake regional Emergency Department quality and safety visits to identify challenges and support safe care and performance improvement.
Verbatim wording from the response “NHS England’s South East region has undertaken Quality & Safety visits to EDs across the region to understand the challenges faced in delivering safe and effective care. This has identified next steps, to include sharing learning and best practice, and ensuring a quality and safety focus on performance recovery and improvement.” Source location Response from NHS England
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue operating-model work with regions to support providers in reducing Emergency Department crowding.
Verbatim wording from the response “NHS England will continue to work through the operating model and assist its Regions with supporting providers to reduce crowding in EDs. In the longer term, NHS England hopes to eliminate this by focusing on reducing the number of patients that wait longer than 12 hours in EDs. Improvements are being demonstrated through NHS England’s operational planning guidance, where systems were asked to focus on areas to deliver improved patient flow such as increasing the proportion of patients streamed to alternative services such as urgent treatment centres (UTCs), same day emergency care (SDEC) and acute frailty services (AFS). This includes increasing the productivity of acute and non-acute hospital services, improving flow as well as clinical outcomes.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Collect daily data on patients experiencing long Emergency Department waits and track actions to support appropriate accommodation and patient-safety review.
Verbatim wording from the response “NHS England has commenced a data collection of patients experiencing long waits in Emergency Departments on a daily basis and will ensure actions are in place to appropriately accommodate these patients as soon as possible. The data is discussed at the National Coordination Centre call, with actions tracked to ensure executive oversight and assurance as well as patient safety and harm reviews of/for patients waiting.” Source location Response from NHS England
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue operational planning guidance requiring systems to improve patient flow through alternative urgent and emergency care services.
Verbatim wording from the response “NHS England will continue to work through the operating model and assist its Regions with supporting providers to reduce crowding in EDs. In the longer term, NHS England hopes to eliminate this by focusing on reducing the number of patients that wait longer than 12 hours in EDs. Improvements are being demonstrated through NHS England’s operational planning guidance, where systems were asked to focus on areas to deliver improved patient flow such as increasing the proportion of patients streamed to alternative services such as urgent treatment centres (UTCs), same day emergency care (SDEC) and acute frailty services (AFS). This includes increasing the productivity of acute and non-acute hospital services, improving flow as well as clinical outcomes.” Source location Response from NHS England
Open published response
31 Jan 2025 Nicola Emma OWENS · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 4 Unavailability of ambulances for attending patients View source Lack of staff and room for patients brought in via ambulance View source Delays in hospital handover of ambulance patients View source Backlog of patients fit for discharge awaiting social care packages View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Nicola Emma OWENS · 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
Nicola Emma Owens collapsed at work on 4 October 2024 and, after a delay of 7 hours and 28 minutes before an ambulance arrived, suffered a cardiac arrest and died in hospital at 00:25 on 5 October 2024. The report identified concerns about ambulance unavailability, hospital handover delays, and backlogs of patients awaiting social care packages, which reduced ambulance availability for seriously ill patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unavailability of ambulances for attending patients
Wider context from the report “The delay in an ambulance attending patients due to the unavailability of ambulances . This delay being significantly contributed to by the handover delays in hospitals. A significant factor contributing to the handover delays in hospitals being the backlog of patients who are fit for discharge but awaiting social care packages. Overall, this entails a lack of staff and room for those patients who are brought in via ambulance thus requiring ambulance crews to remain on hospital premises reducing their ability to attend seriously ill 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 staff and room for patients brought in via ambulance
Wider context from the report “The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals. A significant factor contributing to the handover delays in hospitals being the backlog of patients who are fit for discharge but awaiting social care packages. Overall, this entails a lack of staff and room for those patients who are brought in via ambulance thus requiring ambulance crews to remain on hospital premises reducing their ability to attend seriously ill 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 Delays in hospital handover of ambulance patients
Wider context from the report “The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals. A significant factor contributing to the handover delays in hospitals being the backlog of patients who are fit for discharge but awaiting social care packages. Overall, this entails a lack of staff and room for those patients who are brought in via ambulance thus requiring ambulance crews to remain on hospital premises reducing their ability to attend seriously ill 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 Backlog of patients fit for discharge awaiting social care packages
Wider context from the report “The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals. A significant factor contributing to the handover delays in hospitals being the backlog of patients who are fit for discharge but awaiting social care packages . Overall, this entails a lack of staff and room for those patients who are brought in via ambulance thus requiring ambulance crews to remain on hospital premises reducing their ability to attend seriously ill patients.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the 2025/26 Better Care Fund policy framework and planning requirements to support coordinated health and social care discharge plans.
Verbatim wording from the response “NHS England has also published the 2025/26 Better Care Fund (BCF) policy framework and planning requirements, working alongside the Department of Health and Social Care (DHSC) and Ministry of Housing, Communities and Local Government. The BCF framework supports local systems to jointly agree plans across health and care, including supporting the flow of patients through UEC.” Source location Response from NHS England
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen use of Discharge Ready Date data in operational decision-making to identify delays and support timely discharge.
Verbatim wording from the response “NHS England recognises that delayed discharges have a significant impact on hospital flow, capacity and ambulance handovers. In order to address this, NHS England is strengthening the use of Discharge Ready Date (DRD) data in order to gain a clearer understanding of discharge delays and their key contributing factors.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement plans to improve ambulance handovers, response times and urgent and emergency care flow.
Verbatim wording from the response “NHS England recognises the significant pressure on all NHS services, including ambulance services, and has been prioritising improvements to Category 2 response times and urgent and emergency care (UEC) services. NHS England also recognises that in order to support improved patient flow, there is the need to improve ambulance capacity through growing the workforce, reducing handover delays, speeding up discharges from hospital and expanding new services in the community.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with local areas and health, social care and local government partners to improve timely hospital discharge and maximise discharge-funding impact.
Verbatim wording from the response “NHS England will be working with local areas to support them to maximise the impact of this investment over the coming year, by providing additional or enhanced support to those areas which face particular challenges, and working with partners in local government and social care including Local Government Associations, Directors of Social Services, and Care and Health Improvement advisors to support local systems to improve timely discharge of patients.” Source location Response from NHS England
Open published response
24 Jan 2025 Charlie Marriage · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Failure to maintain medical oversight of medication-dependent patients until appropriately medicated View source Failure to recognise and communicate medication-related crisis vulnerability in medical records View source Failure to provide appropriately urgent clinical support and safety-netting for medication-related crisis risk View source Failure to ensure medication-dependent patients understand medication-related death risks and plan emergency action View source Failure to account for unreliable local pharmacy availability of urgently needed medication View source Provision of generic safety-netting advice to patients at risk of sudden medication-related crisis View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Charlie Marriage · 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
Charlie Marriage, who had epilepsy controlled with Fycompa, was unable to obtain his repeat medication after being told to self-isolate for Covid and encountering difficulties with his GP practice, pharmacy and 111. He suffered a fatal seizure at home after going without medication. The report identified concerns about whether patients with medication-dependent, “cliff-edge conditions” are recognised, prioritised and given appropriate safety-netting and access to emergency supplies.
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 maintain medical oversight of medication-dependent patients until appropriately medicated
Wider context from the report “(1) There are cohorts of patients who are medication dependant. For some their underlying condition is such that absent this medication they are at significant risk of a sudden crisis, and potentially death e.g. SUDEP, or Diabetic Ketoacidosis etc. These were described at the inquest as “cliff-edge conditions”.
(2) It is not apparent that these patients are currently identified within the health system as being at risk of a sudden crisis and death (absent their medication) so as to manage the following concerns giving rise to a risk of future deaths:
(a) that such patients may not be fully aware of the risks of death associated with not being medicated and therefore may (i) not fully understand the importance of avoiding the risk that this scenario arises, and (ii) not have planned the likely best course of action in the event that it does (e.g. to go to A&E, or to approach an identified pharmacy for an emergency supply);
(b) that the potential urgency and level of danger is not quickly identified and understood in the scenario where they seek medical advice and/or medication (i.e. that their potential vulnerability is not well recognised and communicated on/within the medical records accessed by those in the health sector, such that patients are not supported with appropriate urgency or safety-netting advice);
(c) that it is not recognised that sending to them to a pharmacy may not reliably mitigate their risks quickly where it is unlikely the medication can be expected to be in stock (i.e. the risk that it may not be identified that for some patients their medication is not likely easily available on an ad hoc local basis); and
(d) that they are given generic safety-netting/worsening advice, whereas such patients may not present with any developing or new before suffering a sudden crisis and therefore remain at significant risk without medical oversight until appropriately medicated .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and communicate medication-related crisis vulnerability in medical records
Wider context from the report “(1) There are cohorts of patients who are medication dependant. For some their underlying condition is such that absent this medication they are at significant risk of a sudden crisis, and potentially death e.g. SUDEP, or Diabetic Ketoacidosis etc. These were described at the inquest as “cliff-edge conditions”.
(2) It is not apparent that these patients are currently identified within the health system as being at risk of a sudden crisis and death (absent their medication) so as to manage the following concerns giving rise to a risk of future deaths:
(a) that such patients may not be fully aware of the risks of death associated with not being medicated and therefore may (i) not fully understand the importance of avoiding the risk that this scenario arises, and (ii) not have planned the likely best course of action in the event that it does (e.g. to go to A&E, or to approach an identified pharmacy for an emergency supply);
(b) that the potential urgency and level of danger is not quickly identified and understood in the scenario where they seek medical advice and/or medication (i.e. that their potential vulnerability is not well recognised and communicated on/within the medical records accessed by those in the health sector , such that patients are not supported with appropriate urgency or safety-netting advice);
(c) that it is not recognised that sending to them to a pharmacy may not reliably mitigate their risks quickly where it is unlikely the medication can be expected to be in stock (i.e. the risk that it may not be identified that for some patients their medication is not likely easily available on an ad hoc local basis); and
(d) that they are given generic safety-netting/worsening advice, whereas such patients may not present with any developing or new before suffering a sudden crisis and therefore remain at significant risk without medical oversight until appropriately medicated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 appropriately urgent clinical support and safety-netting for medication-related crisis risk
Wider context from the report “(1) There are cohorts of patients who are medication dependant. For some their underlying condition is such that absent this medication they are at significant risk of a sudden crisis, and potentially death e.g. SUDEP, or Diabetic Ketoacidosis etc. These were described at the inquest as “cliff-edge conditions”.
(2) It is not apparent that these patients are currently identified within the health system as being at risk of a sudden crisis and death (absent their medication) so as to manage the following concerns giving rise to a risk of future deaths:
(a) that such patients may not be fully aware of the risks of death associated with not being medicated and therefore may (i) not fully understand the importance of avoiding the risk that this scenario arises, and (ii) not have planned the likely best course of action in the event that it does (e.g. to go to A&E, or to approach an identified pharmacy for an emergency supply);
(b) that the potential urgency and level of danger is not quickly identified and understood in the scenario where they seek medical advice and/or medication (i.e. that their potential vulnerability is not well recognised and communicated on/within the medical records accessed by those in the health sector, such that patients are not supported with appropriate urgency or safety-netting advice );
(c) that it is not recognised that sending to them to a pharmacy may not reliably mitigate their risks quickly where it is unlikely the medication can be expected to be in stock (i.e. the risk that it may not be identified that for some patients their medication is not likely easily available on an ad hoc local basis); and
(d) that they are given generic safety-netting/worsening advice, whereas such patients may not present with any developing or new before suffering a sudden crisis and therefore remain at significant risk without medical oversight until appropriately medicated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 medication-dependent patients understand medication-related death risks and plan emergency action
Wider context from the report “(1) There are cohorts of patients who are medication dependant. For some their underlying condition is such that absent this medication they are at significant risk of a sudden crisis, and potentially death e.g. SUDEP, or Diabetic Ketoacidosis etc. These were described at the inquest as “cliff-edge conditions”.
(2) It is not apparent that these patients are currently identified within the health system as being at risk of a sudden crisis and death (absent their medication) so as to manage the following concerns giving rise to a risk of future deaths:
(a) that such patients may not be fully aware of the risks of death associated with not being medicated and therefore may (i) not fully understand the importance of avoiding the risk that this scenario arises, and (ii) not have planned the likely best course of action in the event that it does (e.g. to go to A&E, or to approach an identified pharmacy for an emergency supply);
(b) that the potential urgency and level of danger is not quickly identified and understood in the scenario where they seek medical advice and/or medication (i.e. that their potential vulnerability is not well recognised and communicated on/within the medical records accessed by those in the health sector, such that patients are not supported with appropriate urgency or safety-netting advice);
(c) that it is not recognised that sending to them to a pharmacy may not reliably mitigate their risks quickly where it is unlikely the medication can be expected to be in stock (i.e. the risk that it may not be identified that for some patients their medication is not likely easily available on an ad hoc local basis); and
(d) that they are given generic safety-netting/worsening advice, whereas such patients may not present with any developing or new before suffering a sudden crisis and therefore remain at significant risk without medical oversight until appropriately medicated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 account for unreliable local pharmacy availability of urgently needed medication
Wider context from the report “(1) There are cohorts of patients who are medication dependant. For some their underlying condition is such that absent this medication they are at significant risk of a sudden crisis, and potentially death e.g. SUDEP, or Diabetic Ketoacidosis etc. These were described at the inquest as “cliff-edge conditions”.
(2) It is not apparent that these patients are currently identified within the health system as being at risk of a sudden crisis and death (absent their medication) so as to manage the following concerns giving rise to a risk of future deaths:
(a) that such patients may not be fully aware of the risks of death associated with not being medicated and therefore may (i) not fully understand the importance of avoiding the risk that this scenario arises, and (ii) not have planned the likely best course of action in the event that it does (e.g. to go to A&E, or to approach an identified pharmacy for an emergency supply);
(b) that the potential urgency and level of danger is not quickly identified and understood in the scenario where they seek medical advice and/or medication (i.e. that their potential vulnerability is not well recognised and communicated on/within the medical records accessed by those in the health sector, such that patients are not supported with appropriate urgency or safety-netting advice);
(c) that it is not recognised that sending to them to a pharmacy may not reliably mitigate their risks quickly where it is unlikely the medication can be expected to be in stock (i.e. the risk that it may not be identified that for some patients their medication is not likely easily available on an ad hoc local basis ); and
(d) that they are given generic safety-netting/worsening advice, whereas such patients may not present with any developing or new before suffering a sudden crisis and therefore remain at significant risk without medical oversight until appropriately medicated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Provision of generic safety-netting advice to patients at risk of sudden medication-related crisis
Wider context from the report “(1) There are cohorts of patients who are medication dependant. For some their underlying condition is such that absent this medication they are at significant risk of a sudden crisis, and potentially death e.g. SUDEP, or Diabetic Ketoacidosis etc. These were described at the inquest as “cliff-edge conditions”.
(2) It is not apparent that these patients are currently identified within the health system as being at risk of a sudden crisis and death (absent their medication) so as to manage the following concerns giving rise to a risk of future deaths:
(a) that such patients may not be fully aware of the risks of death associated with not being medicated and therefore may (i) not fully understand the importance of avoiding the risk that this scenario arises, and (ii) not have planned the likely best course of action in the event that it does (e.g. to go to A&E, or to approach an identified pharmacy for an emergency supply);
(b) that the potential urgency and level of danger is not quickly identified and understood in the scenario where they seek medical advice and/or medication (i.e. that their potential vulnerability is not well recognised and communicated on/within the medical records accessed by those in the health sector, such that patients are not supported with appropriate urgency or safety-netting advice);
(c) that it is not recognised that sending to them to a pharmacy may not reliably mitigate their risks quickly where it is unlikely the medication can be expected to be in stock (i.e. the risk that it may not be identified that for some patients their medication is not likely easily available on an ad hoc local basis); and
(d) that they are given generic safety-netting/worsening advice , whereas such patients may not present with any developing or new before suffering a sudden crisis and therefore remain at significant risk without medical oversight until appropriately medicated.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission and launch the Pharmacy First service to support timely access to urgently required medicines.
Verbatim wording from the response “This guidance is further supported by the service specification for the NHS Pharmacy First service that was launched on 31 January 2024 (NHS England » Launch of NHS Pharmacy First advanced service). In cases where medication that is urgently required is not in stock at the pharmacy, the service specification states that, with the agreement of the patient, the pharmacist should identify another pharmacy that provides the service and forward the electronic referral to them (see 4.19). If the patient is unable to get to the premises, the pharmacist must ensure that the patient is able to obtain the supply in a timely manner by discussing all reasonable options for accessing their medicines (see 4.20).” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Investigate technology to track medication stocks across community pharmacies and improve management of high-impact national shortages.
Verbatim wording from the response “Current technology does not allow the tracking of stocks of medication across community pharmacies. This is being investigated as a strategy to better manage high-impact national shortages of medication.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the Medicines Safety Improvement Programme to improve access to time-critical medicines for people with cliff-edge conditions, including epilepsy, and incorporate learning from Charlie’s death.
Verbatim wording from the response “NHS England has instigated the Medicines Safety Improvement Programme which has been working to improve access to “Time Critical Medicines”. The focus of attention is to identify people with “cliff-edge conditions” and then to ensure they have the time critical medicines they need to prevent rapid deterioration. The programme started in 2024 and has identified a small number of “cliff-edge conditions” that may benefit from improved processes. Epilepsy is one of the conditions identified, and a key ambition of the programme is to improve care for people with epilepsy. This programme is being delivered in partnership with Epilepsy Action and Parkinson’s UK (alongside other charities) and is planned to run until March 2027. It will take into account the learning from Charlie’s death.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Current technology cannot track medication stocks across community pharmacies, limiting the ability to implement such tracking nationally.
Verbatim wording from the response “Current technology does not allow the tracking of stocks of medication across community pharmacies. This is being investigated as a strategy to better manage high-impact national shortages of medication.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation It is not safely possible to differentiate medication urgency because of variable uses, brand names and alternative condition descriptions.
Verbatim wording from the response “All medications are treated with the same high priority. Due to the variable use of medications for different presentations, the use of brand names and alternative descriptions for conditions, it is not safely possible to differentiate between different levels of urgency.” Source location Response from NHS England
Open published response
Concerns raised 2 Failure to provide and replace medical equipment with correct, functional equipment View source Delays in delivering required medical equipment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sheila Josephine WEXLER · 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
Sheila Wexler lived with dementia and other significant comorbidities and died at home on 17 February 2024 from bilateral pulmonary embolism. Delays in supplying equipment and the provision of defective turning equipment significantly increased her immobility, contributing to her death. The report identified ongoing concerns about delays and defective equipment supplied by NRS Healthcare, including wider risks affecting other patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide and replace medical equipment with correct, functional equipment
Wider context from the report “NRS Healthcare related matters:
I heard evidence of a delay in delivering some of the required equipment, which in turn meant a delay in the patient being able to make use of the equipment. The delay meant that the patient’s family, carers, and the district nursing team underwent a period of time in which they were unable to provide the patient with the optimal care required in relation to the pressure ulcer.
When the TOTO turning system arrived it was defective. An urgent repair/replace request was made to NRS Healthcare, which resulted in an engineer attending the patient’s home to replace the pump on 23 January 2024. However, despite advising that they had replaced the pump with a like-for-like pump, it transpired that the replacement pump was a ‘Tri-Pos Bariatric Alternating Air Cushion’ pump. This replacement pump had none of the settings that would allow the proper and effective use of the TOTO system. In this instance, the TOTO system was required to turn the patient from one side to the other every 60 minutes. I was told in evidence that equipment issues would have added to the patients ‘pain and distress’ and the fitting of the incorrect pump meant that the patient was not being turned every 60 minutes, as required. Again, this creates the risk that those caring for the patient were precluded from providing an optimal level of care.
While the presence of a pressure ulcer, in itself, did not add to the underlying risk of the patient developing a pulmonary embolism, the delayed and defective equipment provided significantly increased the patient’s immobility in the weeks prior to her death. There was evidence that immobility is a major risk factor in the development of pulmonary emboli.
I heard evidence that issues with delays and defective equipment from NRS Healthcare persist to date .
NRS Healthcare and NHS England related matters:
I heard evidence that since being awarded the contract to provide such equipment, there had been numerous and ongoing delays and ‘problems’ in the service provided by NRS Healthcare. The evidence was such that the repeated issues and concerns had actually been placed on the Trust/Integrated Care Board’s (ICBs) risk register. While I heard that there had been some improvement, I was told that the service provided was still ‘not great’.
While this particular case is the first in which I have formed the opinion that delayed and defective equipment has created a risk of future deaths, I have heard similar evidence of delayed and defective equipment issues relating to NRS Healthcare in other inquests concerning different NHS Trusts and ICBs. On that basis, I am also of the opinion, given NRS Healthcare’s operations are not confined to organisations within this coroner area, that the risks posed are likely to be more widespread and that action should be taken more widely.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 delivering required medical equipment
Wider context from the report “NRS Healthcare related matters:
I heard evidence of a delay in delivering some of the required equipment , which in turn meant a delay in the patient being able to make use of the equipment. The delay meant that the patient’s family, carers, and the district nursing team underwent a period of time in which they were unable to provide the patient with the optimal care required in relation to the pressure ulcer.
When the TOTO turning system arrived it was defective. An urgent repair/replace request was made to NRS Healthcare, which resulted in an engineer attending the patient’s home to replace the pump on 23 January 2024. However, despite advising that they had replaced the pump with a like-for-like pump, it transpired that the replacement pump was a ‘Tri-Pos Bariatric Alternating Air Cushion’ pump. This replacement pump had none of the settings that would allow the proper and effective use of the TOTO system. In this instance, the TOTO system was required to turn the patient from one side to the other every 60 minutes. I was told in evidence that equipment issues would have added to the patients ‘pain and distress’ and the fitting of the incorrect pump meant that the patient was not being turned every 60 minutes, as required. Again, this creates the risk that those caring for the patient were precluded from providing an optimal level of care.
While the presence of a pressure ulcer, in itself, did not add to the underlying risk of the patient developing a pulmonary embolism, the delayed and defective equipment provided significantly increased the patient’s immobility in the weeks prior to her death. There was evidence that immobility is a major risk factor in the development of pulmonary emboli.
I heard evidence that issues with delays and defective equipment from NRS Healthcare persist to date .
NRS Healthcare and NHS England related matters:
I heard evidence that since being awarded the contract to provide such equipment, there had been numerous and ongoing delays and ‘problems’ in the service provided by NRS Healthcare. The evidence was such that the repeated issues and concerns had actually been placed on the Trust/Integrated Care Board’s (ICBs) risk register. While I heard that there had been some improvement, I was told that the service provided was still ‘not great’.
While this particular case is the first in which I have formed the opinion that delayed and defective equipment has created a risk of future deaths, I have heard similar evidence of delayed and defective equipment issues relating to NRS Healthcare in other inquests concerning different NHS Trusts and ICBs. On that basis, I am also of the opinion, given NRS Healthcare’s operations are not confined to organisations within this coroner area, that the risks posed are likely to be more widespread and that action should be taken more widely.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue regional meetings with equipment commissioners and key partners to oversee performance indicators and support consortium members and associated providers.
Verbatim wording from the response “• NHS England’s London regional team continue to meet with the equipment commissioners and key partners to oversee and monitor key performance indicators, to support consortium members and associated providers.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct weekly oversight meetings with commissioners and key partners to identify equipment-access concerns, review performance indicators, and monitor improvement.
Verbatim wording from the response “To review, address and monitor these issues, weekly oversight meetings were initiated with members of the London regional team, the commissioners of the equipment contract (Royal Borough of Kensington and Chelsea/Westminster City Council) and key partners, to identify areas of concern, review core key performance indicators and monitor improvement trajectories.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for the equipment contract and its oversight rests with the London Community Equipment Consortium and local authorities, not NHS England.
Verbatim wording from the response “NRS Healthcare are listed on the NHS Supply Chain Framework for Aids for Daily Living, for the supply of basic living aids with no service or maintenance provision included in the Framework. The Framework does not include the provision of the lateral turning system. The contract for services described in your Report has not been contracted through NHS England’s NHS Supply Chain team and our national Framework, but through the London Community Equipment Consortium, a consortium of 21 London boroughs/local authorities (LAs), in a contract awarded by the Cabinet Member for Adult Social Care, Public Health and the Voluntary Sector running from 1 April 2023 to 31 March 2028. The Coroner may therefore wish to refer your concerns to the Department of Health and Social Care (DHSC) or the London Consortium.” Source location Response from NHS England
Open published response
2 Jan 2025 Alexandra Bronte Roberts · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1 Inability to prescribe smaller quantities of insulin View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alexandra Bronte Roberts · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alexandra Bronte Roberts, who had a history of mental health issues, self-harm and Type 1 diabetes, died after intentionally overdosing on her prescribed insulin on 13 May 2023. The principal concern was that insulin could only be prescribed in pre-filled pens containing around 10 days’ supply, enabling access to a large overdose, whereas smaller amounts could have reduced the risk.
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 Inability to prescribe smaller quantities of insulin
Wider context from the report “1. The minimum amount of insulin available to be prescribed at the time of Alex’s death was 300 units , amounting to around 10 days of medication for Alex, enabling her to take a large overdose. The Court heard evidence that had it been possible to prescribe a smaller amount, the smaller amount would have been prescribed so as to reduce the risk of overdose .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The MHRA is the more appropriate organisation to respond to concerns about the insulin doses currently available to patients.
Verbatim wording from the response “As your Report notes, the smallest quantity of insulin within a single pen device is currently 300 units of insulin. You may wish to refer to the Medicines and Healthcare products Regulatory Agency (MHRA) as the UK’s regulator of medicines regarding your concerns, as they would be the more appropriate organisation to respond on the insulin doses currently available to patients.” Source location Response from NHS England
Open published response
Concerns raised 2 Restricted access to naloxone kits through substance misuse services View source Failure of supported accommodation providers and mental health NHS trusts to provide naloxone kits to known drug users View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joseph Benjamin FORBES BLACK · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joseph Forbes Black was found deceased at his home on 9 August 2023, having died from acute polydrug toxicity involving heroin adulterated with protonitazene and metonitazene. The report’s principal concern was that naloxone kits were not permitted to be provided by the supported accommodation provider or mental health NHS Trust to known drug users, while access was concentrated through substance misuse services with which many drug users were not engaged. The concern was considered potentially nationwide and heightened by the increased incidence of heroin adulterated with potent synthetic opioids.
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 Restricted access to naloxone kits through substance misuse services
Wider context from the report “The evidence revealed that, neither the supported accommodation provider nor the mental health NHS Trust that was treating Mr Forbes Black were permitted to give naloxone kits to their residents/patients who were known drug users.
In my experience, from this inquest and others, a significant proportion of illicit drug users are not engaged with or decline to engage with substance misuse services for a number of possible reasons. The evidence in the inquest was that, if a drug-user wanted to have naloxone in their possession as a safety-net measure, they would need to obtain this from a local substance misuse service .
I am concerned that this set of circumstances raises the risk of future deaths occurring because the provision of naloxone kits could be made more widely available to those most likely to need them. The present situation appears to be that naloxone is most easily accessed through the very service(s) that many drug-users are not engaged with . My concern, based on the evidence heard at this inquest and others that I am aware of, is that this is not a localised matter and is more likely a nationwide issue and that action should be taken more widely.
It further seems to me that the need for action is heightened by the increased incidence of heroin having been adulterated with ‘nitazenes’ (particularly potent synthetic opioid drugs), which increases the risk of drug users unwittingly overdosing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 supported accommodation providers and mental health NHS trusts to provide naloxone kits to known drug users
Wider context from the report “The evidence revealed that, neither the supported accommodation provider nor the mental health NHS Trust that was treating Mr Forbes Black were permitted to give naloxone kits to their residents/patients who were known drug users .
In my experience, from this inquest and others, a significant proportion of illicit drug users are not engaged with or decline to engage with substance misuse services for a number of possible reasons. The evidence in the inquest was that, if a drug-user wanted to have naloxone in their possession as a safety-net measure, they would need to obtain this from a local substance misuse service.
I am concerned that this set of circumstances raises the risk of future deaths occurring because the provision of naloxone kits could be made more widely available to those most likely to need them. The present situation appears to be that naloxone is most easily accessed through the very service(s) that many drug-users are not engaged with. My concern, based on the evidence heard at this inquest and others that I am aware of, is that this is not a localised matter and is more likely a nationwide issue and that action should be taken more widely.
It further seems to me that the need for action is heightened by the increased incidence of heroin having been adulterated with ‘nitazenes’ (particularly potent synthetic opioid drugs), which increases the risk of drug users unwittingly overdosing.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commissioning drug dependency services, including naloxone provision, rests with local authorities.
Verbatim wording from the response “The responsibility for commissioning drug dependency services rests with local authorities. I note that you have also addressed your Report to the Secretary of State for Health and Social Care, and it is their Department (DHSC) that is the more appropriate organisation to respond to your concerns.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Department of Health and Social Care is the more appropriate organisation to respond to concerns about national naloxone availability.
Verbatim wording from the response “The responsibility for commissioning drug dependency services rests with local authorities. I note that you have also addressed your Report to the Secretary of State for Health and Social Care, and it is their Department (DHSC) that is the more appropriate organisation to respond to your concerns.” Source location Response from NHS England
Open published response
Concerns raised 2 Lack of policy or guidance for assessing risks posed by supplied fixtures and fittings View source Availability of fixtures and fittings that patients with acute mental health conditions may use to take their own life 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
Morgan Rose Betchley · 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
Morgan Rose Betchley had a history of mental health difficulties, self-harm and attempts to take her life, and was receiving inpatient care before she died after hanging herself in hospital grounds while awaiting a discharge meeting. The report identified a lack of policy or guidance for assessing risks posed by hospital fixtures and fittings. The inquest also described failures concerning admission, diagnosis, risk management, record keeping, family involvement, discharge planning, staff conduct and the quality of observations and interactions.
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 policy or guidance for assessing risks posed by supplied fixtures and fittings
Wider context from the report “There is no policy or guidance to staff for the assessment of risk posed by fixtures and fittings supplied by the Trust (in this particular case it was the Sussex Partnership Foundation Trust).
There is therefore the risk that fixtures and fittings supplied and/or not removed by the Trust from patients, who are suffering from acute mental health, are at risk of utilising these items to take their own life.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Availability of fixtures and fittings that patients with acute mental health conditions may use to take their own life
Wider context from the report “There is no policy or guidance to staff for the assessment of risk posed by fixtures and fittings supplied by the Trust (in this particular case it was the Sussex Partnership Foundation Trust).
There is therefore the risk that fixtures and fittings supplied and/or not removed by the Trust from patients, who are suffering from acute mental health, are at risk of utilising these items to take their own life .
” Open source report
2 Jan 2025 Gemma Suzanne Marshall · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 2 Lack of radiologist knowledge of how slipped gastric bands present View source Failure to recognise and report slipped gastric bands on imaging View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Gemma Suzanne 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
Gemma Suzanne Marshall underwent private gastric-band surgery in 2020, attended hospital with black vomiting and lower abdominal pain in March 2024, and died after the band slipped. The report raises concern that an outsourced radiologist failed to identify and report the slipped band on a CT scan, contributing to a failure to refer her to bariatric specialists. It also identifies wider concerns about radiologists’ familiarity with slipped bands and reliance on non-specialist or outsourced reporting during staff shortages.
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 radiologist knowledge of how slipped gastric bands present
Wider context from the report “Evidence was given by the consultant surgeon who fitted the band, a senior bariatric surgeon at the treating hospital and a consultant radiologist at the treating hospital that the gastric band had slipped.
A CT scan was undertaken on 13.03.24 and reported on by a radiologist with expertise in musculoskeletal imaging (rather than gastric or abdominal imaging) who worked for an outsourced company. This was because of staff shortages in the hospital. The scan report mentioned the existence of the band but didn’t comment on the fact that the images clearly showed the band was out of position. That is that the stomach had slipped and had formed a pouch above the band.
This was, in my view, a critical failure in the care Ms Marshall received. Had this image been correctly reported, then a referral to bariatric surgeons would have probably been made which might have meant she would have survived.
Evidence from the consultant radiologist and the consultant surgeon in the hospital was that this failure to report that the band had slipped was because of a lack of familiarity in radiologists as to how slipped bands present , something which was compounded by 1. The increasing rarity of the procedure, 2. The consequences of specialists which are not familiar with the abdomen or bariatric issues and 3. A need to sometimes rely on outsourced third-party radiologists without the relevant specialist because of staff shortage.
While the hospital had taken steps to address this knowledge gap, there remained a concern that this lack of knowledge as to how slipped bands present was an issue of concern across the country and that other patients could face similar failures to Marshall.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and report slipped gastric bands on imaging
Wider context from the report “Evidence was given by the consultant surgeon who fitted the band, a senior bariatric surgeon at the treating hospital and a consultant radiologist at the treating hospital that the gastric band had slipped.
A CT scan was undertaken on 13.03.24 and reported on by a radiologist with expertise in musculoskeletal imaging (rather than gastric or abdominal imaging) who worked for an outsourced company. This was because of staff shortages in the hospital. The scan report mentioned the existence of the band but didn’t comment on the fact that the images clearly showed the band was out of position. That is that the stomach had slipped and had formed a pouch above the band.
This was, in my view, a critical failure in the care Ms Marshall received. Had this image been correctly reported, then a referral to bariatric surgeons would have probably been made which might have meant she would have survived.
Evidence from the consultant radiologist and the consultant surgeon in the hospital was that this failure to report that the band had slipped was because of a lack of familiarity in radiologists as to how slipped bands present, something which was compounded by 1. The increasing rarity of the procedure, 2. The consequences of specialists which are not familiar with the abdomen or bariatric issues and 3. A need to sometimes rely on outsourced third-party radiologists without the relevant specialist because of staff shortage.
While the hospital had taken steps to address this knowledge gap, there remained a concern that this lack of knowledge as to how slipped bands present was an issue of concern across the country and that other patients could face similar failures to Marshall.
” 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 Issue a Patient Safety Update notifying Trusts about national recommendations for imaging alerts and notifications.
Verbatim wording from the response “All Trusts should ensure that they are following these published recommendations and that they work with their teleradiology company to embed their local alerting processes into the teleradiology workflow. On 31 January 2023, NHS England issued a Patient Safety Update to notify Trusts that the Academy of Medical Royal Colleges’ ‘Alerts and Notification’ paper had been published.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Emergency out-of-hours CT reporting is generally a core competency that can be delivered by radiologists without the relevant subspecialist interest.
Verbatim wording from the response “With a few exceptions, the reporting of emergency CT scans out of hours is considered to be a core competency and is routinely delivered by radiologists with other specialist interests, both across the NHS and teleradiology companies.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The external reporting provider is responsible for undertaking its own investigation into discrepancies in the radiological reporting.
Verbatim wording from the response “In addition, the Trust have confirmed that discrepancies in the radiological reporting have been shared with the relevant external reporting provider who reported on the CT scan, who will undertake their own investigation. Discrepancies, alongside other performance markers, are routinely discussed with the external reporting provider as part of their contracting agreement.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS Trusts outsourcing imaging reports remain responsible for patients and must govern teleradiology providers through robust contractual arrangements.
Verbatim wording from the response “All NHS Trusts that outsource reporting of imaging examinations to teleradiology companies remain responsible for the patient. Trusts should have robust contract arrangements in place to ensure the teleradiology service meets the Trust’s clinical and governance standards, overseen by regular performance and management meetings between the teleradiology company and the Trust, to ensure that the Trust’s standards are delivered.” Source location Response from NHS England
Open published response
23 Dec 2024 David Christopher Peter Lodge · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 5 Failure to follow clinical recommendations for 30-minute observations View source Lack of internal investigation of serious incidents View source Failure to appropriately escalate NEWS2 scores above seven for specialist advice View source Failure to accurately assess pain in people unable to communicate with words View source Failure to carry out basic examinations for learning disabled adults at risk of pneumonia in the emergency department View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Christopher Peter Lodge · 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 Christopher Peter Lodge, who had a learning disability, was found unwell beside his deceased father after lying for up to four days and died at Hull Royal Infirmary on 13 January 2022 from bilateral pneumonia. Concerns included inadequate pain assessment, no chest examination, failure to appropriately escalate high NEWS2 scores or transfer him to intensive care, and missed opportunities to learn from the death through a serious incident 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 follow clinical recommendations for 30-minute observations
Wider context from the report “(3) NEWS2 scores above seven are not appropriately escalated for specialist advice. Clinical recommendations for 30 minute observations were not being followed. An independent expert, a Consultant in Intensive Care, gave evidence to the court that Mr Lodge should have been admitted to the Intensive Care Unit at Hull Royal Infirmary at which Mr Lodge would have undergone closer examinations on a lower patient to nurse ratio.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 internal investigation of serious incidents
Wider context from the report “(4) Opportunities for learning from serious incidents are being lost. No internal investigation or other form of serious incident investigation was undertaken. The court heard evidence from independent experts who opined that it would be expected, following a death in these circumstances, for there to have been an internal review to consider improvements to include input from a specialist with a learning disability team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately escalate NEWS2 scores above seven for specialist advice
Wider context from the report “(3) NEWS2 scores above seven are not appropriately escalated for specialist advice. Clinical recommendations for 30 minute observations were not being followed. An independent expert, a Consultant in Intensive Care, gave evidence to the court that Mr Lodge should have been admitted to the Intensive Care Unit at Hull Royal Infirmary at which Mr Lodge would have undergone closer examinations on a lower patient to nurse ratio.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately assess pain in people unable to communicate with words
Wider context from the report “(1) Pain is not accurately assessed in people who are unable to communicate with words. The court heard evidence that Mr Lodge at no point was provided pain relief, despite requests from the attending family member who was speaking on his behalf. An independent expert, a Consultant in Emergency Medicine, gave evidence that there was no evidence of reasonable adjustments in respect of assessing Mr Lodge’s pain to account for his baseline condition .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out basic examinations for learning disabled adults at risk of pneumonia in the emergency department
Wider context from the report “(2) Basic examinations, including chest examinations, are not being carried out for learning disabled adults at risk of pneumonia in the emergency department. The treating physicians in evidence agreed that there should have been a high index of suspicion of pneumonia in Mr Lodge’s case and that it is one of the leading causes of death for people with learning disabilities. The court heard evidence that Mr Lodge did not have a chest examination carried out on him due to him not presenting any signs of respiratory distress. The independent expert gave evidence that a thorough examination should have been undertaken and that there was the opportunity to do so after the sedation medication was given.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish and provide the NEWS2 resource pack to support implementation of standardized assessment and escalation for acute illness.
Verbatim wording from the response “NEWS is based on a simple aggregate scoring system in which a score is allocated to physiological measurements, already recorded in routine practice, when patients present to, or are being monitored in hospital. An aggregated score of above 7 is considered high clinical risk and should trigger an urgent or emergency response by a clinician or team with competence in the assessment and treatment of acutely ill patients, including recognising when the escalation of care to a critical care team is appropriate. The response team must also include staff with critical care skills, including airway management.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hull University Teaching Hospitals NHS Trust should respond to concerns about David’s care and treatment.
Verbatim wording from the response “In response to the specific questions of the Coroner, NHS England was not involved directly in providing clinical care to David and therefore does not have access to the clinical records of the Trust where he was admitted. On account of this, NHS England cannot comment directly on the care he received. I note that your Report was also sent to Hull University Teaching Hospitals NHS Trust, and it appropriate that they respond to the Coroner’s concerns specifically relating to David’s care and treatment. Humber and North Yorkshire Integrated Care Board (ICB), the responsible commissioner for the Trust, is engaging with the Trust on their response and will share” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Without direct clinical involvement or access to Trust records, NHS England cannot comment directly on David’s care.
Verbatim wording from the response “In response to the specific questions of the Coroner, NHS England was not involved directly in providing clinical care to David and therefore does not have access to the clinical records of the Trust where he was admitted. On account of this, NHS England cannot comment directly on the care he received. I note that your Report was also sent to Hull University Teaching Hospitals NHS Trust, and it appropriate that they respond to the Coroner’s concerns specifically relating to David’s care and treatment. Humber and North Yorkshire Integrated Care Board (ICB), the responsible commissioner for the Trust, is engaging with the Trust on their response and will share” Source location Response from NHS England
Open published response
20 Dec 2024 Haydar Jefferies · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 11 Unavailability of medication for acute mental health symptoms overnight View source Unavailability of clinical mental health provision outside weekday office hours View source Failure to record prisoner welfare information provided in telephone calls View source Lack of a composite 24-hour information document for clinicians reviewing CSU prisoners View source Lack of custody staff training to recognise red flags of declining mental health View source Failure to verify completion of requested mental health referrals View source Failure to consolidate and disseminate prisoner concerns in daily briefing sheets View source Insufficient overnight staffing to take prisoners in mental health crisis to hospital View source Failure to provide necessary clinical knowledge for overnight mental health risk assessment View source Failure of the ACCT process to protect non-suicidal prisoners in acute mental health crisis View source Lack of a process to expedite face-to-face parole hearings for eligible IPP prisoners View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Haydar Jefferies · 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
Haydar Jefferies was detained at HMP Coldingley and developed severe depression and psychosis before self-ligaturing in his cell on 1 March 2023; he was resuscitated but died at hospital on 5 March 2023 from hypoxic brain injury and pneumonia. The principal concerns included failures to record and share risk-relevant information, refer him promptly to mental health services, provide an adequate mental health assessment and obtain appropriate clinical care and supervision during his acute deterioration.
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 medication for acute mental health symptoms overnight
Wider context from the report “6. Outside of weekday office hours there is no clinical mental health provision. Overnight staffing levels are such that it is difficult for prisoners in mental health crisis to be taken to hospital. As a result:
a.) custodial staff take decisions about how to keep prisoners safe overnight without the necessary clinical knowledge to assess the risks presented by their mental health conditions.
b.) it is not possible for medication to be obtained to alleviate any acute mental health symptoms between 6.30 pm and 7am the following morning .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 clinical mental health provision outside weekday office hours
Wider context from the report “6. Outside of weekday office hours there is no clinical mental health provision . Overnight staffing levels are such that it is difficult for prisoners in mental health crisis to be taken to hospital. As a result:
a.) custodial staff take decisions about how to keep prisoners safe overnight without the necessary clinical knowledge to assess the risks presented by their mental health conditions.
b.) it is not possible for medication to be obtained to alleviate any acute mental health symptoms between 6.30 pm and 7am the following morning.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 prisoner welfare information provided in telephone calls
Wider context from the report “1. There is no system in place to ensure that information provided in telephone calls in relation to a prisoner’s welfare is recorded .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 composite 24-hour information document for clinicians reviewing CSU prisoners
Wider context from the report “3. There is no composite document for clinicians to review to see all relevant information recorded by custodial staff about a CSU prisoner for the proceeding 24 hour period .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 custody staff training to recognise red flags of declining mental health
Wider context from the report “5. Custody staff are not trained in mental health presentations and are unable to recognise red flag indicators of declining mental health .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 verify completion of requested mental health referrals
Wider context from the report “4. There is no system in place to check that referrals to the mental health teams requested by senior members of the prison staff have in fact been made .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 consolidate and disseminate prisoner concerns in daily briefing sheets
Wider context from the report “2. Matters of concern in relation to prisoners are recorded across a number of different records and there is a risk that the information is missed and not disseminated in daily briefing sheets .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 overnight staffing to take prisoners in mental health crisis to hospital
Wider context from the report “6. Outside of weekday office hours there is no clinical mental health provision. Overnight staffing levels are such that it is difficult for prisoners in mental health crisis to be taken to hospital . As a result:
a.) custodial staff take decisions about how to keep prisoners safe overnight without the necessary clinical knowledge to assess the risks presented by their mental health conditions.
b.) it is not possible for medication to be obtained to alleviate any acute mental health symptoms between 6.30 pm and 7am the following morning.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 necessary clinical knowledge for overnight mental health risk assessment
Wider context from the report “6. Outside of weekday office hours there is no clinical mental health provision. Overnight staffing levels are such that it is difficult for prisoners in mental health crisis to be taken to hospital. As a result:
a.) custodial staff take decisions about how to keep prisoners safe overnight without the necessary clinical knowledge to assess the risks presented by their mental health conditions .
b.) it is not possible for medication to be obtained to alleviate any acute mental health symptoms between 6.30 pm and 7am the following morning.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of the ACCT process to protect non-suicidal prisoners in acute mental health crisis
Wider context from the report “7. The ACCT process is not designed nor effective to protect prisoners in acute mental health crisis who do not appear to be suicidal .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 process to expedite face-to-face parole hearings for eligible IPP prisoners
Wider context from the report “8. Imprisonment under an IPP is a recognised suicide risk. The delay in dealing with the IPP parole hearing exacerbated the risk. There is currently no process in place to expedite face to face parole hearings for IPP prisoners when allegations leading to their recall have been withdrawn and no criminal action is being considered .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement re-commissioned prison healthcare services, including seven-day mental health provision, on-site attendance and out-of-hours urgent referral protocols.
Verbatim wording from the response “I would also like to inform you that since Haydar’s tragic death, the healthcare at HMP Coldingley, including mental health services, has been re-commissioned.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate quarterly audited contract-management processes to review and monitor emergency and urgent referrals, reporting urgent issues through Datix for immediate action.
Verbatim wording from the response “Contract Management Processes are in place to ensure that emergency and urgent referrals are reviewed and monitored regularly. This is a quarterly process which is audited and recorded. With regards to any urgent issues identified, these are reported via Datix (a digital system for reporting incidents and risks used to support risk mitigation and regulatory compliance) and acted upon immediately.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require mental health teams to log all referrals on SystmOne.
Verbatim wording from the response “NHS England’s national health and justice team has also engaged with colleagues from the South East region on the concerns raised in your Report. For improvements to be made, a notice will be issued to healthcare staff that they should record a case note when they ask prisoners if they are having thoughts of self-harm, and they will be advised that negative responses should also be recorded. Good order and discipline reviews will now include questions around prisoners’ thoughts on self-harm and responses will be recorded, and mental health teams will log all referrals on SystmOne. A new template form for mental health referrals is also being designed, which will include prompts to include key information to aid triage and details on what to do with the referral. HMP Coldingley’s Governor will ensure that the new template is circulated to all operational staff.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for the ACCT process and policy rests with HMPPS, which should provide the full response on this concern.
Verbatim wording from the response “Ownership of the ACCT process and policy lies with HMPPS. NHS England are therefore not able to comment on this point and would recommend that this is directed to HMPPS for a full response.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The ACCT process and policy fall outside NHS England’s ownership, so NHS England cannot comment on this concern.
Verbatim wording from the response “Ownership of the ACCT process and policy lies with HMPPS. NHS England are therefore not able to comment on this point and would recommend that this is directed to HMPPS for a full response.” Source location Response from NHS England
Open published response
20 Dec 2024 Oliver James WINSON · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 4 Failure to provide treatment to at-risk patients awaiting adult ADHD services View source Failure to monitor the condition of at-risk patients awaiting adult ADHD services View source Shortage of medication for patients diagnosed with ADHD View source Delays in access to adult ADHD services for at-risk patients View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Oliver James WINSON · 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 James Winson, a 33-year-old man with a history of drug misuse and a referral for adult ADHD assessment, was found deceased at home on 10 June 2024. Toxicology confirmed cocaine use before death, and the medical cause of death was cocaine toxicity. The principal concern was that lengthy adult ADHD waiting lists left at-risk patients without treatment or monitoring, potentially allowing deterioration, harmful behaviour and death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide treatment to at-risk patients awaiting adult ADHD services
Wider context from the report “Evidence received from the mental health Trust confirms that proactive steps have been taken by them to try and improve access and mitigate delays as far as possible and they provide details of some additional funding received from the local integrated care board in November 2021. Based on the evidence heard at inquest we know that this action in 2021 did not significantly reduce the waiting time, as at the time of his death Mr Winson had been waiting for four years.
I also heard evidence that despite local and national efforts, the scale of demand for adult ADHD services is a system wide issue across the country.
It is of concern that patients who have been identified specifically of being at risk as a result of undiagnosed and/or untreated ADHD (and it was also noted in the evidence that there is a shortage of medication for those patients who have been diagnosed) remain on significantly lengthy waiting lists during which time they are not receiving treatment , their condition is not monitored and there is a risk as with Mr Winson, that their condition may deteriorate or lead to risk or harmful behaviour and death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor the condition of at-risk patients awaiting adult ADHD services
Wider context from the report “Evidence received from the mental health Trust confirms that proactive steps have been taken by them to try and improve access and mitigate delays as far as possible and they provide details of some additional funding received from the local integrated care board in November 2021. Based on the evidence heard at inquest we know that this action in 2021 did not significantly reduce the waiting time, as at the time of his death Mr Winson had been waiting for four years.
I also heard evidence that despite local and national efforts, the scale of demand for adult ADHD services is a system wide issue across the country.
It is of concern that patients who have been identified specifically of being at risk as a result of undiagnosed and/or untreated ADHD (and it was also noted in the evidence that there is a shortage of medication for those patients who have been diagnosed) remain on significantly lengthy waiting lists during which time they are not receiving treatment, their condition is not monitored and there is a risk as with Mr Winson, that their condition may deteriorate or lead to risk or harmful behaviour and death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Shortage of medication for patients diagnosed with ADHD
Wider context from the report “Evidence received from the mental health Trust confirms that proactive steps have been taken by them to try and improve access and mitigate delays as far as possible and they provide details of some additional funding received from the local integrated care board in November 2021. Based on the evidence heard at inquest we know that this action in 2021 did not significantly reduce the waiting time, as at the time of his death Mr Winson had been waiting for four years.
I also heard evidence that despite local and national efforts, the scale of demand for adult ADHD services is a system wide issue across the country.
It is of concern that patients who have been identified specifically of being at risk as a result of undiagnosed and/or untreated ADHD (and it was also noted in the evidence that there is a shortage of medication for those patients who have been diagnosed ) remain on significantly lengthy waiting lists during which time they are not receiving treatment, their condition is not monitored and there is a risk as with Mr Winson, that their condition may deteriorate or lead to risk or harmful behaviour and death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in access to adult ADHD services for at-risk patients
Wider context from the report “Evidence received from the mental health Trust confirms that proactive steps have been taken by them to try and improve access and mitigate delays as far as possible and they provide details of some additional funding received from the local integrated care board in November 2021. Based on the evidence heard at inquest we know that this action in 2021 did not significantly reduce the waiting time , as at the time of his death Mr Winson had been waiting for four years.
I also heard evidence that despite local and national efforts, the scale of demand for adult ADHD services is a system wide issue across the country.
It is of concern that patients who have been identified specifically of being at risk as a result of undiagnosed and/or untreated ADHD (and it was also noted in the evidence that there is a shortage of medication for those patients who have been diagnosed) remain on significantly lengthy waiting lists during which time they are not receiving treatment, their condition is not monitored and there is a risk as with Mr Winson, that their condition may deteriorate or lead to risk or harmful behaviour and death.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and share guidance supporting systems to respond to ADHD medication shortages.
Verbatim wording from the response “Your Report also referred to there being a shortage of medication for those patients who have been diagnosed with ADHD. NHS England works closely with the Department of Health and Social Care (DHSC), who are responsible for medication supplies in England. NHS England has developed specific guidance for systems, shared via the Specialist Pharmacy Service, to support the system response to the medication shortages. At this time, the availability of most medicines used to treat ADHD has been restored, though there remains some disruption to supplies of methylphenidate prolonged-release capsules and tablets².” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore opportunities with partners to standardise ADHD pathways for greater consistency and transparency.
Verbatim wording from the response “NHS England is committed to working with system partners, including commissioners and providers of ADHD support, to improve health-related experience and outcomes for those with ADHD, including exploring opportunities to:” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore opportunities with partners to expand ADHD pathways with pre-diagnostic or waiting-well support.
Verbatim wording from the response “NHS England is committed to working with system partners, including commissioners and providers of ADHD support, to improve health-related experience and outcomes for those with ADHD, including exploring opportunities to:” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the independent ADHD Taskforce to develop cross-sector understanding and improve joined-up access to early support.
Verbatim wording from the response “Considering the challenges being reported about ADHD services, NHS England undertook a rapid review in December 2023. This identified several key areas of work in relation to ADHD which are now underway, including improving available data, developing resources to support commissioners in improving the quality and consistency of ADHD services nationally, and facilitating the sharing of information, innovation and good practice. NHS England has also convened the independent ADHD Taskforce, which works cross-sector to better understand more about the issues impacting those with ADHD and their families, and how service provision can be better joined up to meet people’s needs, including access to early support. It is increasingly recognised that ADHD is not solely a health concern, and that a cross-sector approach is needed to effect change.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local Integrated Care Boards commission ADHD services, including decisions on local pathways and provision.
Verbatim wording from the response “ADHD services are a complex landscape. They are commissioned locally by Integrated Care Boards (ICBs) with significant national variation existing in pathways and provision, including independent sector providers operating under the Right to Choose framework.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Department of Health and Social Care is responsible for ADHD medication supplies in England.
Verbatim wording from the response “Your Report also referred to there being a shortage of medication for those patients who have been diagnosed with ADHD. NHS England works closely with the Department of Health and Social Care (DHSC), who are responsible for medication supplies in England. NHS England has developed specific guidance for systems, shared via the Specialist Pharmacy Service, to support the system response to the medication shortages. At this time, the availability of most medicines used to treat ADHD has been restored, though there remains some disruption to supplies of methylphenidate prolonged-release capsules and tablets².” Source location Response from NHS England
Open published response
Concerns raised 3 Persistent ambulance queuing at hospitals View source Lack of oversight of ambulance service delay concerns View source Sustained excessive ambulance service operational pressure View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrew Michael Lewis · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Andrew Michael Lewis died at home on 7 May 2024 after calling 111 with weakness in his legs and an earlier fall. An ambulance arrived about 10 hours after his first call, although the call had been categorised as requiring attendance within two hours; the report states there was simply no ambulance available to send earlier. The inquest recorded the cause of death as acute on chronic gastrointestinal haemorrhage, bleeding oesophageal varices, alcoholic liver cirrhosis, and low volume subdural haemorrhage, with the conclusion of an alcohol-related death contributed to by head injury.
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 Persistent ambulance queuing at hospitals
Wider context from the report “• I have also been provided with data regarding the number of hours that ambulances have spent queuing at hospitals in the last 3 months (September to November 2024). This amounts to 23,253 hours. This is an average of 255.5 hours across the service every single day.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 oversight of ambulance service delay concerns
Wider context from the report “2. There appears to be no oversight of this issue , and a number of ambulance trusts have not responded to these reports at all.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Sustained excessive ambulance service operational pressure
Wider context from the report “• SCAS has been at REAP 3 or above for 90% of this time period. They have been constantly at REAP 4 since 9 October 2024.
• The lowest escalation level that this ambulance service has been at in this period is REAP 2. They have never been at steady state (REAP 1) during this period.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with trusts and services facing significant front-end handover challenges to reduce ambulance handover delays.
Verbatim wording from the response “Improvements to ambulance response times are also being enabled by addressing excessive handover delays. Rapid handovers are essential to ensure that patients reach definitive care promptly, which includes both those waiting to receive care in the Emergency Department (ED), and those waiting in the community. NHS England continues to work with trusts and services with significant handover challenges at the” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with local authorities to improve timely patient discharge and monitor performance using discharge metrics.
Verbatim wording from the response “NHS England recognises the significant pressures on all NHS services, including ambulances, and has been prioritising improvements to Category 2 response times and urgent and emergency care services. NHS England has also recognised the need to increase ambulance capacity through growing the workforce, improving flow through hospitals and reducing handover delays, speeding up discharges from hospital and expanding new services in the community; all of which support improved patient flow and ambulance response times. The NHS is also working more closely with local authorities to improve the timely discharge of patients and has developed discharge metrics to monitor performance improvements.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase ambulance capacity by growing the workforce, improving hospital flow, reducing handover delays, speeding discharges, and expanding community services.
Verbatim wording from the response “NHS England recognises the significant pressures on all NHS services, including ambulances, and has been prioritising improvements to Category 2 response times and urgent and emergency care services. NHS England has also recognised the need to increase ambulance capacity through growing the workforce, improving flow through hospitals and reducing handover delays, speeding up discharges from hospital and expanding new services in the community; all of which support improved patient flow and ambulance response times. The NHS is also working more closely with local authorities to improve the timely discharge of patients and has developed discharge metrics to monitor performance improvements.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review all ambulance-service Prevention of Future Deaths reports received by NHS England and discuss them through the Regulation 28 Working Group.
Verbatim wording from the response “Your Report also raised that there appears to be no oversight of Prevention of Future Death (PFD) Reports written to ambulance trusts, and a significant number of these Reports relate to ambulance delays. PFD Reports sent to ambulance services are reviewed by the Association of Ambulance Chief Executives (AACE) National Ambulance Services Medical Directors’ Group (NASMeD) and the AACE Quality Governance Group to capture themes and learning. I also wish to provide assurance that all PFDs regarding ambulance services that are sent to NHS England are reviewed by our National Ambulance Team, as well as being discussed at our Regulation 28 Working Group (see separate paragraph below). NHS England is unable to provide comment on individual trusts not responding to PFD Reports.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing national and ambulance-sector review arrangements provide oversight of ambulance-service Prevention of Future Death Reports and capture emerging learning.
Verbatim wording from the response “Your Report also raised that there appears to be no oversight of Prevention of Future Death (PFD) Reports written to ambulance trusts, and a significant number of these Reports relate to ambulance delays. PFD Reports sent to ambulance services are reviewed by the Association of Ambulance Chief Executives (AACE) National Ambulance Services Medical Directors’ Group (NASMeD) and the AACE Quality Governance Group to capture themes and learning. I also wish to provide assurance that all PFDs regarding ambulance services that are sent to NHS England are reviewed by our National Ambulance Team, as well as being discussed at our Regulation 28 Working Group (see separate paragraph below). NHS England is unable to provide comment on individual trusts not responding to PFD Reports.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is unable to comment on individual ambulance trusts that do not respond to Prevention of Future Death Reports.
Verbatim wording from the response “Your Report also raised that there appears to be no oversight of Prevention of Future Death (PFD) Reports written to ambulance trusts, and a significant number of these Reports relate to ambulance delays. PFD Reports sent to ambulance services are reviewed by the Association of Ambulance Chief Executives (AACE) National Ambulance Services Medical Directors’ Group (NASMeD) and the AACE Quality Governance Group to capture themes and learning. I also wish to provide assurance that all PFDs regarding ambulance services that are sent to NHS England are reviewed by our National Ambulance Team, as well as being discussed at our Regulation 28 Working Group (see separate paragraph below). NHS England is unable to provide comment on individual trusts not responding to PFD Reports.” Source location Response from NHS England
Open published response
18 Dec 2024 Eleanor Hazel ALDRED-OWEN · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1 Lack of radiographer procedures for escalating care and issuing urgent arrest calls when there are clear signs of imminent danger to life 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
Eleanor Hazel ALDRED-OWEN · 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
Eleanor Hazel ALDRED-OWEN was admitted for elective craniofacial surgery and developed respiratory distress after the procedure. She suffered a cardiac arrest associated with a right-sided tension pneumothorax, and died after life-sustaining measures were withdrawn following catastrophic hypoxic-ischaemic brain injury. The report raised concern that radiographers’ standard operating procedures did not provide for escalation of care or an urgent arrest call when there were clear signs of imminent danger to life.
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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 radiographer procedures for escalating care and issuing urgent arrest calls when there are clear signs of imminent danger to life
Wider context from the report “Evidence was given at the inquest that the standard operating procedure for radiographers did not include provision for radiographers to escalate care and put out an urgent arrest call where there were clear signs of imminent danger to life . It was not known whether this was also the case in other Trusts on a national level.
” Open source report
Concerns raised 5 Lack of inpatient mental health beds View source Gap in services for people too high risk to be sent home but not meeting Mental Health Act detention criteria View source Delays in referral to the Assessment and Treatment Service View source Shortage of mental health beds suitable for Autistic patients and transgender patients requiring a mixed ward View source Unsuitability of the A&E environment as a holding place for people awaiting mental health beds View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Matthew Zak Sheldrick (Matty) · 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 Zak Sheldrick (Matty), who identified as non-binary, had a history of mental health difficulties and was admitted to A&E in crisis on 3 November 2022 after a previous 26-day wait for a psychiatric bed. After being assessed under the Mental Health Act and not detained, Matty left hospital and was found hanging in the hospital grounds. Concerns included shortages and long waits for mental health beds, the unsuitability of A&E for neurodivergent patients, gaps in services and discharge planning, and shortcomings in the mental health assessment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of inpatient mental health beds
Wider context from the report “1. There is a lack of inpatient beds leading to unacceptable wait times in A&E for those suffering with their mental health who are awaiting beds. In Matty’s case a bed was not found for them within a 26-day period.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Gap in services for people too high risk to be sent home but not meeting Mental Health Act detention criteria
Wider context from the report “4. There is a gap in services for those who do not meet the criteria for detention under the Mental Health Act but who are too high a risk to be sent 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 Delays in referral to the Assessment and Treatment Service
Wider context from the report “5. There is a significant wait time for referral to the Assessment and Treatment Service. Therefore, any therapeutic input is delayed , and this results in repetitive attendances at A&E when in crisis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 mental health beds suitable for Autistic patients and transgender patients requiring a mixed ward
Wider context from the report “2. There being a national shortage of mental health beds in particular for Autistic patients and those who are transgender requiring a mixed ward.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unsuitability of the A&E environment as a holding place for people awaiting mental health beds
Wider context from the report “3. The unsuitability of the environment of A&E as a holding place for those in need of a mental health bed. The environment in A&E as a holding place is not conducive for those suffering with Autism and/or who are neurodiverse. The environment in A&E can exacerbate their mental health.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Secure investment to provide 24-hour liaison psychiatry access in 70% of hospitals in England by the end of 2023/24.
Verbatim wording from the response “Patients attending A&E suffering with a mental health crisis remain there until a suitable mental health bed can be found. Since the introduction of the Mental Health Crisis Care Concordat, investment was secured to provide 24-hour access to Liaison Psychiatry Services in 70% of hospitals in England by the end of 2023/24. On arrival, patients should receive a mental health triage assessment to determine the level of observation they require and where they should be placed within the A&E department.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish Mental Health Response Vehicles to assess and treat people away from A&E.
Verbatim wording from the response “The NHS LTP saw an additional £2.3 billion of funding invested in mental health services from 2019/20 to 2023/24, around £1.3 billion of which was for adult community, crisis and acute mental health services to allow people to get faster access to the care they need and prevent deterioration and hospital admission where it is avoidable. The NHS 111 mental health call option has also been established around the country to support reductions in A&E attendance and Mental Health Response Vehicles have also been established to see and treat patients away from an A&E setting. New integrated operational pressures escalation levels (OPEL) scoring systems have also been established for mental health, enabling greater transparency and escalation of risks across mental health pathways.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Direct systems to reduce adult acute mental health ward length of stay and improve access to local inpatient beds.
Verbatim wording from the response “NHS England’s 2024/25 priorities and operational planning guidance continues this focus on improving patient flow as a key priority – with systems directed to reduce the average length of stay in adult acute mental health wards in order to deliver more timely access to local beds. This is being supplemented by a further £42 million recurrent investment from 2024/25, for all Integrated Care Boards (ICBs) in the country to recommission inpatient care in line with local models that provide the best evidence of therapeutic support.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £42 million recurrent investment for ICBs to recommission inpatient care in line with locally appropriate therapeutic models.
Verbatim wording from the response “NHS England’s 2024/25 priorities and operational planning guidance continues this focus on improving patient flow as a key priority – with systems directed to reduce the average length of stay in adult acute mental health wards in order to deliver more timely access to local beds. This is being supplemented by a further £42 million recurrent investment from 2024/25, for all Integrated Care Boards (ICBs) in the country to recommission inpatient care in line with local models that provide the best evidence of therapeutic support.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish guidance for meeting autistic adults’ needs in mental health services, including sensory adjustments relevant to acute healthcare settings.
Verbatim wording from the response “NHS England’s guidance (NHS England » Meeting the needs of autistic adults in mental health services), which is aimed at ICBs, health organisations and wider system partners, was published in December 2023. The guidance includes information in relation to accommodating people's sensory reactivity, which would also apply to acute healthcare settings, including:” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest £150 million in capital projects supporting urgent mental health care and crisis response closer to home.
Verbatim wording from the response “Existing crisis services, such as liaison psychiatry services, local crisis resolution and home treatment (CRHT) teams are also in place to help support people suffering mental health crisis, but who do not meet the criteria for admission. Additionally, the Urgent and Emergency Care Recovery Plan has also set out that the NHS is investing an additional £150 million capital funding for new projects to support urgent mental health care and crisis response. This will also help to support people to be provided with the care and support they need closer to home and reduce the number of admissions to hospital.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local provider-level inpatient accommodation availability falls outside NHS England’s national policy and programme remit.
Verbatim wording from the response “Your Report raises concerns about the service provision and availability of services for patients suffering with their mental health, and the appropriateness of the Emergency Department as an environment for people who are autistic and/or neurodiverse to be held as they await a mental health bed. My response to the Coroner addresses the issues raised that sit within NHS England’s national policy and programme remit.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS Sussex ICB is the responsible commissioner for the relevant local services, with the Trust responsible for its action plan.
Verbatim wording from the response “NHS England’s South East regional colleagues have also engaged with NHS Sussex ICB, the responsible commissioner for the services described, on the concerns raised. We are advised that they have identified actions which include the provision of leaflets to patients and carers explaining delays in access to mental health beds, with information and signposting to support lines and apps. There are also now arrangements in place to support escalation and clinical discussion of patient flow and referral reviews. The ICB have requested an update from the Trust on their action plan, following Matty’s death.” Source location Response from NHS England
Open published response
12 Dec 2024 James Robert Michael ALDERMAN · Prevention of Future Deaths report West London
View report summary
Concerns raised 3 Lack of guidance on breastfeeding young babies in carriers/slings View source Risk of suffocation for young babies in carriers/slings View source Lack of safety and positioning information for young babies in carriers/slings 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
James Robert Michael ALDERMAN · 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
Jimmy was being breastfed in a baby carrier worn by his mother when he collapsed after five minutes. He died three days later in hospital from accidental suffocation after his airway was occluded while he was not held in a safe position. The report identified insufficient information and guidance for parents about safe positioning of young babies in carriers or slings, particularly when breastfeeding, and raised concerns about the need for industry safety standards.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on breastfeeding young babies in carriers/slings
Wider context from the report “(1) There is very little information available to inform parents of safety and positioning advice of young babies in carriers/slings and in particular nothing in relation to breastfeeding in carriers/slings
(2) This notwithstanding a significant increase over recent years in the use of such equipment.
(3) The question of whether it is safe to breastfeed "hands free" is not addressed or referred to in the public domain or manufacturers literature.
(4) The NHS available literature provides no guidance or advice.
(5) The only current "tips" are provided on the National Childbirth Trust (NCT) website but these are in fact unhelpful
(6) Young babies are at risk of suffocation.
(7) Consideration should be given to industry standards to promote the safe use of slings/carriers, to warn users of the risks and whether any such standards should be voluntary or mandatory.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Risk of suffocation for young babies in carriers/slings
Wider context from the report “(1) There is very little information available to inform parents of safety and positioning advice of young babies in carriers/slings and in particular nothing in relation to breastfeeding in carriers/slings
(2) This notwithstanding a significant increase over recent years in the use of such equipment.
(3) The question of whether it is safe to breastfeed "hands free" is not addressed or referred to in the public domain or manufacturers literature.
(4) The NHS available literature provides no guidance or advice.
(5) The only current "tips" are provided on the National Childbirth Trust (NCT) website but these are in fact unhelpful
(6) Young babies are at risk of suffocation.
(7) Consideration should be given to industry standards to promote the safe use of slings/carriers, to warn users of the risks and whether any such standards should be voluntary or mandatory.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 safety and positioning information for young babies in carriers/slings
Wider context from the report “(1) There is very little information available to inform parents of safety and positioning advice of young babies in carriers/slings and in particular nothing in relation to breastfeeding in carriers/slings
(2) This notwithstanding a significant increase over recent years in the use of such equipment.
(3) The question of whether it is safe to breastfeed "hands free" is not addressed or referred to in the public domain or manufacturers literature.
(4) The NHS available literature provides no guidance or advice.
(5) The only current "tips" are provided on the National Childbirth Trust (NCT) website but these are in fact unhelpful
(6) Young babies are at risk of suffocation.
(7) Consideration should be given to industry standards to promote the safe use of slings/carriers, to warn users of the risks and whether any such standards should be voluntary or mandatory.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refer safe sling-use advice for consideration in NICE guidance.
Verbatim wording from the response “Turning to antenatal advice given to women in healthcare settings, NHS Maternity Services are required to follow guidance from the National Institute for Health and Care Excellence (NICE), which develops evidence-based guidelines on what advice and care should be routinely provided. We are not aware of specific recommendations or advice on the safe use of slings, and we have referred this issue to NICE for consideration in response to your concerns. We have also passed on the details of this case to UNICEF-UK. As you may be aware, a significant proportion of maternity services in England work to achieve the standards of infant feeding advice and support” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the NHS.UK website team to make sling-safety guidance easier to find and link it to relevant breastfeeding information.
Verbatim wording from the response “Advice is available on the NHS.UK website on the safe use of slings – including information on the UK Sling Consortium’s ‘TICKS’ rules, and links to guidance from the Royal Society for the Prevention of Accidents and the Lullaby Trust on baby sling safety – in pages on caring for a newborn baby, and separately on safe sleep and preventing Sudden Infant Death Syndrome. However, on review, NHS England agree that this guidance could be easier to find and isn’t currently linked to breastfeeding information. Our Maternity Team will work with the NHS.UK website team so that guidance on the safe use of slings is easier to find, and is linked to more relevant website pages, such as on breastfeeding.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Product manufacturers bear significant responsibility for providing parents with adequate guidance on the safe use of newborn carriers and slings.
Verbatim wording from the response “There are a significant number of products marketed for use with newborns. In the context of limited time for midwives to provide advice in antenatal appointments, NHS England consider that the manufacturers of these products bear a significant responsibility for ensuring that parents receive adequate guidance on their safe use. I note that you have also written to the Office for Product Safety and Standards, and we are supportive of a revised industry standard in this area, in particular around the safe use of slings / carriers while breastfeeding.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NICE is responsible for considering whether recommendations on safe sling use should be included in routine antenatal advice.
Verbatim wording from the response “Turning to antenatal advice given to women in healthcare settings, NHS Maternity Services are required to follow guidance from the National Institute for Health and Care Excellence (NICE), which develops evidence-based guidelines on what advice and care should be routinely provided. We are not aware of specific recommendations or advice on the safe use of slings, and we have referred this issue to NICE for consideration in response to your concerns. We have also passed on the details of this case to UNICEF-UK. As you may be aware, a significant proportion of maternity services in England work to achieve the standards of infant feeding advice and support” Source location Response from NHS England
Open published response
Concerns raised 2 Unavailability of essential patient information to treating clinicians in new clinical settings View source Non-uniform hospital discharge notes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Patricia CURTIS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Patricia Curtis underwent complex cardiac surgery and was transferred to Bedford Hospital, where she deteriorated rapidly and died from a haemothorax identified at post-mortem examination. The report states that a haemothorax was not included in the differential diagnosis when clinical signs first appeared. It also raises concern that non-uniform hospital discharge notes may result in essential information being unavailable after transfer between hospitals, potentially delaying life-saving care and treatment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unavailability of essential patient information to treating clinicians in new clinical settings
Wider context from the report “Hospital Discharge notes are not uniform across Hospital Trusts. This carries the risk of essential patient information not being available to treating clinicians when a patient is received into a new clinical setting , leading to potential delay in providing life saving care and treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Non-uniform hospital discharge notes
Wider context from the report “Hospital Discharge notes are not uniform across Hospital Trusts. This carries the risk of essential patient information not being available to treating clinicians when a patient is received into a new clinical setting, leading to potential delay in providing life saving care and treatment.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual NHS Trusts are responsible for their own hospital discharge policies.
Verbatim wording from the response “Individual Trusts are responsible for their own discharge policies. However, the Hospital Discharge Service guidance and operating model, published by the Department of Health and Social Care (DHSC) in August 2020 and last updated in January 2024, details the national discharge requirements for all NHS Trusts, community interest companies, private care providers of acute care, community beds and community health services and social care staff in England. The guidance, which is based on successful discharge to assess principles, aims to ensure that all individuals are discharged from hospital in a safe, appropriate and timely way.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Royal Papworth Hospital reported no concerns about the quality or format of its discharge summaries.
Verbatim wording from the response “NHS England has engaged with the Royal Papworth Hospital NHS Foundation Trust regarding your Report. We note that, in response to your concerns, their Discharge Planning Group have taken steps to improve their processes for ensuring that next of kin are updated on patient transfers. They advise that there were no concerns regarding the quality or format of their discharge summaries.” Source location Response from NHS England
Open published response
2 Dec 2024 Elton Deutekom · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 10 Failure to disclose evidence relevant to deaths to the coroner under the duty of candor View source Insufficient supervision of newly qualified midwives managing women in labour View source Provision of assistance to write neonatal death records retrospectively View source Failure of neonatologists to pass sufficient and appropriate information to pathologists during consented post-mortem examinations View source Lack of a regular CTG review system on the central CTG monitoring board View source Failure to appropriately refer neonatal deaths to the coroner View source Failure of neonatologists to appropriately report deaths to the coroner View source Lack of Medical Examiner access to obstetric records when reviewing deaths View source Understaffing of the labour ward View source Destruction of contemporaneous handwritten notes following neonatal deaths View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Elton Deutekom · 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
Elton suffered acute hypoxic-ischaemic injury following a placental abruption during labour and was delivered by forceps at 04:35 on 12 January 2022; despite resuscitation, he was recognised as life extinct at 05:12. The report identifies failures to recognise and respond to abnormal CTG changes, and raises wider concerns about neonatal death referrals, disclosure of evidence, record-keeping, staffing, supervision and CTG monitoring.
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 disclose evidence relevant to deaths to the coroner under the duty of candor
Wider context from the report “2. That Chelsea and Westminster hospital may not be complying with the duty of candor to disclose evidence relevant to a death to the coroner until forced to by court directions made in public , which thus raises the same concern as above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 supervision of newly qualified midwives managing women in labour
Wider context from the report “5. That newly qualified midwives should have more supervision whilst they are managing women in labour .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Provision of assistance to write neonatal death records retrospectively
Wider context from the report “3. That following neonatal deaths assistance is given to midwifery staff as to how to write records in retrospect and contemporaneous handwritten notes are destroyed possibly reducing the accuracy of the records and thus risking that lessons may not be learned that may save the lives of others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 neonatologists to pass sufficient and appropriate information to pathologists during consented post-mortem examinations
Wider context from the report “8. That the neonatologists at Chelsea and Westminster are not passing sufficient and appropriate information to the pathologists when consented post- mortem examinations occur such that the cause of death found by the pathologist may be inaccurate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 regular CTG review system on the central CTG monitoring board
Wider context from the report “6. That there is no regular review system for CTGs on the central CTG monitoring board .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 refer neonatal deaths to the coroner
Wider context from the report “1. That Chelsea and Westminster Hospital are not appropriately referring neonatal deaths to coroner- either late or not at all , and this raises the possibility that lessons may not be learned from the investigation of these deaths that may save the lives of others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 neonatologists to appropriately report deaths to the coroner
Wider context from the report “9. That neonatologists in other hospitals may not be appropriately reporting deaths to the coroner .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 Medical Examiner access to obstetric records when reviewing deaths
Wider context from the report “7. That in some hospitals the Medical Examiners do not have access to obstetric records when reviewing deaths .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Understaffing of the labour ward
Wider context from the report “4. That the labour ward is understaffed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Destruction of contemporaneous handwritten notes following neonatal deaths
Wider context from the report “3. That following neonatal deaths assistance is given to midwifery staff as to how to write records in retrospect and contemporaneous handwritten notes are destroyed possibly reducing the accuracy of the records and thus risking that lessons may not be learned that may save the lives of others.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Chelsea and Westminster NHS Foundation Trust should respond to concerns specific to its hospital and care.
Verbatim wording from the response “My response to your Report focuses on the areas of concern raised by the Coroner that sit within NHS England’s national policy and programme remit. Your Report raises a number of concerns specific to Chelsea and Westminster Hospital and it is appropriate that Chelsea and Westminster NHS Foundation Trust, who I note you have also sent your Report to, respond to you on these matters. I wish to assure you that the National Medical Examiner, who you have also addressed your Report to, has reviewed your Report and has input into my response.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The response addresses only concerns within NHS England’s national policy and programme remit, excluding hospital-specific matters.
Verbatim wording from the response “My response to your Report focuses on the areas of concern raised by the Coroner that sit within NHS England’s national policy and programme remit. Your Report raises a number of concerns specific to Chelsea and Westminster Hospital and it is appropriate that Chelsea and Westminster NHS Foundation Trust, who I note you have also sent your Report to, respond to you on these matters. I wish to assure you that the National Medical Examiner, who you have also addressed your Report to, has reviewed your Report and has input into my response.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS providers are responsible for designing preceptorship programmes and determining additional support for newly qualified midwives.
Verbatim wording from the response “NHS providers, under the NHS Standard Contract, are required to ensure that all midwives meet the necessary qualifications, competencies, and receive adequate supervision, including preceptorship and oversight.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Maternity and Neonatal Programme cannot comment on local CTG review practice or guidance.
Verbatim wording from the response “That there is no regular review system for CTGs on the central CTG monitoring board (concern no.6)” Source location Response from NHS England
Open published response
2 Dec 2024 Keith David FOORD · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 1 Failure to classify transfers for aortic dissection requiring emergency surgery as category 1 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
Keith David FOORD · 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
Keith David FOORD died on 3 May 2022 after suffering an acute type A aortic dissection and undergoing emergency repair. The principal concern was that ambulance transfers for aortic dissection requiring emergency surgery should be categorised as category 1 rather than category 2.
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 classify transfers for aortic dissection requiring emergency surgery as category 1
Wider context from the report “namely that for aortic dissection requiring emergency surgery and inter facility transfer, the category of this type of case for transfer should be raised to category 1 .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Inter-facility transfers requiring immediate treatment at a receiving facility are categorised by clinical condition and urgency, rather than diagnosis, as Category 2.
Verbatim wording from the response “IFT Level 2 (IFT2) Category 2” Source location Response from NHS England
Open published response
Concerns raised 2 Lack of care plans in Summary Care Records View source Delays in paramedic-arrived patients’ access to hospital records and history 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
Emma Victoria Sanders · 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
Emma Victoria Sanders died on 19 March 2023 after being found unresponsive in a hospital toilet with a ligature fashioned from nasal cannula tubing around her neck. The report raised concerns about delays in accessing hospital records and care plans, particularly when patients are placed in cohorting areas, and about the absence of care-plan information from Summary Care Records.
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 care plans in Summary Care Records
Wider context from the report “ii. The Summary Care Record does not detail care plans in place for individuals in Dorset, the wider South West region and may be nationally . Lack of access to these plans could impact on patient care and lead to a future death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in paramedic-arrived patients’ access to hospital records and history
Wider context from the report “i. There can be a delay in accessing a patient’s hospital record and history when they are taken to hospital by a paramedic depending on the method of booking in and triage which could impact on patient care, especially if there are delays in them being assessed such as when they are placed in cohorting areas , and this could lead to a future death.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Registered GP practices must enter care-plan information into the Summary Care Record using an appropriate clinical code.
Verbatim wording from the response “The SCR content is only authored from the patient’s registered GP Practice. For information about the existence of a care plan to be shared in this way, the patient’s GP Practice needs to be made aware of the care plan and then enter this information using an appropriate specific clinical code.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Summary Care Record cannot include the full detail of a patient’s care plan because its design and format do not support it.
Verbatim wording from the response “The SCR is not intended to include the full detail of a patient’s care plan, and the design / format of the SCR does not support this. However, the SCR can include a signpost to the existence of a care plan by using a relevant code for the following, or otherwise a free-text entry:” Source location Response from NHS England
Open published response
24 Nov 2024 Colin Wiles · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 5 Failure to hold Vulnerable Adult Risk Management meetings when there are multifactorial concerns about comorbidities and self neglect View source Excessive ambulance patient handover waiting times at Hull Royal Infirmary View source Inability to hand over emergency ambulance patients into the emergency department at Hull Royal Infirmary View source Lack of criteria to reside for patients arriving in emergency ambulances View source Unclear advice to callers about calling emergency services back when concerns continue View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Colin Wiles · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Colin Wiles, who lived alone and experienced self-neglect and hypothermia, was found collapsed at home and died at Hull Royal Infirmary on 27 March 2023. The principal concerns were that no Vulnerable Adult Risk Management meeting was held despite safeguarding concerns, and that excessive ambulance response and hospital handover times caused delays and lost ambulance capacity.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to hold Vulnerable Adult Risk Management meetings when there are multifactorial concerns about comorbidities and self neglect
Wider context from the report “(1) No Vulnerable Adult Risk Management meeting was held despite multifactorial concerns with Mr Wiles’ comorbidities and self neglect leading to poor living conditions and increased risk to his safety
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Excessive ambulance patient handover waiting times at Hull Royal Infirmary
Wider context from the report “(3) The waiting times for ambulances to hand over patients at Hull Royal Infirmary were excessive that day leading to 160 hours of lost ambulance time.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inability to hand over emergency ambulance patients into the emergency department at Hull Royal Infirmary
Wider context from the report “(4) There appears to be an issue with no criteria to reside patients and the ability to hand over patients into ED in Hull Royal Infirmary who arrive in emergency ambulances .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 criteria to reside for patients arriving in emergency ambulances
Wider context from the report “(4) There appears to be an issue with no criteria to reside patients and the ability to hand over patients into ED in Hull Royal Infirmary who arrive in emergency ambulances.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 advice to callers about calling emergency services back when concerns continue
Wider context from the report “(2) It does not seem clear whether callers are advised to call the emergency services back if they continue to have concerns.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prioritise improving length of stay for admitted patients, particularly emergency admissions lasting at least one day.
Verbatim wording from the response “NHS England will also be prioritising:” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prioritise reducing delays in urgent and emergency care pathways.
Verbatim wording from the response “NHS England will also be prioritising:” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prioritise improving length of stay in NHS-commissioned community beds.
Verbatim wording from the response “NHS England will also be prioritising:” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with trusts and services facing significant ambulance handover challenges.
Verbatim wording from the response “the community. NHS England are continuing to work with trusts and services with significant handover challenges at the ‘front end’, alongside recognising the importance of reducing length of stay and timely discharge to maintain adequate patient flow and allow new patients to be handed over more promptly to EDs.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local and system concerns fall outside NHS England’s national policy and programme remit.
Verbatim wording from the response “My response to the Coroner focuses on those areas of concern that sit within NHS England’s national policy and programme remit. It is appropriate for the other organisations you have addressed your Report to, Hull University Teaching Hospitals NHS Trust and East Riding of Yorkshire Council Adult Social Care and Health, to address the local and system concerns you raise.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The relevant ambulance service must resolve unclear callback instructions locally as a call-handler training issue.
Verbatim wording from the response “Instructions on worsening conditions, including specifically to call back on 999 should the patient’s condition change or deteriorate, are standard components of the case exit script. If the call is made via a second party, ambulance services should ensure there is a process in place to be assured the caller is able to monitor the condition of the patient, and that they can be called back when the patient is not able to call back or answer a call themselves. If this was not provided in a clear and easy to interpret manner, this is a matter for the relevant ambulance service to resolve locally as a training issue for their call handlers.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Worsening-condition and 999 callback instructions are standard components of the case exit script.
Verbatim wording from the response “You raised the concern that it does not seem clear whether callers are advised to call the emergency services back if they continue to have concerns.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local organisations should address the local and system concerns raised in the report.
Verbatim wording from the response “My response to the Coroner focuses on those areas of concern that sit within NHS England’s national policy and programme remit. It is appropriate for the other organisations you have addressed your Report to, Hull University Teaching Hospitals NHS Trust and East Riding of Yorkshire Council Adult Social Care and Health, to address the local and system concerns you raise.” Source location Response from NHS England
Open published response
22 Nov 2024 Nicolette Elizabeth McCARTHY · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 3 Inadequacy of national guidance on smoking and section 17 leave View source Failure of the NHS smoke-free policy to reflect the safety requirements of mental health wards and patients seeking leave to smoke View source Poor supervision of patients smoking during short grounds leave View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nicolette Elizabeth McCARTHY · 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
Nicolette Elizabeth McCarthy was detained in a secure mental health unit after attempts to take her life and remained at risk of suicide. On 19 September 2023, she failed to return from a short period of leave and was not promptly treated as absent without leave; the inquest identified failures in systems and procedures intended to ensure her safety. The report raises concerns that smoke-free policies and unclear guidance may increase the risk of self-harm or suicide for mental health patients on unescorted leave.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of national guidance on smoking and section 17 leave
Wider context from the report “1) During the course of the inquest, I heard evidence from clinicians and staff at the Trust to the effect that the NHS England smoke free policy is placing mental health in patients at an increased risk from self-harm and suicide.
2) Although smoking cessation advice and treatment (e.g. gum, vapes etc.) are routinely offered to patients, the evidence was that many struggle to give up smoking on their admission to the ward, in part because the anxiety associated with stopping exacerbates their mental health symptoms. Staff also felt that forcing patients to stop smoking against their will (e.g. by prohibiting them from smoking while on leave) would have a negative effect on their sense of autonomy and wellbeing, which are important for recovery.
3) The Trust understand that they are bound by the Health Act 2006 and by NHS England policy not to permit or facilitate smoking on the ward or anywhere on the grounds of the hospital. This is taken seriously and is interpreted to mean that staff are prohibited from facilitating smoking, for example by granting leave for the purpose of smoking or by escorting patients to smoke outside on short periods of leave. Senior staff also believed that it would be contrary to NHS policy to permit smoking in a secure area, for example the enclosed ward garden. At the same time, it was acknowledged that patients would inevitably seek leave to smoke and that this could not be denied without a negative impact on their mental health.
4) The jury heard evidence that patients, like Mrs McCarthy, were routinely given 15-minute grounds leave for the purpose of smoking, a practice that is discouraged by the Trust. Clinical staff felt that the policy placed them in a difficult position, torn between the need to comply with the smoke free policy, while also supporting patient autonomy and keeping safe those patients who are at a higher risk of self-harm or suicide.
5) There is a further contradiction caused by the smoke free policy, in that patients are not permitted to smoke on the grounds, but are not supposed to leave the grounds during short periods of ‘grounds’ leave. The result is that patients would spend their 15-minute leave smoking by the side of the road on the edge of the ward grounds, which is a poorly supervised area, and staff would avoid asking them too closely where they were going and would avoid standing close to them, even when smoking themselves. This contributed to the circumstances that allowed Mrs McCarthy to slip away unnoticed and ultimately to take her own life.
6) I also heard evidence from senior staff that the national policy guidance intended to address smoking and s17 leave (e.g. the NICE guidance and CQC guidance) does not adequately resolve these contradictions .
7) I am concerned that the NHS smoke free policy, while clearly motivated by a genuine and pressing concern to protect life and promote health, may not be adequately tailored to reflect the safety requirements of mental health wards or the reality that some mental health patients will inevitably seek short periods of leave to smoke. Action may need to be taken at the national policy level to provide clearer guidance and/or review the law to reduce the risk of patients in mental health wards absconding while on unescorted grounds leave.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of the NHS smoke-free policy to reflect the safety requirements of mental health wards and patients seeking leave to smoke
Wider context from the report “1) During the course of the inquest, I heard evidence from clinicians and staff at the Trust to the effect that the NHS England smoke free policy is placing mental health in patients at an increased risk from self-harm and suicide .
2) Although smoking cessation advice and treatment (e.g. gum, vapes etc.) are routinely offered to patients, the evidence was that many struggle to give up smoking on their admission to the ward, in part because the anxiety associated with stopping exacerbates their mental health symptoms. Staff also felt that forcing patients to stop smoking against their will (e.g. by prohibiting them from smoking while on leave) would have a negative effect on their sense of autonomy and wellbeing, which are important for recovery.
3) The Trust understand that they are bound by the Health Act 2006 and by NHS England policy not to permit or facilitate smoking on the ward or anywhere on the grounds of the hospital. This is taken seriously and is interpreted to mean that staff are prohibited from facilitating smoking, for example by granting leave for the purpose of smoking or by escorting patients to smoke outside on short periods of leave. Senior staff also believed that it would be contrary to NHS policy to permit smoking in a secure area, for example the enclosed ward garden. At the same time, it was acknowledged that patients would inevitably seek leave to smoke and that this could not be denied without a negative impact on their mental health.
4) The jury heard evidence that patients, like Mrs McCarthy, were routinely given 15-minute grounds leave for the purpose of smoking, a practice that is discouraged by the Trust. Clinical staff felt that the policy placed them in a difficult position, torn between the need to comply with the smoke free policy, while also supporting patient autonomy and keeping safe those patients who are at a higher risk of self-harm or suicide.
5) There is a further contradiction caused by the smoke free policy, in that patients are not permitted to smoke on the grounds, but are not supposed to leave the grounds during short periods of ‘grounds’ leave. The result is that patients would spend their 15-minute leave smoking by the side of the road on the edge of the ward grounds, which is a poorly supervised area, and staff would avoid asking them too closely where they were going and would avoid standing close to them, even when smoking themselves. This contributed to the circumstances that allowed Mrs McCarthy to slip away unnoticed and ultimately to take her own life.
6) I also heard evidence from senior staff that the national policy guidance intended to address smoking and s17 leave (e.g. the NICE guidance and CQC guidance) does not adequately resolve these contradictions.
7) I am concerned that the NHS smoke free policy, while clearly motivated by a genuine and pressing concern to protect life and promote health, may not be adequately tailored to reflect the safety requirements of mental health wards or the reality that some mental health patients will inevitably seek short periods of leave to smoke . Action may need to be taken at the national policy level to provide clearer guidance and/or review the law to reduce the risk of patients in mental health wards absconding while on unescorted grounds leave.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Poor supervision of patients smoking during short grounds leave
Wider context from the report “1) During the course of the inquest, I heard evidence from clinicians and staff at the Trust to the effect that the NHS England smoke free policy is placing mental health in patients at an increased risk from self-harm and suicide.
2) Although smoking cessation advice and treatment (e.g. gum, vapes etc.) are routinely offered to patients, the evidence was that many struggle to give up smoking on their admission to the ward, in part because the anxiety associated with stopping exacerbates their mental health symptoms. Staff also felt that forcing patients to stop smoking against their will (e.g. by prohibiting them from smoking while on leave) would have a negative effect on their sense of autonomy and wellbeing, which are important for recovery.
3) The Trust understand that they are bound by the Health Act 2006 and by NHS England policy not to permit or facilitate smoking on the ward or anywhere on the grounds of the hospital. This is taken seriously and is interpreted to mean that staff are prohibited from facilitating smoking, for example by granting leave for the purpose of smoking or by escorting patients to smoke outside on short periods of leave. Senior staff also believed that it would be contrary to NHS policy to permit smoking in a secure area, for example the enclosed ward garden. At the same time, it was acknowledged that patients would inevitably seek leave to smoke and that this could not be denied without a negative impact on their mental health.
4) The jury heard evidence that patients, like Mrs McCarthy, were routinely given 15-minute grounds leave for the purpose of smoking, a practice that is discouraged by the Trust. Clinical staff felt that the policy placed them in a difficult position, torn between the need to comply with the smoke free policy, while also supporting patient autonomy and keeping safe those patients who are at a higher risk of self-harm or suicide.
5) There is a further contradiction caused by the smoke free policy, in that patients are not permitted to smoke on the grounds, but are not supposed to leave the grounds during short periods of ‘grounds’ leave. The result is that patients would spend their 15-minute leave smoking by the side of the road on the edge of the ward grounds, which is a poorly supervised area , and staff would avoid asking them too closely where they were going and would avoid standing close to them , even when smoking themselves. This contributed to the circumstances that allowed Mrs McCarthy to slip away unnoticed and ultimately to take her own life.
6) I also heard evidence from senior staff that the national policy guidance intended to address smoking and s17 leave (e.g. the NICE guidance and CQC guidance) does not adequately resolve these contradictions.
7) I am concerned that the NHS smoke free policy, while clearly motivated by a genuine and pressing concern to protect life and promote health, may not be adequately tailored to reflect the safety requirements of mental health wards or the reality that some mental health patients will inevitably seek short periods of leave to smoke. Action may need to be taken at the national policy level to provide clearer guidance and/or review the law to reduce the risk of patients in mental health wards absconding while on unescorted grounds leave.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NICE and DHSC are responsible for responding to concerns about national smoking and Section 17 leave policy.
Verbatim wording from the response “I note that you have also addressed your concerns to NICE and the DHSC, and it would be appropriate for these organisations to respond to the Coroner, as the responsible policy holders for the issues raised. Individual NHS Trusts are responsible for the local implementation of these policies and not the wider NHS England Estates Team.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual NHS trusts are responsible for locally implementing smoke-free policies, rather than NHS England’s wider Estates Team.
Verbatim wording from the response “I note that you have also addressed your concerns to NICE and the DHSC, and it would be appropriate for these organisations to respond to the Coroner, as the responsible policy holders for the issues raised. Individual NHS Trusts are responsible for the local implementation of these policies and not the wider NHS England Estates Team.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There is no known published evidence that smoke-free policies increase mental health patients’ risk of self-harm or suicide.
Verbatim wording from the response “Your report states that NHS England’s smoke free policy places mental health inpatients at an increased risk of self-harm and suicide. Currently, there is no known published evidence that smoke free policies place patients at an increased risk of self-harm or suicide.²” Source location Response from NHS England
Open published response
15 Nov 2024 Yousef Al-Kharboush and 2 others · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Lack of requirements for section 10 exempt entities to report adverse-event findings to the MHRA and other relevant organisations View source Unclear thresholds for section 10 entity reporting to NHSE and the CQC View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Yousef Al-Kharboush and 2 others · 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
Aviva Otte died in January 2014 after receiving TPN provided and compounded by an NHS establishment; the TPN was, on balance, contaminated with Bacillus cereus. Oscar Barker and Yousef Al-Kharboush died in June 2014 after receiving TPN compounded by a commercial provider that was also contaminated with Bacillus cereus. The principal concerns were unclear or absent requirements for section 10 exempt entities to report adverse-event findings and uncertainty about reporting thresholds and wider dissemination of information that could help other providers assess risks.
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 requirements for section 10 exempt entities to report adverse-event findings to the MHRA and other relevant organisations
Wider context from the report “(1) There is no requirement for a section 10 exempt entity to report any of its findings to the MHRA or indeed to other Trusts or the industry in general if an adverse event occurs.
(2) The current reporting structures (for a section 10 entity) involve reporting to NHSE and the CQC but the threshold of necessity for such reporting appears unclear and, in essence, up to the Trust.
(3) There may be times when section 10 entities reach conclusions which would assist the wider industry and help to assist both other Trusts and commercial organisations in assessing their own risks and improving the provision of highly specific medication to a group of vulnerable patients.
(4) the same may also be true of commercial organisations but they have the power of the MHRA controlling and effecting recalls and actions and the wider dissemination of information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unclear thresholds for section 10 entity reporting to NHSE and the CQC
Wider context from the report “(1) There is no requirement for a section 10 exempt entity to report any of its findings to the MHRA or indeed to other Trusts or the industry in general if an adverse event occurs.
(2) The current reporting structures (for a section 10 entity) involve reporting to NHSE and the CQC but the threshold of necessity for such reporting appears unclear and, in essence, up to the Trust.
(3) There may be times when section 10 entities reach conclusions which would assist the wider industry and help to assist both other Trusts and commercial organisations in assessing their own risks and improving the provision of highly specific medication to a group of vulnerable patients.
(4) the same may also be true of commercial organisations but they have the power of the MHRA controlling and effecting recalls and actions and the wider dissemination of information.
” 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 Require incidents from NHS section 10 aseptic services to enter the patient safety incident reporting route and LFPSE system.
Verbatim wording from the response “In general, any NHS Trust providing aseptic services under a section 10 exemption does not need to report to the MHRA as they’re not licensed units. However, all incidents from these services will be reported via the current patient safety incident reporting route and into the NHS Learn From Patient Safety Events (LFPSE) system.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish updated national guidance governing assurance and escalation for NHS section 10 aseptic preparation units.
Verbatim wording from the response “The reporting structure for section 10 units is now much clearer following the publication of the NHS England » Assurance of aseptic preparation of medicines.pdf in March 2023, and replacing the previous guidance from 1997. This guidance “applies to all NHS pharmacy aseptic facilities in England undertaking preparation of sterile medicinal products under Section 10 exemption to the Medicines Act 1968 (as amended)…”. It is my understanding that a copy of this was previously shared with the Coroner. The document outlines the escalation processes for:” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide national aseptic-services risk and learning dissemination through SPS newsletters, virtual workshops and seminars for NHS staff.
Verbatim wording from the response “The SPS quality assurance service issues a regular newsletter and holds virtual workshops and seminars for NHS staff to highlight risks and support in aseptic services. This does not extend to commercial manufacturers producing TPN, who can continue to seek guidance and input from the MHRA. The SPS is intended to connect NHS s.10 exempt pharmacies and share sector knowledge as part of continuous improvement and learning across that group.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate quarterly section 10 unit status reporting with immediate escalation of high-risk failures and serious patient safety incidents.
Verbatim wording from the response “Quarterly unit status overview reports are routinely sent to NHSE Regional Chief Pharmacists (RCPs), the NHSE Chief Pharmaceutical Officer and CQC Medicines Optimisation. This achieves a cross sector sharing of s.10 exempt manufacturing and ensures the CQC have awareness of any high risk failings or serious incidents. This notification/reporting is not a decision made at local level by an NHS body/Trust, but forms part of the SPS oversight and escalation in place. Following implementation of the new guidance, the first of these quarterly reports was received in Jul 2024. There is immediate escalation of high-risk failings or serious patient safety incidents to the relevant RCP in the first instance.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation MHRA reporting is not required because section 10 units are outside the MHRA’s regulatory mandate and scope of activity.
Verbatim wording from the response “In general, any NHS Trust providing aseptic services under a section 10 exemption does not need to report to the MHRA as they’re not licensed units. However, all incidents from these services will be reported via the current patient safety incident reporting route and into the NHS Learn From Patient Safety Events (LFPSE) system.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing NHS England guidance, SPS oversight, escalation, and patient-safety reporting routes sufficiently address reporting by section 10 NHS aseptic units.
Verbatim wording from the response “The reporting structure for section 10 units is now much clearer following the publication of the NHS England » Assurance of aseptic preparation of medicines.pdf in March 2023, and replacing the previous guidance from 1997. This guidance “applies to all NHS pharmacy aseptic facilities in England undertaking preparation of sterile medicinal products under Section 10 exemption to the Medicines Act 1968 (as amended)…”. It is my understanding that a copy of this was previously shared with the Coroner. The document outlines the escalation processes for:” Source location Response from NHS England
Open published response
Concerns raised 3 Unavailability of methylene blue on ambulances for relevant chemical ingestions View source Failure to assign sufficiently urgent dispositions for time-sensitive chemical ingestions View source Failure to differentiate overdose call classification by clinical severity and relevant ingestion factors View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joel Phillip COLK · 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
Joel Phillip Colk called 999 after ingesting at least 50g of a substance and was attended by an ambulance after the call was upgraded from category 3 to category 2. He was in cardiac arrest on attendance and died at home on 2 October 2023. The concerns include that NHS Pathways did not differentiate overdoses by substance, amount, timing or patient weight, and did not reflect the time-sensitive treatment required for this ingestion; ambulances also did not carry the antidote in the area described.
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 methylene blue on ambulances for relevant chemical ingestions
Wider context from the report “The Court heard that when a call is made to 999 that the call is categorised using NHS Pathways and that all overdoses would be in the same classification resulting in the same disposition and response category. The system does not differentiate between types of, severity of or the drugs/chemicals reported as being the cause of the overdose. The system also does not differentiate call classification taking into account the amount reported as ingested, the timing of ingestion or the patient's weight. The Court heard that all of these factors can impact on the time in which care needs to be rendered to prevent death. The example given to the Court was that someone who had taken a relatively small paracetamol that would be unlikely to cause harm would, using Pathways, have the same resultant disposition as someone who had ingested a significant amount of a known lethal chemical.
Secondly, the Court heard that in the case of ████████ ingestion that treatment is only effective if medications are administered before the patient suffers a cardiac arrest. This likely will occur incredibly rapidly and is a known effect of the chemical. The Pathways system does not reflect the time sensitive nature of an effective response when it is known that ████████ has been ingested and would not create a higher disposition requiring more urgent attendance than category 3.
The Court was also told that clinicians do not carry on any Ambulances within South East Coast Ambulance Service NHS Foundation Trust Methylene Blue which is the antidote to ████████ ingestion as this is not within national guidance. I heard that in some areas there are ongoing trials for some areas that this is on board vehicles within the HART (Hazardous Area Response Team). Therefore in this area the treatment is only available when a patient reaches an acute hospital with an A&E department and the evidence was that often patients enter cardiac arrest before this occurs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 assign sufficiently urgent dispositions for time-sensitive chemical ingestions
Wider context from the report “The Court heard that when a call is made to 999 that the call is categorised using NHS Pathways and that all overdoses would be in the same classification resulting in the same disposition and response category. The system does not differentiate between types of, severity of or the drugs/chemicals reported as being the cause of the overdose. The system also does not differentiate call classification taking into account the amount reported as ingested, the timing of ingestion or the patient's weight. The Court heard that all of these factors can impact on the time in which care needs to be rendered to prevent death. The example given to the Court was that someone who had taken a relatively small paracetamol that would be unlikely to cause harm would, using Pathways, have the same resultant disposition as someone who had ingested a significant amount of a known lethal chemical.
Secondly, the Court heard that in the case of ████████ ingestion that treatment is only effective if medications are administered before the patient suffers a cardiac arrest. This likely will occur incredibly rapidly and is a known effect of the chemical. The Pathways system does not reflect the time sensitive nature of an effective response when it is known that ████████ has been ingested and would not create a higher disposition requiring more urgent attendance than category 3 .
The Court was also told that clinicians do not carry on any Ambulances within South East Coast Ambulance Service NHS Foundation Trust Methylene Blue which is the antidote to ████████ ingestion as this is not within national guidance. I heard that in some areas there are ongoing trials for some areas that this is on board vehicles within the HART (Hazardous Area Response Team). Therefore in this area the treatment is only available when a patient reaches an acute hospital with an A&E department and the evidence was that often patients enter cardiac arrest before this occurs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 differentiate overdose call classification by clinical severity and relevant ingestion factors
Wider context from the report “The Court heard that when a call is made to 999 that the call is categorised using NHS Pathways and that all overdoses would be in the same classification resulting in the same disposition and response category . The system does not differentiate between types of, severity of or the drugs/chemicals reported as being the cause of the overdose . The system also does not differentiate call classification taking into account the amount reported as ingested, the timing of ingestion or the patient's weight . The Court heard that all of these factors can impact on the time in which care needs to be rendered to prevent death. The example given to the Court was that someone who had taken a relatively small paracetamol that would be unlikely to cause harm would, using Pathways, have the same resultant disposition as someone who had ingested a significant amount of a known lethal chemical.
Secondly, the Court heard that in the case of ████████ ingestion that treatment is only effective if medications are administered before the patient suffers a cardiac arrest. This likely will occur incredibly rapidly and is a known effect of the chemical. The Pathways system does not reflect the time sensitive nature of an effective response when it is known that ████████ has been ingested and would not create a higher disposition requiring more urgent attendance than category 3.
The Court was also told that clinicians do not carry on any Ambulances within South East Coast Ambulance Service NHS Foundation Trust Methylene Blue which is the antidote to ████████ ingestion as this is not within national guidance. I heard that in some areas there are ongoing trials for some areas that this is on board vehicles within the HART (Hazardous Area Response Team). Therefore in this area the treatment is only available when a patient reaches an acute hospital with an A&E department and the evidence was that often patients enter cardiac arrest before this occurs.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a national operational procedure requiring clinical oversight and timely escalation for Category 3 overdose and suicidal-ideation calls.
Verbatim wording from the response “In April 2021, NHS England in conjunction with the Association of Ambulance Chief Executives (AACE) published a new operational procedure for all ambulance services in England entitled, “Category 3/ 999 Overdose and Suicidal Ideation Calls; Initial Assessment of Lethality/Toxicity Principles Document”. This document followed a detailed review that had been undertaken to consider agreed ambulance control room processes, to ensure suicidal patients receive the correct clinical response. This review had also been the catalyst for NHS England contacting all ambulance and NHS 111 services in early 2019 as described above. The guidance highlights the critical importance of clinical oversight and review (rather than, for example, a re-categorisation of calls to Category 1 on a case-by-case basis) and sets out that:” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update overdose guidance to include Category 5 dispositions and require urgent remote clinical assessment pending appropriate ambulance response.
Verbatim wording from the response “Most recently, the overdose guidance was updated in November 2023 to include callers who reach a Category 5 disposition (hear and treat). This followed a review by ECPAG, NHS England and NASMeD, part of the AACE, to ensure it remained clinically fit for purpose. For those cases which do not automatically result in a Category 1 or 2 emergency ambulance response, an urgent remote clinical assessment will take place, pending which the case will be dealt with as a Category 3 emergency ambulance response. The objective of further remote clinical assessment” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual ambulance trusts are responsible for deciding whether to carry Methylene Blue; NHS England does not mandate this operational arrangement.
Verbatim wording from the response “The carrying of particular medication by ambulance services is an operational issue and is up to individual ambulance trusts; NHS England does not mandate such issues. NHS England is aware of a small number of ambulance specialist units who carry Methylene Blue. This antidote is carried by specialist clinical teams for administration in cases of moderate/severe ████████ poisoning which can be measured through an exhaled breath monitor. Clinical feedback suggests it is likely Methylene Blue would not be used except for severe cases or where there is a long journey time to definitive care.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mandating ambulance services to carry Methylene Blue is outside NHS England’s remit because medication carriage is an operational matter for individual trusts.
Verbatim wording from the response “The carrying of particular medication by ambulance services is an operational issue and is up to individual ambulance trusts; NHS England does not mandate such issues. NHS England is aware of a small number of ambulance specialist units who carry Methylene Blue. This antidote is carried by specialist clinical teams for administration in cases of moderate/severe ████████ poisoning which can be measured through an exhaled breath monitor. Clinical feedback suggests it is likely Methylene Blue would not be used except for severe cases or where there is a long journey time to definitive care.” Source location Response from NHS England
Open published response
Concerns raised 6 Inconsistent coordination between specialist and non-specialist hospitals View source Inconsistent decision-making about whether patients remain in non-specialist areas or are transferred View source Lack of consistent understanding of appropriate specialist contacts and engagement timing View source Failure to clearly define patient information for specialist renal hospitals View source Lack of consistent awareness of and access to kidney transplant care guidelines and protocols View source Lack of consistent understanding of responsibility for initiating patient transfers View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
John Frederick Doyle · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Frederick Doyle, a kidney transplant recipient, was admitted with rectal bleeding and a persistent cough and was later diagnosed with a severe cytomegalovirus infection after delays in testing, diagnosis and transfer to specialist care. He deteriorated to multiple organ failure and died on 30 December 2023. Concerns included unclear arrangements for contacting specialist centres, sharing information, accessing renal guidance, initiating transfers and coordinating care between specialist and non-specialist hospitals.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inconsistent coordination between specialist and non-specialist hospitals
Wider context from the report “Concern 6: Coordination Between Specialist and Non-Specialist Hospitals
There may be variation in how specialist renal hospitals engage with non-specialist hospitals that rely on their expertise , impacting collaborative efforts in patient care. Currently, there is no clear guidance on how specialist and non-specialist teams should work together effectively to ensure consistent, high-quality care for these 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 Inconsistent decision-making about whether patients remain in non-specialist areas or are transferred
Wider context from the report “Concern 5: Decision-Making for Patient Location
Considerations regarding whether patients should remain in non-specialist areas or be transferred may differ , potentially affecting consistency in care approaches.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 consistent understanding of appropriate specialist contacts and engagement timing
Wider context from the report “Concern 1: Contacting Specialist Centres
Non-specialist medical staff may have varied understanding of the appropriate contacts and timing for engaging with specialist renal hospitals .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 clearly define patient information for specialist renal hospitals
Wider context from the report “Concern 2: Information Sharing with Specialist Centres
The specific patient information that non-specialist staff should provide to specialist renal hospitals may not always be clearly defined .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 consistent awareness of and access to kidney transplant care guidelines and protocols
Wider context from the report “Concern 3: Accessibility to Renal Care Guidelines
Non-specialist staff may experience varying levels of awareness or accessibility to guidelines and protocols for treating kidney transplant patients . This could lead to a misunderstanding of the significance and urgency of the actions recommended by specialist renal hospitals.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 consistent understanding of responsibility for initiating patient transfers
Wider context from the report “Concern 4: Transfer Responsibility
There may be some inconsistency across non-specialist hospitals and renal hospitals in understanding who is responsible for initiating patient transfers .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Oversight of delegated renal medicine services rests with individual Integrated Care Boards, including Coventry and Warwickshire ICB.
Verbatim wording from the response “Renal medicine is a specialist service that is delegated to individual Integrated Care Boards. My regional colleagues in the Midlands have been sighted on your Report, and have shared it with Coventry and Warwickshire ICB, for the appropriate oversight.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Providers involved in the care should respond to concerns about local arrangements and processes, rather than NHS England.
Verbatim wording from the response “I note that your Report has also been sent to University Hospitals Coventry and Warwickshire NHS Trust (UHCW) and George Eliot Hospital NHS Trust (GEH). It is appropriate that the providers involved in John’s care respond to the Coroner regarding the concerns raised which relate to local arrangements and process. NHS England has asked to be sighted on their responses once these are in due course and whether any further actions are required from our Specialised Commissioning Teams.” Source location Response from NHS England
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations