Concerns raised 1 Failure to ensure access to histological analysis for privately funded procedures without a separate cost barrier 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
Gregor Patrick Edward Lynn · 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
Gregor Patrick Edward Lynn developed a neck lesion in March 2019, which was excised privately without histological analysis because of the additional cost. When the lesion recurred in May 2020, it was diagnosed as melanoma that had metastasised, and he died on 8 July 2022 after the disease spread to his brain. The principal concern was that patients paying privately for procedures may decline histological analysis because it is an additional cost, unlike within NHS treatment.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure access to histological analysis for privately funded procedures without a separate cost barrier
Wider context from the report “• I was not able to conclude that, had the sample been sent for analysis in March 2019, any sign of melanoma would have been detected. Nevertheless, it is of concern that the barrier to undergoing a complete procedure, including histological analysis, appears to be one of cost . Anecdotal evidence received at inquest from treating clinicians was that the further costs associated with histological or other review, which on the NHS would be routinely included within the procedure at no charge to the patient, was a common disincentive to patients who would regularly opt not to have the further tests carried out .
• While it is acknowledged that there have to be criteria for routine and non-emergency procedures to be conducted on the NHS, my concern relates to the disparity in what is included within the treatment when undertaken privately (where histological analysis is a separate and additional cost) and what is routinely included as part of NHS treatment.
• It therefore seems to me that there is a risk of future deaths if patients not meeting the NHS referral criteria, who have to pay for procedures to be carried out privately, opt on cost grounds not to have the histological analysis which would otherwise be provided on the NHS at no charge , as it is well-established fact that earlier detection and treatment is crucial in minimising the risks of developing metastatic cancers including melanoma.
” 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 NHS England and NHS commissioners cannot influence how private care is delivered.
Verbatim wording from the response “As you have outlined in your Report, the GP who undertook the excision in this case was doing so on a private patient basis. NHS England and NHS commissioners are not able to influence how private care is delivered to patients. I note that you have also sent your Report to the Department of Health and Social Care. You may also wish to refer this case to the Care Quality Commission (CQC) who are responsible for ensuring that standards of quality and safety are upheld within private hospitals and clinics.” Source location Response from NHS England
Open published response
11 Dec 2023 Amarnih Lewis-Daniel · Prevention of Future Deaths report East London
View report summary
Concerns raised 6 Lack of knowledge of guidance for safe prescribing of bridging hormones View source Lack of local support for patients awaiting Gender Identity Clinic assessment and treatment View source Lack of clarity about responsibility for patient wellbeing during the waiting period View source Lack of specialist knowledge in local mental health services about supporting people with GID View source Very long waiting lists for Gender Identity Clinics View source Failure of primary and secondary/tertiary services to work optimally together to support patients during lengthy waiting periods View source See 3 more concerns
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AI-generated summary
Amarnih Lewis-Daniel · 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
Amarnih Lewis-Daniel, who had experienced mental health difficulties and gender dysphoria, died after sustaining fatal injuries in a fall on 17 March 2021 while awaiting care from a Gender Identity Clinic. The report raised concerns about lengthy waiting lists, limited local support during the wait, unclear responsibility for patients’ wellbeing, limited specialist knowledge in local mental health services, and unclear guidance on prescribing bridging hormones.
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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 knowledge of guidance for safe prescribing of bridging hormones
Wider context from the report “5. Those in attendance at the inquest were unclear about guidance available to GPs and other healthcare professionals to support them with the safe prescribing of bridging hormones , during the lengthy waiting period. The BMA’s guidance on the role of GPs in managing patients with gender incongruence (2022) and the Royal College of Psychiatrist’s advice relating to bridging prescriptions was not known by the healthcare professionals in attendance at the inquest hearing . There is a concern that primary and secondary/tertiary services are not working optimally, to support those during the lengthy waiting periods.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of local support for patients awaiting Gender Identity Clinic assessment and treatment
Wider context from the report “2. The inquest also heard that there is little local support available to patients who are waiting for assessment and treatment by Gender Identity Clinics .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about responsibility for patient wellbeing during the waiting period
Wider context from the report “3. There was a lack of clarity as to who is responsible for the wellbeing of the patient during the wait for period , for any distress caused by the gender dysphoria. There was a lack of consensus as to whether it would be the referrer or the GID clinic itself .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 specialist knowledge in local mental health services about supporting people with GID
Wider context from the report “4. Local mental health services have very little specialist knowledge as to how best to support a person suffering from GID .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Very long waiting lists for Gender Identity Clinics
Wider context from the report “1. The inquest heard that there are very long waiting lists for GID clinics . In September 2023, the average waiting time was in the region of 7 years . The expert instructed at the inquest identified that long waiting lists could intensify distress arising from gender dysphoria.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 primary and secondary/tertiary services to work optimally together to support patients during lengthy waiting periods
Wider context from the report “5. Those in attendance at the inquest were unclear about guidance available to GPs and other healthcare professionals to support them with the safe prescribing of bridging hormones, during the lengthy waiting period. The BMA’s guidance on the role of GPs in managing patients with gender incongruence (2022) and the Royal College of Psychiatrist’s advice relating to bridging prescriptions was not known by the healthcare professionals in attendance at the inquest hearing. There is a concern that primary and secondary/tertiary services are not working optimally, to support those during the lengthy waiting periods .
” 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 Refresh adult gender dysphoria service specifications, including consideration of service inefficiencies and further clinical-capacity expansion.
Verbatim wording from the response “NHS England’s overall planned spend on all gender dysphoria services (adults and children) in 2023/24 is £78.17m – up from £33.4m in 2018/19, representing an overall increase in funding of 134% in five years. In 2024/25 NHS England will refresh the service specifications for adult gender dysphoria services, which will include consideration of how to identify and address inefficiencies that may reside in the way in which GDCs manage and deliver their services and which may contribute to long waiting times – and how to expand clinical capacity further taking the learning from the pilot services. It is too early in the current year to provide precise figures for the planned budget for gender dysphoria services in 2024/25 but the figure given represents recurrent funding commitments and so should be regarded as the opening baseline figure for planning assumptions.” 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 Commission waiting-list support resources, including referral screening, outreach and peer workers, advice lines, and pre-assessment workshops.
Verbatim wording from the response “NHS England also continues to support the expansion of services in the established GDCs where this is possible. In 2021/22 NHS England invited all seven GDCs to put forward a business case for funding for the expansion of clinical capacity or direct patient support as part of a discretionary investment process. An additional investment of £2.2m was set aside for this purpose. Although all this funding was deployed into the GDCs by NHS England, some of the funding was directed by the providers to non-clinical forms of support for patients on the waiting list due to the difficulties in attracting clinical staff to work in the service itself. There is clinical opinion that telephone and online support are a useful service for patients on the waiting list. We have also commissioned support resources at Gender Dysphoria Clinics, to include:” 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 and fund the UK’s first accredited gender identity healthcare training programme.
Verbatim wording from the response “As mentioned above, to support the growth of clinical capacity NHS England also established and funded the UK’s first accredited training programme in gender identity healthcare which was launched in 2020 and delivered through the Royal College of Physicians. The purpose of this investment is to encourage growth in the specialist clinical workforce available to contribute to the assessment and care of those presenting with gender incongruence and to treatment following a diagnosis of gender dysphoria.” 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 the procurement process for a substantive Cheshire and Merseyside gender dysphoria service contract.
Verbatim wording from the response “In 2023 the pilot services at Chelsea and Westminster Hospital NHS Foundation Trust (London) and GTD Healthcare (Greater Manchester) were moved to substantive seven-year contracts with NHS England following positive evaluations. The GTD service is now open to new referrals of patients who are registered with a GP in Greater Manchester, and the London service is now taking increased numbers of patients from the waiting list of its nearest GDC – the Tavistock and Portman NHS Foundation Trust. NHS England is currently out to tender to award a substantive contract for the service in Cheshire and Merseyside following positive evaluation of this service, and there is an expectation that a similar process will be followed for the other two pilots when their evaluations are complete in 2024 (East England) and 2026 (Sussex).” 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 Deploy £2.2 million of additional investment to established clinics for clinical-capacity expansion or direct patient support.
Verbatim wording from the response “NHS England also continues to support the expansion of services in the established GDCs where this is possible. In 2021/22 NHS England invited all seven GDCs to put forward a business case for funding for the expansion of clinical capacity or direct patient support as part of a discretionary investment process. An additional investment of £2.2m was set aside for this purpose. Although all this funding was deployed into the GDCs by NHS England, some of the funding was directed by the providers to non-clinical forms of support for patients on the waiting list due to the difficulties in attracting clinical staff to work in the service itself. There is clinical opinion that telephone and online support are a useful service for patients on the waiting list. We have also commissioned support resources at Gender Dysphoria Clinics, to include:” 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 Move the London and Greater Manchester pilot services to substantive seven-year contracts following positive evaluations.
Verbatim wording from the response “In 2023 the pilot services at Chelsea and Westminster Hospital NHS Foundation Trust (London) and GTD Healthcare (Greater Manchester) were moved to substantive seven-year contracts with NHS England following positive evaluations. The GTD service is now open to new referrals of patients who are registered with a GP in Greater Manchester, and the London service is now taking increased numbers of patients from the waiting list of its nearest GDC – the Tavistock and Portman NHS Foundation Trust. NHS England is currently out to tender to award a substantive contract for the service in Cheshire and Merseyside following positive evaluation of this service, and there is an expectation that a similar process will be followed for the other two pilots when their evaluations are complete in 2024 (East England) and 2026 (Sussex).” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop five pilot gender dysphoria services to expand clinical capacity and reduce established-clinic waiting lists.
Verbatim wording from the response “In the circumstances, NHS England sought to grow capacity in an alternative way. Five pilot services were developed. The proposal was to build a new clinical workforce using professionals who had tended not to specialise in gender identity healthcare previously, based in primary care and local sexual health services, which presented the opportunity to develop and expand clinical capacity to an extent not possible under the historical delivery model. There were various eligibility criteria for accessing the different pilot services (for example, being registered with a GP in the relevant geographical catchment area) but all the pilot services only took patients from the waiting lists of the established GDCs, in chronological order of waiting. Between April 2020 and August 2023 around 2,500 individuals were removed from a GDC waiting list to be seen by one of the pilot services.” 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 Sufficient gender dysphoria clinic capacity cannot be commissioned because specialist clinical staff are unavailable amid increasing demand.
Verbatim wording from the response “The consultant-led services provided by the GDCs when adult patients are referred to them are amongst those intended to commence within 18 weeks of referral. NHS England has been unable to commission sufficient capacity to meet that expectation because of the lack of specialist clinical staff (recruitment and retention) – against a backdrop of significant increasing demand. Unfortunately, waiting times for a first appointment at a GDC remain very high. Of patients who received their first appointment in November 2023 they had on average been referred 382 weeks previously.” 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 Clinical responsibility during a GDC waiting period rests with the patient’s GP or involved local healthcare professional, not an unseen clinician.
Verbatim wording from the response “It is clear that no individual healthcare professional can be deemed to hold clinical responsibility for a patient that they have never seen for the purpose of a clinical consultation. Consequently, the individual healthcare professional that holds clinical responsibility for a patient while they remain on the waiting list for a GDC will be the patient’s GP, if the patient presents to the GP, or the local healthcare professional who is involved in the provision of care to the individual. Our response above has described some of the various training and support materials that are available to the relevant health professionals.” 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 Commissioning responsibility for local support services rests with Integrated Care Boards, not NHS England.
Verbatim wording from the response “Commissioning responsibility for local services rests with Integrated Care Boards (ICBs) rather than NHS England. The make-up of local services, and their approach to service delivery, training and education, can differ according to each ICB’s commissioning strategy.” Source location Response from NHS England
Open published response
Concerns raised 4 Failure to enforce pharmacy questioning and pharmacist presence for over-the-counter cyclizine purchases View source Lack of professional understanding of using the Controlled Drugs local intelligence network for non-controlled drugs View source Absence of a commissioned pathway for GPs to refer compromised community patients requiring blood tests View source Failure to consider cyclizine addiction in eating disorder services 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
Charlene 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
Charlene Roberts died at Fairfield General Hospital on 12 January 2023 after suffering cardiac arrest during an inpatient admission; her cause of death was confirmed as cyclizine toxicity, with aspiration pneumonia, anorexia and factitious disorder also recorded. The principal concerns included the availability and prescribing of cyclizine, limited professional understanding of cyclizine dependence and the use of local intelligence systems for non-controlled drugs, and the lack of a commissioned community pathway for obtaining blood samples from compromised patients.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to enforce pharmacy questioning and pharmacist presence for over-the-counter cyclizine purchases
Wider context from the report “The court heard evidence that intravenous cyclizine is by prescription only but oral cyclizine can be purchased over the counter at a pharmacy. In order to purchase oral cyclizine in a pharmacy a pharmacist should seek information as to why it is required and should be present . Charlene’s family gave evidence that following Charlene’s death they had been able to obtain cyclizine in a pharmacy directly from a pharmacy assistant with no questions being asked of them .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of professional understanding of using the Controlled Drugs local intelligence network for non-controlled drugs
Wider context from the report “Cyclizine is not a controlled drug. At one stage consideration was given to using the Controlled Drugs local intelligence network as convened by NHS England (Controlled Drugs (Supervision and Management of Use) Regulations 2013) to put an alert out to local pharmacies to warn them about Charlene’s purchasing of cyclizine.
From the evidence there was a lack of clarity and understanding from professionals as to whether this local network could be used for drugs which are not controlled drugs . The fact that the legislation refers to controlled drugs may mean there is a lack of understanding about using this for system for non controlled drugs such as cyclizine.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Absence of a commissioned pathway for GPs to refer compromised community patients requiring blood tests
Wider context from the report “During the course of the evidence the court heard evidence from the GP who was responsible for obtaining weekly bloods to monitor her eating disorder. There is no commissioned pathway in Rochdale for GPs to refer patients who require bloods but who are compromised and therefore hard to obtain blood from . As a result patients are attending A&E departments for these to be taken .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to consider cyclizine addiction in eating disorder services
Wider context from the report “The court was made aware of the research conducted in 2009 as published in the journal PNS, “Proceedings of the Nutrition Society”, “Cyclizine dependence in patients with complex nutritional requirements” Thursby-Pelham, De Silva, Stroud and Fine, 23 July 2009. This identified cyclizine dependence in four female patients who all had complex nutritional problems.
Whilst it is acknowledged that this is one study and as stated cyclizine addiction is rare, it was not something which had been considered before Charlene’s addiction by the Eating Disorder Service . For the Manchester Eating Disorder Service there is now a greater awareness of cyclizine. This may be important nationally given its use as an anti-emetic.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Controlled Drugs Local Intelligence Network cannot support sharing information about non-controlled drugs under the 2013 Regulations.
Verbatim wording from the response “The provisions of the Controlled Drugs (Supervision of Management and Use) Regulations 2013 (the “2013 Regulations”) relate to controlled drugs only. They provide the legal framework under which information should be shared about an individual working in health and/or social care, a “relevant person” (see Regulation 5). The Local Intelligence Network supports the sharing of this information and members have a duty to co-operate and share information concerning the safe use and management of controlled drugs. The Regulations do not, however, provide a framework to share information about patients.” 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 safeguarding duties and Caldicott-compliant information sharing between healthcare teams should address relevant patient safety information needs.
Verbatim wording from the response “However, all healthcare providers and healthcare professionals, have a duty to safeguard their patients. We would anticipate that relevant information would be shared with other clinical teams that may be involved in the provision of care to an individual patient, including community pharmacy contractors, in line with the Caldicott principles linked to above.” Source location Response from NHS England
Open published response
8 Dec 2023 Jasbir Pahal · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 3 Reliance on ad hoc voluntary interventional neuroradiologist availability for out-of-hours thrombectomy View source Failure of the nearest hyper-acute stroke hospital to offer a thrombectomy service View source Insufficient commissioned out-of-hours thrombectomy provision for stroke patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Jasbir Pahal · 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
Jasbir Pahal suffered an acute left middle cerebral artery stroke on 13 November 2022 and was transferred between hospitals while arrangements for thrombectomy were being considered. Imaging later showed extensive infarction, active treatment was withdrawn on 27 November, and she died on 30 November 2022. The principal concern was that thrombectomy access for patients at Calderdale Royal Hospital was available only during limited weekday hours, leaving patients without reliable access to potentially life-saving treatment outside those hours and subjecting access to local arrangements.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Reliance on ad hoc voluntary interventional neuroradiologist availability for out-of-hours thrombectomy
Wider context from the report “(6) That this level of service is inadequate is illustrated by the historical practice of thrombectomies being performed at LGI outside of the stated hours on an occasional ad hoc basis, dependent (among other factors) upon the availability and willingness of an interventional neuroradiologist to attend on a voluntary basis when not on call , to perform a potentially life-saving procedure. Among other reasons, it being considered inappropriate that clinicians should be exposed to the moral dilemma of agreeing or declining to perform such a life-saving procedure outside of their working or on-call hours, LTHT has as from June 2023 stopped accepting such ad hoc referrals .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 nearest hyper-acute stroke hospital to offer a thrombectomy service
Wider context from the report “(1) Calderdale Royal Hospital (CRH), the hospital with a hyper-acute stroke unit closest to Jasbir’s home address, does not offer a thrombectomy service, whether in or out of hours .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 commissioned out-of-hours thrombectomy provision for stroke patients
Wider context from the report “(3) In common with similar arrangements applying to other district general hospital NHS Trusts in West Yorkshire, NHS England has commissioned the provision of a thrombectomy service to Calderdale and Huddersfield NHS Foundation Trust (CHFT) stroke patients by Leeds Teaching Hospitals NHS Trust (LTHT), whereby stroke patients admitted to Calderdale Royal Hospital and potentially requiring thrombectomy can be transferred for this purpose to Leeds General Infirmary (LGI).
(4) No similar service has been commissioned for CHFT stroke patients from any other Trust.
(5) The existing arrangement between CHFT and LTHT (and between other Trusts within the Regional Integrated Stroke Delivery Network and LTHT) operates only between 0800 and 1500 hrs on weekdays (Monday to Friday), that is, for 35 out of 168 hours in a week (or 20.8%). Anyone who needs heart hyper-acute stroke unit is at a district general hospital in West Yorkshire and who suffers a stroke outside of those hours during the week, or between 1500 hrs on a Friday and 0800 hrs the following Monday, does not have access to a thrombectomy service .
” Open source report
Concerns raised 1 Insufficient medical practitioner cover for assessing patients' care needs 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
Patricia Ann WALTON · 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 Ann Walton fell while visiting her granddaughter on Christmas Day 2022 and was later admitted to hospital with a fractured right ankle and shoulder injury. She subsequently received warfarin and dalteparin without a clear review or stopping plan; the dalteparin was not stopped when her INR rose above 2, and she later developed a haemorrhage, pneumonia and deteriorating health before dying on 9 January 2023. The principal concern was insufficient medical cover to assess patients’ ongoing care needs over the New Year Bank Holiday period.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient medical practitioner cover for assessing patients' care needs
Wider context from the report “The evidence at the inquest that no medical practitioner saw this lady from the 30 December 2022 to the 03 January 2023, over the New Year Bank Holiday period. My concerns are that whilst there might be a doctor available on call to treat emergencies that occur, there is insufficient cover to assess the subtleties of care required by patients , the absence of which may be as detrimental to the patient as not having emergency cover.
” 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 NHS Long Term Workforce Plan setting out workforce training, retention and reform over fifteen years.
Verbatim wording from the response “Workforce and staffing levels continue to be a challenge across the NHS and we know that this can present issues to Trusts. In June 2023, NHS England published the NHS Long Term Workforce Plan, setting out how it will train, retain and reform its workforce across the next fifteen years to ensure that we are improving access, providing safe and timely urgent and emergency care and continuing to reduce elective care backlogs. The Plan is underpinned by the biggest recruitment drive in NHS history.” 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 the 7-Day Hospital Services Programme introducing clinical standards for consistent seven-day acute care.
Verbatim wording from the response “In 2016, NHS England published its 7-Day Hospital Services (7DS) Programme which introduced clinical standards regarding the provision of a “truly seven-day NHS” and requiring acute trusts to provide board assurance compliance. The Programme focuses on the provision of acute medical care in such a way that there is no difference in quality for patients, whichever day they attend at hospital.” 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 Continue encouraging local health systems to develop workforce plans providing sufficient qualified staff for population care needs.
Verbatim wording from the response “The NHS continues to encourage local health systems to develop effective workforce planning to ensure that they have the sufficient qualified staff working across their Trusts and wider system that are required for their population care needs. The NHS People Promise helps NHS providers to consider ways to recruit and retain staff. Work is in progress to ensure that future distribution of training posts to help ensure the supply of doctors is matched to population need.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop future training-post distribution to align the supply of doctors with population need.
Verbatim wording from the response “The NHS continues to encourage local health systems to develop effective workforce planning to ensure that they have the sufficient qualified staff working across their Trusts and wider system that are required for their population care needs. The NHS People Promise helps NHS providers to consider ways to recruit and retain staff. Work is in progress to ensure that future distribution of training posts to help ensure the supply of doctors is matched to population need.” Source location Response from NHS England
Open published response
Concerns raised 4 Lack of flagging of and access to key dates affecting prisoners’ safety View source Lack of national guidance for managing in-possession medication View source Failure of NOMIS information accessibility to support risk assessments View source Lack of national guidance for managing safety risks associated with key dates 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
Samuel Lewis Jones · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Samuel Lewis Jones died on 30 April 2021 after suspending himself by a ligature in his cell at HMP Portland. The concerns identified included the lack of systems and national guidance for recording and flagging significant dates, difficulties accessing key information in prison records, and insufficient national guidance on managing medication held in prisoners’ possession.
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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 flagging of and access to key dates affecting prisoners’ safety
Wider context from the report “i. The lack of flagging of, and access to, key dates which may have an impact on prisoners’ 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 Lack of national guidance for managing in-possession medication
Wider context from the report “iv. The lack of national guidance around the operation of in possession medication in prisons either by HMPPS or NHS England to ensure prisoners do not stockpile or retain medication when they have stopped using it .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 NOMIS information accessibility to support risk assessments
Wider context from the report “iii. The accessibility of information recorded on NOMIS and the potential to miss key information which could impact on risk assessments .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for managing safety risks associated with key dates
Wider context from the report “ii. The lack of national Prison Service or NHS guidance on how to manage key dates where risks to the safety of the prisoner may be increased , such as a bereavement or traumatic incident or any other key dates.
” 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 Share learning from HMP Portland’s key-date screening process with regional health and justice commissioners and request dissemination to healthcare providers.
Verbatim wording from the response “I note you reference in the report that in response to the learning from this incident, a local process has been put in place by HMP Portland to ‘ensure prisoners will be asked about any significant or trigger dates at the initial and second healthcare screen when they arrive at prison’. As you have identified this as good practice, NHS England will contact HMP Portland to obtain more information, and share this learning and subsequent action with regional health and justice commissioners, requesting they bring this to the attention of their own healthcare providers.” 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 HMPPS is responsible for conducting cell searches where there are concerns that prisoners may be hoarding or stockpiling medication.
Verbatim wording from the response “Had any concerns been raised that Samuel may have been hoarding or stockpiling his medication (Sertraline), responsibility for a cell search lies with HMPPS. NHS England contacted HMPPS to discuss this matter of concern and it has been confirmed this will be addressed in the direct response from the HMPPS Director General.” 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 HMPPS is responsible for responding to concerns about national guidance and the accessibility of key information recorded on NOMIS.
Verbatim wording from the response “It is my understanding that ████████, Director General for His Majesty’s Prison and Probation Service (HMPPS) is intending to write to you directly in response to the matters highlighted in concerns two and three.” Source location Response from NHS England
Open published response
Concerns raised 5 Lack of provision of mental health care for people waiting for gender-affirming treatment View source Delays in access to gender-affirming healthcare View source Lack of clarity for Primary Care clinicians supporting young transgender individuals View source Lack of clarity for mental health clinicians supporting young transgender individuals View source Lack of knowledge and training for managing and offering mental health care to transgender people 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
Alice LITMAN · 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
Alice Litman, a 20-year-old trans female, was found dead on 26 May 2022 after a descent from height. The report raised concerns about mental-health training and support for transgender people, delays in accessing gender-affirming healthcare, and insufficient clarity and provision of care while awaiting 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 Lack of provision of mental health care for people waiting for gender-affirming treatment
Wider context from the report “c) The lack of provision of mental health care for those waiting for gender affirming 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 Delays in access to gender-affirming healthcare
Wider context from the report “b) The delays in access to gender affirming healthcare .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity for Primary Care clinicians supporting young transgender individuals
Wider context from the report “d) The lack of clarity for clinicians who are in place to support young transgender individuals in Primary Care
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity for mental health clinicians supporting young transgender individuals
Wider context from the report “e) The lack of clarity for clinicians who are in place to support young transgender individuals in the Mental Health Setting .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge and training for managing and offering mental health care to transgender people
Wider context from the report “a) The knowledge and training for those in the mental health setting for managing and offering care to those in the transgender community .
” 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 Distribute guidance to primary-care professionals on CYP gender services, relevant learning modules, and waiting-list support resources.
Verbatim wording from the response “Additionally, with the support of NHS England’s Medical Director for Primary care, a set of guidance will be distributed for general practitioners and other primary care professionals providing information on the CYP Gender Services, access to learning through the MindEd modules (see above) and signposting other resources while patients remain on the waiting list.” 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 an enhanced risk-assessment approach with local CYP mental health services for children and young people on the national waiting list.
Verbatim wording from the response “In order to strengthen further the approach to risk mitigation on the waiting list, NHS England is now in the process of implementing an enhanced risk assessment approach with local mental health services through an initiative that is being managed jointly by the NHS National Director for Mental Health and the NHS National Medical Director for Specialised Services. It is planned that from April 2024 all local mental health services for children and young people across England will have arrangements in place to offer appointments to children and young people on the national waiting list for CYP Gender Services, and their families.” 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 Move the London and Greater Manchester pilot services to substantive seven-year NHS England contracts.
Verbatim wording from the response “In 2023 the pilot services at Chelsea and Westminster Hospital NHS Foundation Trust (London) and GTD Healthcare (Greater Manchester) were moved to substantive seven-year contracts with NHS England following positive evaluations. The GTD service is now open to new referrals of patients who are registered with a GP in Greater Manchester, and the London service is now taking increased numbers of patients from the waiting list of its nearest GDC – the Tavistock and Portman NHS Foundation Trust. NHS England is currently out to tender to award a substantive contract for the service in Cheshire and Merseyside following positive evaluation of this service, and there is an expectation that a similar process will be followed for the other two pilots when their evaluations are complete in 2024 (East England) and 2026 (Sussex).” 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 additional funding to local mental health teams to deploy resources for timely waiting-list risk-assessment access.
Verbatim wording from the response “Additional funding will be made available to local mental health teams by NHS England so that each mental health service can identify and deploy additional resource, thereby ensuring that local mental health service provision is not denuded and in order to secure timely access to the service.” 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 Refresh adult gender dysphoria service specifications, including consideration of inefficiencies, further clinical-capacity expansion, and learning from pilot services.
Verbatim wording from the response “NHS England’s overall planned spend on all gender dysphoria services (adults and children) in 2023/24 is £78.17m – up from £33.4m in 2018/19, representing an overall increase in funding of 134% in five years. In 2024/25 NHS England will refresh the service specifications for adult gender dysphoria services, which will include consideration of how to identify and address inefficiencies that may reside in the way in which GDCs manage and deliver their services and which may contribute to long waiting times – and how to expand clinical capacity further taking the learning from the pilot services. It is too early in the current year to provide precise figures for the planned budget for gender dysphoria services in 2024/25 but the figure given represents recurrent funding commitments and so should be regarded as the opening baseline figure for planning assumptions.” 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 Reconfigure children’s and young people’s specialised gender services, including closing the Tavistock service and establishing around seven regional services.
Verbatim wording from the response “NHS England is currently leading a significant programme of work to reconfigure the provision of specialised services for children and young people with gender incongruence, in line with the interim recommendations of the independent Cass Review. This involves the managed closure of the current CYP children’s gender service at the Tavistock and Portman NHS Foundation Trust on 28 March 2024, and the establishment of around seven new regional services by 2026, the first of which are planned to become operational in April 2024 through collaboratives hosted by Great Ormond Street Hospital for Children NHS Foundation Trust and Alder Hey Children’s NHS Foundation Trust.” 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 Commission and deliver an accredited postgraduate training programme in gender identity healthcare.
Verbatim wording from the response “first accredited post-graduate training course in gender identity healthcare; the course began in 2020. Although aimed primarily at health professionals who wish to specialise in gender identity healthcare, individual modules are also suitable for other healthcare professionals who work in local settings and who wish to improve the experience of individuals with gender dysphoria in using generalist services intended for the whole population including mental health services or primary care services: https://www.rcplondon.ac.uk/education-practice/courses/gender-identity-healthcare-credentials-gihn
September 2023 NHS England published online training materials for health and education professionals in how to support young people up to 18 years with gender distress: https://www.minded.org.uk/catalogue/TileView” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and fund five pilot services to expand gender dysphoria clinical capacity and reduce established-clinic waiting lists.
Verbatim wording from the response “NHS England has sought to address the serious imbalance between the demand for gender dysphoria services and the shortage in trained clinicians who are available to train and work in this field, which has led to long waiting times. In 2019/20, NHS England re-procured the provision of gender dysphoria services for adults. The expectation was that the re-procurement would bring forward new entrants and enable NHS England to increase the number of GDCs, and funding was identified by NHS England for that purpose. That expectation was not met. In fact, no new providers came forward from either the NHS or independent sector. All of the seven existing GDCs submitted bids and award of renewal of contract was confirmed for all of them. In the circumstances, NHS England sought to grow capacity in an alternative way. Five pilot services were developed.” 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 Run the tender for a substantive Cheshire and Merseyside gender service contract.
Verbatim wording from the response “In 2023 the pilot services at Chelsea and Westminster Hospital NHS Foundation Trust (London) and GTD Healthcare (Greater Manchester) were moved to substantive seven-year contracts with NHS England following positive evaluations. The GTD service is now open to new referrals of patients who are registered with a GP in Greater Manchester, and the London service is now taking increased numbers of patients from the waiting list of its nearest GDC – the Tavistock and Portman NHS Foundation Trust. NHS England is currently out to tender to award a substantive contract for the service in Cheshire and Merseyside following positive evaluation of this service, and there is an expectation that a similar process will be followed for the other two pilots when their evaluations are complete in 2024 (East England) and 2026 (Sussex).” 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 Sufficient gender dysphoria service capacity could not be commissioned because specialist clinical staff were unavailable amid substantially increasing demand.
Verbatim wording from the response “Unfortunately, NHSE has been unable to commission sufficient capacity to meet that expectation because of the lack of specialist clinical staff (recruitment and retention) – against a backdrop of significant increasing demand, reflecting an international trend. Unfortunately, waiting times for a first appointment at a GDC remain very high. Of patients who received their first appointment in November 2023 they had on average been referred 382 weeks previously.” 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 mental health service commissioning, including training and education, rests with Integrated Care Boards rather than NHS England.
Verbatim wording from the response “Commissioning responsibility for local mental health services rests with Integrated Care Boards (ICB) rather than NHS England. The make-up of local services, and their approach to service delivery, training and education, can differ according to each ICB’s commissioning strategy. We anticipate the other recipients of your Report will address these concerns in more detail.” Source location Response from NHS England
Open published response
1 Dec 2023 Anthony Eric Williams · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Shortage of specialist scanning facilities causing delays in cancer diagnosis View source Delays in compliance with the two-week cancer pathway View source Delays in accessing cancer treatment after diagnosis View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Anthony Eric Williams · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Anthony Eric Williams was diagnosed with advanced colorectal cancer after presenting with abdominal pain and later developing a bowel mass, spinal cord compression and brain spread. He died at Stamford Court on 28 April 2023. The concerns included national delays in specialist scanning, compliance with the two-week cancer pathway, and access to treatment, which were described as contributing to poorer outcomes and reduced chances of successful 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 Shortage of specialist scanning facilities causing delays in cancer diagnosis
Wider context from the report “The inquest heard evidence that a national shortage of specialist scanning facilities such as was required in Mr Williams’ case meant that there were delays nationally with the diagnosis of cancers . This in turn led to delays in treatment and poorer outcomes for cancer patients as delays in diagnosis meant that the cancer would often have advanced further, and treatment was less likely to be successful. This was compounded by the fact that additional complications such as cord compression could arise whilst a scan was awaited and that the patient would be less able to cope with treatment such as chemotherapy when it ultimately started.
The inquest also heard evidence that there were significant delays nationally in compliance with the two-week cancer pathway which led to poorer outcomes for patients as any delay in treatment reduced the likelihood of a successful outcome.
Evidence was also heard that the delay Mr Williams faced between diagnosis and being seen for a plan to be developed was also part of a wider national picture of delay in accessing treatment and again reduced the chances of a successful treatment outcome.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 compliance with the two-week cancer pathway
Wider context from the report “The inquest heard evidence that a national shortage of specialist scanning facilities such as was required in Mr Williams’ case meant that there were delays nationally with the diagnosis of cancers. This in turn led to delays in treatment and poorer outcomes for cancer patients as delays in diagnosis meant that the cancer would often have advanced further, and treatment was less likely to be successful. This was compounded by the fact that additional complications such as cord compression could arise whilst a scan was awaited and that the patient would be less able to cope with treatment such as chemotherapy when it ultimately started.
The inquest also heard evidence that there were significant delays nationally in compliance with the two-week cancer pathway which led to poorer outcomes for patients as any delay in treatment reduced the likelihood of a successful outcome.
Evidence was also heard that the delay Mr Williams faced between diagnosis and being seen for a plan to be developed was also part of a wider national picture of delay in accessing treatment and again reduced the chances of a successful treatment outcome.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 accessing cancer treatment after diagnosis
Wider context from the report “The inquest heard evidence that a national shortage of specialist scanning facilities such as was required in Mr Williams’ case meant that there were delays nationally with the diagnosis of cancers. This in turn led to delays in treatment and poorer outcomes for cancer patients as delays in diagnosis meant that the cancer would often have advanced further, and treatment was less likely to be successful. This was compounded by the fact that additional complications such as cord compression could arise whilst a scan was awaited and that the patient would be less able to cope with treatment such as chemotherapy when it ultimately started.
The inquest also heard evidence that there were significant delays nationally in compliance with the two-week cancer pathway which led to poorer outcomes for patients as any delay in treatment reduced the likelihood of a successful outcome.
Evidence was also heard that the delay Mr Williams faced between diagnosis and being seen for a plan to be developed was also part of a wider national picture of delay in accessing treatment and again reduced the chances of a successful treatment outcome.
” 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 Support NHS trusts to increase diagnostic reporting capacity through additional reporting radiographers, radiologist trainees, international recruitment and workforce planning tools.
Verbatim wording from the response “The guidance includes caveats for sufficient availability of workforce as the numbers of reporting staff (radiologists and reporting radiographers) are not increasing in line with demand. We are supporting Trusts to increase reporting capacity by increasing the number of reporting radiographers and radiologist trainees per financial year, international recruitment initiatives and workforce demand and capacity planning tools.” 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 Consolidate cancer waiting-time requirements into the Faster Diagnosis, 62-day referral-to-treatment and 31-day decision-to-treat standards.
Verbatim wording from the response “As part of the NHS reform of cancer standards, it was announced in August 2023 that cancer targets would be consolidated into three key standards:” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a national network of diagnostic hubs and roll out at least 100 community diagnostic centres to expand testing capacity and reduce waiting times.
Verbatim wording from the response “In August 2022, NHS England published the Delivery plan for tackling the COVID-19 backlog of elective care. The plan sets out how NHS intends to recover elective care (which includes cancer pathways) over three years with one of the ambitions including ensuring that 95% of patients who need diagnostic tests receive them within six weeks of referral. To do this, we have committed to patients having three more convenient access to diagnostic procedures and tests, by developing a network of diagnostic hubs across England. The plan is supported by a government spend of £28 billion, and this includes £2.3 billion to help increase the volume of diagnostic activity and reduce patient waiting times through the roll out of at least 100 community diagnostic centres to help clear backlogs of people waiting for tests such as MRI, ultrasound and CT scans.” 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 imaging reporting turnaround-time guidance, including a three-day maximum for outpatient cancer-pathway PET-CT reporting.
Verbatim wording from the response “In August 2023, NHS England published the Image report turnaround time guidance available here: NHS England » Diagnostic imaging reporting turnaround times. The guidance sets out the maximum turnaround times for referral for a number of imaging services, including position emission tomography CT scans (PET CT). The turnaround times for PET CT scans for outpatient cancer pathway diagnosis is three days.” 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 the NHS Long Term Workforce Plan through expanded healthcare staff training, retention and reform to improve service capacity.
Verbatim wording from the response “In June 2023, NHS England also published the NHS Long Term Workforce Plan, in response to the current lack of sufficient workforce. The plan sets out how we will train, retain and reform healthcare staff across the NHS over the next fifteen years, and is underpinned by the biggest recruitment drive in NHS history which will further improve service capacity and delivery.” Source location Response from NHS England
Open published response
30 Nov 2023 Katherine Sarah FLYNN · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 2 Unclear nursing escalation policy when an external ventricular drain stops draining but continues to oscillate View source Lack of a standard national policy for external ventricular drain management when drainage stops but oscillation continues 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
Katherine Sarah FLYNN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Katherine Sarah Flynn, aged 34, underwent surgery for a malignant brain tumour and subsequently became dependent on an external ventricular drain. She died on 6 March 2022 after the drain stopped draining, hydrocephalus developed, and the drain was found to have dislodged. Concerns included failures to escalate reduced drainage and leakage to the medical team, and unclear guidance on escalation when a drain stopped draining but continued to oscillate.
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 Unclear nursing escalation policy when an external ventricular drain stops draining but continues to oscillate
Wider context from the report “The case is a complex death where the immediate cause of death was blockage of an external ventricular drain resulting in hydrocephalus and coning. The written policy at this Trust, at the time, was not entirely clear about how the nursing staff should escalate things when a drain stopped draining but was still seen to be oscillating . Though some Trusts have developed their own policy on this area, these are varying as there is currently no standard national policy dealing with this issue. This is a risk which needs to be highlighted at a national level.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a standard national policy for external ventricular drain management when drainage stops but oscillation continues
Wider context from the report “The case is a complex death where the immediate cause of death was blockage of an external ventricular drain resulting in hydrocephalus and coning. The written policy at this Trust, at the time, was not entirely clear about how the nursing staff should escalate things when a drain stopped draining but was still seen to be oscillating. Though some Trusts have developed their own policy on this area, these are varying as there is currently no standard national policy dealing with this issue . This is a risk which needs to be highlighted at a national level.
” 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 Engage the Society of British Neurological Surgeons and NHS nurse specialists to develop an action plan and national guideline for external ventricular drain management.
Verbatim wording from the response “It is proposed that the Society of British Neurological Surgeons (SBNS) co-lead with NHS Nurse Specialists to develop an action plan and national guideline for EVD management. A short life Working Group (comprising both Surgeons and Specialist Nurses) should be considered as the way forward with input from NHS England’s National Patient Safety Team. The Patient Safety Team plans to reach out to the SBNS, who we note that you also sent your Report to.” 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 local policies, educational materials and professional guidance address EVD care, while locally relevant policies remain appropriate for individual neurosurgical units.
Verbatim wording from the response “While there is currently no NHS-wide national policy available regarding nursing care of patients with EVDs, local policies (examples of which are included in the footnote below¹) and educational material regarding best practice are readily available. There is also national nursing guidance available from the British Association of Neuroscience Nurses regarding Cerebrospinal Fluid (CSF) Management. Leading Clinical Neurosurgery colleagues have also reviewed your Report and advised that every neurosurgical unit will have their own work skill mix and resources and be expected to develop locally relevant policies that would be valuable, relevant and safe. We note that in Katherine’s case, local policy was unfortunately not followed.” Source location Response from NHS England
Open published response
27 Nov 2023 Boycie [Alexander/Chatterton] · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 1 Lack of a properly managed and funded national register for TOF cases View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Boycie [Alexander/Chatterton] · 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
Boycie was born at 36 weeks and 6 days with congenital oesophageal atresia and tracheo-oesophageal fistula, underwent three planned surgical procedures, and died after developing respiratory complications following the third procedure. Experts expressed concern that treatment would be better supported by a properly managed and funded national register for tracheo-oesophageal fistula cases, which they considered likely to improve outcomes and survival rates.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a properly managed and funded national register for TOF cases
Wider context from the report “1. I heard from experts giving evidence that the treatment of conditions such as OA with or without TOF would be better served by a properly managed and funded national register for TOF cases , which would in their view likely serve to improve outcomes and survival rates going forward.
” Open source report
27 Nov 2023 Amirah KHALIFA · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 2 Lack of SCR recording of the clinical indication for drug initiation View source Failure of the SCR model to automatically flag long-term steroid use for appropriate monitoring 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
Amirah KHALIFA · 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
Amirah Khalifa was admitted to hospital in December 2022 after feeling generally unwell and deteriorated despite active treatment, dying on 31 January 2023. The report states that multiple organ failure caused by sepsis and intestinal haemorrhage was more likely than not related to long-term steroid therapy. Principal concerns included failures to document, monitor and review the steroid treatment, recognise its complications, and ensure that its clinical indication and intended duration were communicated to primary care; the SCR also did not automatically flag long-term steroid use or record the clinical indication for prescribed drugs.
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 SCR recording of the clinical indication for drug initiation
Wider context from the report “In addition, the SCR does not have a space recording for clinical indication for initiation of the drugs , to aid a future prescriber to consider whether the drug is still clinically indicated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 SCR model to automatically flag long-term steroid use for appropriate monitoring
Wider context from the report “The current SCR model does not appear to automatically flag drugs such as steroids , which are known to have potentially fatal side effects if used for the long term without appropriate monitoring. It is understood that some drugs do have these flags, but that steroids do not .
” Open source report
Concerns raised 1 Unavailability of timely out-of-hours in-person cardiologist assessment for patients with suspected cardiac problems View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Charlotte Burton · 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
Charlotte Burton, who was 40 and recently postpartum, returned to hospital on 27 November 2020 with shortness of breath and coughing up blood. She later deteriorated, suffered a cardiac arrest and died from acute left ventricular failure associated with cardiomyopathy, morbid obesity and pre-eclampsia. The report identified delayed recognition and treatment of likely diastolic heart failure, delayed escalation, and limited out-of-hours access to cardiology assessment as concerns.
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 timely out-of-hours in-person cardiologist assessment for patients with suspected cardiac problems
Wider context from the report “1. The evidence indicates that there is a nationwide shortage of suitably trained Cardiologists and that, particularly in District General Hospital setting, this means that out of hours there is no provision for patients presenting with suspected cardiac problems to be assessed in person by a Cardiologist . The system is therefore reliant upon doctors of different specialities or cardiac nurses recognising the condition and the need for contact with specialist at a different Trust . This still does not allow for in person assessment unless there is a transfer which is not always possible due to the severity of the condition or cannot be achieved in a suitable timescale and this represents an ongoing risk of future deaths.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue delivering the Medical Specialty Distribution programme to redistribute postgraduate cardiology training places according to population need.
Verbatim wording from the response “NHS England, together with the wider health system is also continuing to deliver the Medical Specialty Distribution programme; the programme was developed in light of the Facing the Facts, Shaping the Future report, published by the former Health Education England (now part of NHS England) and NHS England and a joint review of distribution of postgraduate medical training places. The Programme commenced in Autumn 2022, initially looking at three specialties, one of which is Cardiology, and will continue over the next 10-15 years. Work is in progress to ensure that the distribution of post graduate specialty training is done in a way 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 Publish the NHS Long Term Workforce Plan to expand, retain and reform the NHS workforce.
Verbatim wording from the response “In June 2023, NHS England published the NHS Long Term Workforce Plan, setting out how it will train, retain and reform its workforce across the next fifteen years to ensure that we are improving access, providing safe and timely urgent and emergency care and continuing to reduce elective care backlogs. The Plan is underpinned by the biggest recruitment drive in NHS history.” 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 seven-day cardiovascular service standards requiring timely consultant review, diagnostic access, consultant-directed interventions and ongoing high-dependency review.
Verbatim wording from the response “In 2013, NHS England published its 7-Day Hospital Services (7DS) Programme which introduced clinical standards regarding the provision of a “truly seven-day NHS” and requiring acute trusts to provide board assurance compliance. This included a requirement for all cardiovascular networks to implement the four priority standards of timely consultant review, improved access to diagnostics, consultant directed interventions and ongoing review into high dependency areas across all seven days of the week. There is a good level of compliance with these standards across acute trusts and many services and surgical and diagnostic lists are operating at weekends and evenings.” 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 Cambridgeshire and Peterborough ICB is responsible for explaining local cardiology provision, workforce arrangements and weekend transfer policy.
Verbatim wording from the response “The NHS continues to encourage local health systems to develop effective workforce planning to ensure that they have the sufficient qualified staff working across their Trusts and wider system that are required for their population care needs. The NHS People Promise also helps NHS providers to consider ways to recruit and retain staff. Work is in progress to ensure that future distribution of training posts to help ensure the supply of doctors is matched to population need. You will need to refer to Cambridgeshire and Peterborough Integrated Care Board (ICB) on what system arrangements they have in place for their cardiology provision and workforce, to include transfer policy on weekends.” Source location Response from NHS England
Open published response
Concerns raised 3 Failure to maintain sufficient staffing and funding capacity for timely surgery View source Failure to ensure adequate and experienced staffing for Friday injuries View source Limited weekend clinical cover for injuries sustained on Fridays View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mrs Kathleen Booth · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Kathleen Booth was admitted to hospital after a fall in her garden on 9 June 2023, sustaining a fractured neck of femur. Surgery was delayed for four days and, after the operation, she deteriorated suddenly and died. The concerns included staffing and funding pressures, limited weekend cover, and the potential disadvantage to patients injured on a Friday.
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 sufficient staffing and funding capacity for timely surgery
Wider context from the report “1. There was a 4 day delay in her receiving surgery due to NHS wide under staffing and underfunding ; and wards having to undertake elective and emergency work at the same time . Additionally, the fact that the injury happened on a Friday, meaning less staff and experience was available.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure adequate and experienced staffing for Friday injuries
Wider context from the report “1. There was a 4 day delay in her receiving surgery due to NHS wide under staffing and underfunding; and wards having to undertake elective and emergency work at the same time. Additionally, the fact that the injury happened on a Friday, meaning less staff and experience was available .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Limited weekend clinical cover for injuries sustained on Fridays
Wider context from the report “3. Patients can be disadvantaged by not receiving treatment if an injury is sustained on a Friday as cover over the weekend is limited .
” 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 local workforce planning and distribute future training posts to match doctors’ supply with population need.
Verbatim wording from the response “The NHS continues to encourage local health systems to develop effective workforce planning to ensure that they have the sufficient qualified staff working across their Trusts and wider system that are required for their population care needs. The NHS People Promise also helps NHS providers to consider ways to recruit and retain staff. Work is in progress to ensure that future distribution of training posts to help ensure the supply of doctors is matched to population need. You will need to refer to Staffordshire and Stoke-on-Trent Integrated Care System on what system arrangements they have in place for their UEC provision and workforce.” 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 elective care capacity, prioritise diagnosis and treatment, transform care delivery, and improve patient information and support.
Verbatim wording from the response “Elective care recovery also continues to be a priority for the NHS. In February 2023 the Delivery plan for tackling the Covid-19 backlog of elective care was published by NHS England. This focused on four areas of delivery to increase health service capacity, prioritise diagnosis and treatment, transform how we provide elective care and provide better information and support to patients. This is supported by a government spend of more than £8 billion between 2022/23 and 2024/25, including a £5.9 billion capital investment in new beds, equipment, and technology. Further priorities were set out in a letter to NHS acute Trusts in May 2023, which can be found here: NHS England » Elective care 2023/24 priorities.” 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 urgent and emergency care capacity, including funding additional capacity and 5,000 new beds.
Verbatim wording from the response “In January 2023, NHS England published the Delivery plan for recovering urgent and emergency care services. This is a two-year delivery plan which sets the NHS commitment to the public to improve waiting times and patient experience within urgent and emergency care (UEC). This includes commitments 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 Grow the urgent and emergency care workforce, including introducing more flexible ways of working.
Verbatim wording from the response “In January 2023, NHS England published the Delivery plan for recovering urgent and emergency care services. This is a two-year delivery plan which sets the NHS commitment to the public to improve waiting times and patient experience within urgent and emergency care (UEC). This includes commitments 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 Implement seven-day clinical standards and require acute trusts to provide board assurance of compliance.
Verbatim wording from the response “In 2013, NHS England published its 7-Day Hospital Services (7DS) Programme which introduced clinical standards regarding the provision of a “truly seven-day NHS” and requiring acute trusts to provide board assurance of compliance. The Programme focuses on the provision of acute medical care in such a way that there is no difference in quality for patients, whether it is a weekday or a weekend. There is a good level of compliance with these standards across acute trusts and many services and surgical and diagnostic lists are operating at weekends and evenings.” 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 Train, retain and reform the NHS workforce through the Long Term Workforce Plan.
Verbatim wording from the response “In June 2023, NHS England also published the NHS Long Term Workforce Plan, setting out how it will train, retain and reform its workforce across the next fifteen years” 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 Staffordshire and Stoke-on-Trent Integrated Care System is responsible for local urgent and emergency care workforce arrangements.
Verbatim wording from the response “The NHS continues to encourage local health systems to develop effective workforce planning to ensure that they have the sufficient qualified staff working across their Trusts and wider system that are required for their population care needs. The NHS People Promise also helps NHS providers to consider ways to recruit and retain staff. Work is in progress to ensure that future distribution of training posts to help ensure the supply of doctors is matched to population need. You will need to refer to Staffordshire and Stoke-on-Trent Integrated Care System on what system arrangements they have in place for their UEC provision and workforce.” Source location Response from NHS England
Open published response
Concerns raised 2 Failure of regional coordination of thrombectomy services View source Lack of thrombectomy service provision in Lancashire after 5pm View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sarah Elizabeth READ · 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
Sarah Elizabeth Read had a mechanical mitral valve replacement and required intense anticoagulation. During pregnancy, anticoagulation was adjusted and interrupted following a stroke and a decision to terminate the pregnancy; she then suffered another stroke three days later and did not recover. Evidence raised concern that thrombectomy was unavailable in Lancashire after 5pm, with no regional coordination to ensure access to this urgent treatment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of regional coordination of thrombectomy services
Wider context from the report “(1) Evidence was heard that there is no provision in Lancashire for
Thrombectomy Service following a stroke after 5pm and that neighbouring
Trusts who provide this service are no longer able to accept patients from
Lancashire. Despite efforts made to resolve this, there is nothing in place for
coordination of this service regionally to ensure that this urgent lifesaving
treatment is available when required after 5pm.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 thrombectomy service provision in Lancashire after 5pm
Wider context from the report “(1) Evidence was heard that there is no provision in Lancashire for
Thrombectomy Service following a stroke after 5pm and that neighbouring
Trusts who provide this service are no longer able to accept patients from
Lancashire . Despite efforts made to resolve this, there is nothing in place for
coordination of this service regionally to ensure that this urgent lifesaving
treatment is available when required after 5pm.
” 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 Extend Lancashire thrombectomy service hours to 8am–11pm seven days a week from April 2024.
Verbatim wording from the response “For Lancashire Teaching Hospitals NHS Foundation Trust (LTH), mechanical thrombectomy operated Monday to Friday, 8am to 6pm prior to September 2023. Since September 2023, and following a successful recruitment campaign, the Trust has been able to increase its number of interventional Radiologists to enable the service to operate seven days a week, 8am to 6pm. A further expansion plan is now in place, with the ambition to further extend the hours to between 8am and 11pm seven days a week from April 2024 and for the service to operated 24/7 from September” 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 Formalise the interim mutual-aid arrangement for Lancashire patients with three North West thrombectomy units.
Verbatim wording from the response “Regarding your concern about access to neighbouring services, mutual aid between different units and Trusts is offered on an informal and case-by-case basis and is reliant on capacity within the neighbouring units. The interim offer for Lancashire is in the process of being formalised, led by the Medical Director for Specialised Commissioning who is working with the three units across the North West.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support Lancashire Teaching Hospitals in identifying risks and mitigations for achieving 24/7 thrombectomy provision.
Verbatim wording from the response “Additionally, there are building works currently underway to accommodate a second bi-plane angiogram unit, which are expected to be completed by Summer 2024. LTH are currently being supported by Specialised Commissioning with their capital bid for this second biplane which will also need to be supported by a successful recruitment campaign. There are several interdependencies to achieve the 24/7 thrombectomy service, and the North West Specialised Commissioning Team are supporting LTH to understand the risks and mitigations required. LTH have confirmed that they are committed to operating the 24/7 service by September 2024.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a 24/7 Lancashire thrombectomy service by September 2024, subject to required capacity and approvals.
Verbatim wording from the response “For Lancashire Teaching Hospitals NHS Foundation Trust (LTH), mechanical thrombectomy operated Monday to Friday, 8am to 6pm prior to September 2023. Since September 2023, and following a successful recruitment campaign, the Trust has been able to increase its number of interventional Radiologists to enable the service to operate seven days a week, 8am to 6pm. A further expansion plan is now in place, with the ambition to further extend the hours to between 8am and 11pm seven days a week from April 2024 and for the service to operated 24/7 from September” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support Lancashire Teaching Hospitals’ capital bid and building works for a second bi-plane angiogram unit.
Verbatim wording from the response “Additionally, there are building works currently underway to accommodate a second bi-plane angiogram unit, which are expected to be completed by Summer 2024. LTH are currently being supported by Specialised Commissioning with their capital bid for this second biplane which will also need to be supported by a successful recruitment campaign. There are several interdependencies to achieve the 24/7 thrombectomy service, and the North West Specialised Commissioning Team are supporting LTH to understand the risks and mitigations required. LTH have confirmed that they are committed to operating the 24/7 service by September 2024.” 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 interventional radiologist capacity to operate thrombectomy services seven days a week from 8am to 6pm.
Verbatim wording from the response “For Lancashire Teaching Hospitals NHS Foundation Trust (LTH), mechanical thrombectomy operated Monday to Friday, 8am to 6pm prior to September 2023. Since September 2023, and following a successful recruitment campaign, the Trust has been able to increase its number of interventional Radiologists to enable the service to operate seven days a week, 8am to 6pm. A further expansion plan is now in place, with the ambition to further extend the hours to between 8am and 11pm seven days a week from April 2024 and for the service to operated 24/7 from September” Source location Response from NHS England
Open published response
16 Nov 2023 John Joseph SINGLETON · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1 Failure of the electronic patient system to flag uncollected or undispensed medication for early identification of non-compliance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Joseph SINGLETON · 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 Joseph Singleton, who was serving a prison sentence at HMP Risley, was found hanging in his locked cell on 1 September 2019 and later died in hospital on 10 September 2019. The report identifies concerns about sporadic medication compliance and the difficulty of detecting non-collection of medication, including the lack of an automated warning flag in the SymStone system. These issues were stated not to have caused or contributed to his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of the electronic patient system to flag uncollected or undispensed medication for early identification of non-compliance
Wider context from the report “During the inquest it came to light that John was prescribed medications for depression and epilepsy whilst incarcerated. His compliance with medications was found to be sporadic and as a result he failed to collect a number of prescriptions to enable continuity of his medication. Some of the reasons around this were anxiety in attending to collect his medications and also periods of self-isolation. Whilst Healthcare at the prison were aware of some of the periods of non-compliance and in fact a GP referral and action was taken to enable John to have weekly in-possession medication to support his compliance, other periods were not flagged or identified and it became clear that monitoring those prisoners who are not medication compliant, particularly if receiving weekly or monthly medication was challenging due to the SymStone electronic patient system not being able to flag a warning for non-compliant prisoners for early identification and referral .
John subsequently suffered a decline in his mental health and whilst the lack of medication compliance was not deemed to cause or contribute to his death, the importance of consistent medication for medical conditions and early identification of prisoners who do not comply was an issue which was raised and explored within the inquest.
The action taken by the prison after John's suicide was to put a cross check system in place by which pharmacy technicians cross reference the medication by way of a weekly stock check to identify the prisoners who have not collected medications or had the same dispensed, so that referrals can be made to the Healthcare team and or GP to task. Such a system is less than ideal as it is both resource heavy, carries real risks of not being accurate and in the Coroners view, for prisoners in possession of medication, there is likely to be a much longer period before non-compliance is identified which carries real risks of fatalities . The inquest touched upon the SymStone electronic record used across the Prison estates by Healthcare. From the evidence it appears that the system has a facility to flag concerns and tasks to action and in fact, certain flags are generated automatically to alert healthcare staff to live issues around a prisoner, however, something as simple and the system generating a warning flag to identify when medication is not dispensed or collected was neither possible nor available on the current operating system . An automated flag alert via the system upon the failure to dispense or collect medication by a prisoner would be a far more efficient and effective way in which prisoners failing to comply with medications could be identified and actioned quickly and in which future deaths could be prevented.
” 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 Investigate HJIS reporting functions to identify a mechanism for detecting non-collection of in-possession medicines.
Verbatim wording from the response “I can advise that work is underway now to investigate the reporting functions in HJIS to establish whether there is a suitable mechanism that can be used by provider services, to identify non-collections of in-possession medication. This would be used to prioritise medicines supply room checks and follow up. Once an effective way forward is identified and agreed, the national NHS England Health and Justice team will work to facilitate roll out across the estate.” 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 Write to Health and Justice regional teams and request commissioners remind prison healthcare staff to monitor uncollected in-possession medicines using available HJIS and local processes.
Verbatim wording from the response “In the interim, in response to the concerns noted, NHS England's National Director of Health & Justice, Armed Forces and Sexual Assault Services Commissioning, will write to Health and Justice regional teams sharing these concerns, and asking commissioners to work with prison healthcare provider organisations, to remind all staff of the requirement to monitor uncollected in-possession medicines and the current options available within HJIS and in local processes to support this.” 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 An automated medication non-compliance flag would not improve safety because it would be seen only when a clinician opens the patient record.
Verbatim wording from the response “It is our view that a flag in a record is not a solution that would improve safety, as the flag would not be seen until a clinician opens that patient record, whereas a HJIS generated report will detail every individual who missed doses, or supplies, in the timeframe reported on.” Source location Response from NHS England
Open published response
Concerns raised 1 Insufficient national availability of Tier 4 paediatric mental health beds for timely allocation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Madeleine Eve SAVORY · 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
Madeleine Savory, aged 15, died on 26 February 2022 after being found ligatured in a bathroom on Bergholt Ward at Ipswich Hospital, following a period during which their whereabouts were unknown. The substantive concerns included the availability of Tier 4 paediatric mental health beds, failures in risk assessment and communication, ward staff understanding of risk, and the implementation of a school safety plan.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient national availability of Tier 4 paediatric mental health beds for timely allocation
Wider context from the report “I also received helpful evidence from the East of England Provider Collaborative concerning the measures which that organisation had undertaken in their area of responsibility to address my concern in relation to the availability and allocation of Tier 4 beds in a paediatric mental health facilities to children such as Madeleine .
The availability, nationally, of Tier 4 beds in paediatric mental health facilities to allow for the timely allocation to children in need of care in such facilities such as Madeleine Savory.
” 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 Introduce NHS-led Provider Collaboratives to bring children’s and young people’s inpatient care closer to home.
Verbatim wording from the response “NHS England has sought to improve the availability of local inpatient (Tier 4) care for children and young people through several actions:” 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 Invest capital and revenue funding in localised Tier 4 inpatient and alternative-to-inpatient provision over three years.
Verbatim wording from the response “• Investing capital and revenue funding into localised inpatient (Tier 4) and alternative to inpatient provision over a three-year period.” 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 Issue planning guidance requiring Lead Provider Collaboratives and Integrated Care Systems to provide adolescent and psychiatric intensive care units for local needs.
Verbatim wording from the response “• The NHS Planning Guidance 2022/23 outlined the need for Lead Provider Collaboratives (LPCs) and Integrated Care Systems (ICSs) to ensure the provision of General Adolescent and Psychiatric Intensive care Units to meet the needs of their local population.” 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 Commission a review of the children’s and young people’s inpatient model addressing pathway pressures, quality, safety and future care requirements.
Verbatim wording from the response “• In 2022, NHS England commissioned a review of the Children and Young People’s inpatient model recognising the continued pathway pressures and quality and safety challenges. The review included how our English model compares internationally, the views of children, young people and their families and requests from local teams to work together to improve the model of care. The findings of the review will present a future vision for CYPMH inpatient care and will be published in Quarter 2 of 2023/24. Support will then be provided to local systems and provider collaboratives to plan a timeline for implementing the changes, coupled with implementation support as requested.” 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 Lead Provider Collaboratives and Integrated Care Systems are responsible for ensuring local provision of required adolescent psychiatric inpatient services.
Verbatim wording from the response “• The NHS Planning Guidance 2022/23 outlined the need for Lead Provider Collaboratives (LPCs) and Integrated Care Systems (ICSs) to ensure the provision of General Adolescent and Psychiatric Intensive care Units to meet the needs of their local population.” Source location Response from NHS England
Open published response
Concerns raised 8 Failure to provide continuing care addressing cyclical chronic mental ill health outside periods of crisis View source Lack of steps to address isolation among service users suffering ill health View source Potentially inappropriate housing of vulnerable adults needing care and support View source Failure to clearly record service users' consent to disclosure to family members View source Failure to provide 72-hour follow-up after Emergency Department presentation View source Delays in accessing mental health services and treatment View source Lack of means for mental health practitioners to engage service users' families in treatment support View source Insufficient staffing capacity for mental health treatment View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Roger Adrian Stevenson · 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
Roger Adrian Stevenson was found deceased in supported accommodation on 2 May 2022, having last been known to be alive on 30 April 2022; the medical cause of death was fatal toxic morphine intoxication. The report identified concerns that Roger had become lost to mental health services, including a lack of follow-up, delays in care-coordinator allocation, insufficient continuity between services, and limited long-term support for cyclical mental ill health.
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 continuing care addressing cyclical chronic mental ill health outside periods of crisis
Wider context from the report “1. That Roger, as a vulnerable adult who had been recognised to be in need of care and support, had been lost in the system (e.g. with a lack of 72 hour follow up in 2021) and may have been inappropriately housed.
2. There was a need for recognition of service users with cyclical chronic mental ill health issues – in this case being that help Roger received tended to be only at the time of crisis thus doing nothing to address long-term underlying chronic conditions .
3. That there was a lack steps taken to address isolation felt by service users suffering ill health where there were likely to be substantial delays in accessing services (such as being allocated a care co-ordinator) and receiving treatment which could lead to further feelings of desperation leading to thoughts of suicide and self-harm.
4. KMPT needed to ensure service users do receive a 72 hour follow up after presenting to an Emergency Department,
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of steps to address isolation among service users suffering ill health
Wider context from the report “1. That Roger, as a vulnerable adult who had been recognised to be in need of care and support, had been lost in the system (e.g. with a lack of 72 hour follow up in 2021) and may have been inappropriately housed.
2. There was a need for recognition of service users with cyclical chronic mental ill health issues – in this case being that help Roger received tended to be only at the time of crisis thus doing nothing to address long-term underlying chronic conditions.
3. That there was a lack steps taken to address isolation felt by service users suffering ill health where there were likely to be substantial delays in accessing services (such as being allocated a care co-ordinator) and receiving treatment which could lead to further feelings of desperation leading to thoughts of suicide and self-harm.
4. KMPT needed to ensure service users do receive a 72 hour follow up after presenting to an Emergency Department,
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Potentially inappropriate housing of vulnerable adults needing care and support
Wider context from the report “1. That Roger, as a vulnerable adult who had been recognised to be in need of care and support, had been lost in the system (e.g. with a lack of 72 hour follow up in 2021) and may have been inappropriately housed .
2. There was a need for recognition of service users with cyclical chronic mental ill health issues – in this case being that help Roger received tended to be only at the time of crisis thus doing nothing to address long-term underlying chronic conditions.
3. That there was a lack steps taken to address isolation felt by service users suffering ill health where there were likely to be substantial delays in accessing services (such as being allocated a care co-ordinator) and receiving treatment which could lead to further feelings of desperation leading to thoughts of suicide and self-harm.
4. KMPT needed to ensure service users do receive a 72 hour follow up after presenting to an Emergency Department,
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly record service users' consent to disclosure to family members
Wider context from the report “6. That mental health practitioners did not have means by which to engage with the families of service users, effectively recognising such families as an additional resource able to support mental health treatment by monitoring service users and encouraging them to engage with such treatment (and as an adjunct to that a way of noting that where consent has been given by a service user to disclose matters to family members this is clearly noted so that mental health staff are aware of it and can act promptly in so doing ).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 72-hour follow-up after Emergency Department presentation
Wider context from the report “1. That Roger, as a vulnerable adult who had been recognised to be in need of care and support, had been lost in the system (e.g. with a lack of 72 hour follow up in 2021 ) and may have been inappropriately housed.
2. There was a need for recognition of service users with cyclical chronic mental ill health issues – in this case being that help Roger received tended to be only at the time of crisis thus doing nothing to address long-term underlying chronic conditions.
3. That there was a lack steps taken to address isolation felt by service users suffering ill health where there were likely to be substantial delays in accessing services (such as being allocated a care co-ordinator) and receiving treatment which could lead to further feelings of desperation leading to thoughts of suicide and self-harm.
4. KMPT needed to ensure service users do receive a 72 hour follow up after presenting to an Emergency Department ,
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in accessing mental health services and treatment
Wider context from the report “1. That Roger, as a vulnerable adult who had been recognised to be in need of care and support, had been lost in the system (e.g. with a lack of 72 hour follow up in 2021) and may have been inappropriately housed.
2. There was a need for recognition of service users with cyclical chronic mental ill health issues – in this case being that help Roger received tended to be only at the time of crisis thus doing nothing to address long-term underlying chronic conditions.
3. That there was a lack steps taken to address isolation felt by service users suffering ill health where there were likely to be substantial delays in accessing services (such as being allocated a care co-ordinator ) and receiving treatment which could lead to further feelings of desperation leading to thoughts of suicide and self-harm.
4. KMPT needed to ensure service users do receive a 72 hour follow up after presenting to an Emergency Department,
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of means for mental health practitioners to engage service users' families in treatment support
Wider context from the report “6. That mental health practitioners did not have means by which to engage with the families of service users , effectively recognising such families as an additional resource able to support mental health treatment by monitoring service users and encouraging them to engage with such treatment (and as an adjunct to that a way of noting that where consent has been given by a service user to disclose matters to family members this is clearly noted so that mental health staff are aware of it and can act promptly in so doing).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing capacity for mental health treatment
Wider context from the report “7. That staffing shortages continue to be a major issue in mental health treatment and that although efforts towards recruitment may alleviate this to some extent KMPT adding text to template letters giving a little more information to service users as to when they may expect to be seen is unlikely to be sufficient. Where such text is used though there would be an opportunity of referring to 3rd party agencies from whom additional support can be sought including charities like the Samaritans or emergency numbers (999 and 111).
” Open source report
10 Nov 2023 Christopher Richard ALLUM · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 3 Unavailability of NHS notes to private healthcare providers at admission View source Failure to obtain and record previous methods of self-harm and suicide at referral and admission View source Failure to seek and record relevant information from family at referral and admission 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
Christopher Richard ALLUM · 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
Christopher Richard Allum had escalating mental health issues and a history of deliberate self-harm before being admitted to the Langford Centre on 14 May 2022. He was found unresponsive in his room on the evening of 15 May 2022, and death was confirmed at 23:01; the inquest concluded that he died as a result of suicide. The concerns identified included gaps in obtaining and recording previous methods of self-harm and relevant family information at referral and admission, and difficulties accessing NHS notes in private healthcare settings.
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 NHS notes to private healthcare providers at admission
Wider context from the report “Initial referral - there seems to be a gap at the initial referral and admission stage in obtaining information about and recording previous methods of self-harm and suicide. There also appears to be a gap in the seeking and recording of relevant information from an individual's family at the point of referral and admission. An individual's family is often able to provide detailed and useful information about events that may not have been previously reported and/or be able to bridge the gap in communications between various health agencies involved in someone's care.
Access to notes - the other concerning issue is the difficulty prevalent within the private sector in accessing of NHS notes . It appears to be the position across the private sector that access to an individual's notes is not provided as standard . This means that there may be a significant gap in the information available when someone is admitted to a premises run by a private healthcare provider, even within an NHS allocated bed . This gap in information can have an impact on an individual's risk assessment and their subsequent care plan.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and record previous methods of self-harm and suicide at referral and admission
Wider context from the report “Initial referral - there seems to be a gap at the initial referral and admission stage in obtaining information about and recording previous methods of self-harm and suicide . There also appears to be a gap in the seeking and recording of relevant information from an individual's family at the point of referral and admission. An individual's family is often able to provide detailed and useful information about events that may not have been previously reported and/or be able to bridge the gap in communications between various health agencies involved in someone's care.
Access to notes - the other concerning issue is the difficulty prevalent within the private sector in accessing of NHS notes. It appears to be the position across the private sector that access to an individual's notes is not provided as standard. This means that there may be a significant gap in the information available when someone is admitted to a premises run by a private healthcare provider, even within an NHS allocated bed. This gap in information can have an impact on an individual's risk assessment and their subsequent care plan.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 seek and record relevant information from family at referral and admission
Wider context from the report “Initial referral - there seems to be a gap at the initial referral and admission stage in obtaining information about and recording previous methods of self-harm and suicide. There also appears to be a gap in the seeking and recording of relevant information from an individual's family at the point of referral and admission . An individual's family is often able to provide detailed and useful information about events that may not have been previously reported and/or be able to bridge the gap in communications between various health agencies involved in someone's care.
Access to notes - the other concerning issue is the difficulty prevalent within the private sector in accessing of NHS notes. It appears to be the position across the private sector that access to an individual's notes is not provided as standard. This means that there may be a significant gap in the information available when someone is admitted to a premises run by a private healthcare provider, even within an NHS allocated bed. This gap in information can have an impact on an individual's risk assessment and their subsequent care plan.
” 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 guidance on information sharing and holistic assessment during admission, including key actions within 72 hours.
Verbatim wording from the response “Christopher’s case does highlight the importance of effective information sharing to support providing the best care possible where individuals are transferred between different care settings. That is why joined up partnership working is one of the four key principles underpinning NHS England’s guidance on Acute inpatient mental health care for adults and older adults that was published in July 2023. This document provides specific advice on good practice on information sharing as well as guidance on the holistic assessment that should take place when someone enters a new facility, including identifying any safeguarding or risk issues, including risk to self and others. This includes guidance on the key actions that should take place within 72 hours of admission which include:” 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 Enhance sharing of patient information with commissioned voluntary, charitable, social enterprise and independent-sector providers.
Verbatim wording from the response “NHS England is working to enhance the sharing of patient information to and from Voluntary, Charity and Social Enterprise (VCSE) and other independent sector providers who are commissioned by NHS organisations.” 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 Increase the role of family voice in the inpatient transformation programme.
Verbatim wording from the response “In 2022, NHS England also established its Mental Health, Learning Disability and Autism Inpatient Transformation Programme to support cultural change and” 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 Langford Centre, operated by an independent provider, is the appropriate organisation to respond to concerns about information collection and recording.
Verbatim wording from the response “The Langford Centre is operated by Bramley Healthcare, an independent Mental Health Care Provider providing services within the South of England. I note that you have also addressed your Report to the Centre, and they would be the appropriate organisation to respond to the above concerns. NHS England will carefully review and consider their response to you.” 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 Integrated Care Boards are responsible for determining which independent providers connect to local Shared Care Records and supporting their connection.
Verbatim wording from the response “NHS England is working to enhance the sharing of patient information to and from Voluntary, Charity and Social Enterprise (VCSE) and other independent sector providers who are commissioned by NHS organisations.” Source location Response from NHS England
Open published response
Concerns raised 2 Long lie after a fall in elderly people View source Failure to provide allocated ambulance responses within the expected response time 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
Michael John VINCENT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael John Vincent died in hospital on 20 December 2022 after falling at home and remaining on the floor for many hours while awaiting an ambulance response. He later suffered a cardiac arrest and died from a combination of undiagnosed bronchopneumonia, severe coronary artery disease and a long lie. The principal concern was the substantial delay in responding to an appropriately categorised emergency call, with concern that another frail elderly person could have the same experience.
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 Long lie after a fall in elderly people
Wider context from the report “Mr Vincent had fallen many hours prior to making his first call to the ambulance service. There then followed a further ten hour delay, during which time he had a cardiac arrest, before he was admitted to the Emergency Department. He had been allocated an appropriate response time, expected within 18 minutes at 1929 on the 19th December 2022. For the reasons given in the circumstances above, that target was missed by an enormous margin. There is a strong possibility, even arguably a probability that another frail, elderly individual, will have the same experience. Long lie after a fall, especially in the elderly often results in a terminal kidney injury and death . Consideration should be given to review of how these types of emergency call are managed and thereafter monitored.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 allocated ambulance responses within the expected response time
Wider context from the report “Mr Vincent had fallen many hours prior to making his first call to the ambulance service. There then followed a further ten hour delay , during which time he had a cardiac arrest, before he was admitted to the Emergency Department. He had been allocated an appropriate response time, expected within 18 minutes at 1929 on the 19th December 2022. For the reasons given in the circumstances above, that target was missed by an enormous margin . There is a strong possibility, even arguably a probability that another frail, elderly individual, will have the same experience . Long lie after a fall, especially in the elderly often results in a terminal kidney injury and death. Consideration should be given to review of how these types of emergency call are managed and thereafter monitored.
” Open source report
Concerns raised 4 Failure to track outstanding diagnostic results for patients leaving the Accident and Emergency Department View source Insufficient hospital capacity for callback of patients leaving the Accident and Emergency Department View source Failure to implement periodic clinician-led review of abnormal diagnostic results View source Lack of independently auditable callback handover 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
Kai TAKAGI · 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
Kai Takagi attended Chelsea and Westminster Hospital on 11 June 2021 with severe stomach pain and left before an abnormal blood result, suggestive of acute pancreatitis, was received. The hospital planned to contact him but did not do so, and he was found dead at home on 14 June 2021; the stated medical cause of death was acute peritonitis from a perforated gastric ulcer. Concerns included inadequate tracking and follow-up of patients who leave with outstanding abnormal test results, reliance on oral handover, and incomplete implementation of a clinician-led review system.
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 track outstanding diagnostic results for patients leaving the Accident and Emergency Department
Wider context from the report “(1) Patients that leave the hospital Accident and Emergency Department with outstanding blood results or other diagnostic tests are not followed up and “tracked” in the same way that in-patients are , thus giving rise to the risk that they are missed and urgent follow-up care is not actioned or offered.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 hospital capacity for callback of patients leaving the Accident and Emergency Department
Wider context from the report “(2) That as reliance on Accident and Emergency departments for routine out of hours health care increases, the burden of call back also increases for hospitals for patients who have left at a time when their departments are already over-stretched in dealing with admissions and those presenting to the department , thus increasing the risk that patients will not be called back for urgent follow-up assessment or treatment which may be life-saving.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to implement periodic clinician-led review of abnormal diagnostic results
Wider context from the report “(4) That a periodic clinician led review of all abnormal blood results (and other test results) , which the hospital has explored since I raised the matter in the hearing has not been fully implemented giving rise to the risk that patients who have left the hospital with potentially life-threatening conditions suggested by the tests may not be contacted urgently asking them to return thus increasing the risk of their untimely 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 Lack of independently auditable callback handover
Wider context from the report “(3) That the system remains heavily dependent on oral handover, which is not amenable to independent audit as it assumes a person has done what was asked of them. Short of an individual doctor being asked if the call back had been actioned, there is no way of checking that it has .
” 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 national standards for communicating diagnostic test results after hospital discharge.
Verbatim wording from the response “In your Report you raised the concern that patients that leave Accident and Emergency (A&E) departments with outstanding diagnostic test results are not followed up and tracked. Both NHS England and the Royal Colleges have published national guidance and standards for following up on test results following discharge from hospital, please see below:” 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 Trusts are responsible for procedures following national guidance and for responding on handover arrangements and clinician-led review of abnormal blood results.
Verbatim wording from the response “It is the responsibility of Trusts to ensure that they have the necessary procedures and arrangements in place to follow national guidance. It will also be for the Trust to comment on your concerns surrounding their handover arrangements and the clinician led review into abnormal blood results. NHS England notes that you have also addressed your Report to Chelsea and Westminster Hospital. We will carefully consider their response to you which we have asked to be sighted on.” Source location Response from NHS England
Open published response
Concerns raised 1 Unavailability of Tissue Viability Team over weekends causing delays in patient assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Myra Maxfield · 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
Myra Maxfield, aged 89, fell at home, fractured her right hip, and subsequently developed a Grade 4 pressure sore and osteomyelitis. She died in hospital on 12 March 2022 following a further upper gastrointestinal bleed; concerns included delays in pressure-ulcer patients being assessed by the Tissue Viability Team and the lack of weekend availability at Royal Stoke University 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 Unavailability of Tissue Viability Team over weekends causing delays in patient assessment
Wider context from the report “1. Evidence emerged during the inquest that it was crucial that patients who were at risk of developing pressure ulcers, had ulcers already, or had developed them whilst in hospital, saw the Tissue Viability Team as soon as possible, and usually within 6 hours .
2. It was said that, delays in doing so, could be causative in the death of patients.
3. Evidence emerged that at the Royal Stoke University Hospital, Tissue Viability is not available over the weekend, and this leads to substantial delay in patients being seen .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The relevant NHS Trust is responsible for commenting on tissue viability provision at Royal Stoke University Hospital.
Verbatim wording from the response “NHS England is not able to provide comment on the provision of the service specifically within Royal Stoke University Hospital and would refer you to the Trust on this issue.” 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 or the National Wound Care Strategy Programme should be engaged because no specific guidance sets tissue viability referral timings.
Verbatim wording from the response “There are no specific guidelines for when patients should be referred to a Tissue Viability Specialist (TVS) within the NICE guidance or in the international best practice guidelines. You may wish to engage with NICE or the NWCSP regarding this issue.” Source location Response from NHS England
Open published response
Concerns raised 1 Failure to measure the incision from the insular to the Temporal Horn at appropriate intra-operative times 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
Tracy Gambrill · 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
Tracy Gambrill underwent neurosurgery on 7 November 2016 and sustained serious brain injury after excessively deep incisions were made while locating the temporal horn. She died in hospital on 19 November 2016. The principal concern was that it was not current and expected practice to measure the incision from the insular to the temporal horn at appropriate times during the operation.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to measure the incision from the insular to the Temporal Horn at appropriate intra-operative times
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
Each of the three surgical incisions were far too deep considering the average distance between the insular and the Temporal Horn. Only the second incision was measured intra operatively using a cannula and this was after the completion of the incision. From the evidence it is apparent that this operation is undertaken with surgeons relying on anatomical landmarks and head position to perform the procedure safely. The inquest did hear from an expert neurosurgical witness whose practice it was to measure the length of his incisions intra-operatively at appropriate times. This practice resulted in him having aborted an operation after failing to find the Temporal Horn within expected limits. Post-operatively he discovered that the patient’s head had moved from the correct position.
I am concerned that it remains the position that it is not current and expected practice to measure the incision from the insular to the Temporal Horn at appropriate times during the operation.
” Open source report
20 Oct 2023 Kirsty Michelle Hendry · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of primary-care awareness and understanding of burst-aneurysm symptoms View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kirsty Michelle Hendry · 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
Kirsty Michelle Hendry developed headache and vomiting, later deteriorated, and died at Salford Royal Hospital on 11 April 2023. The report describes a subarachnoid haemorrhage caused by a burst aneurysm that was not identified until severe vasospasm and neurological compromise had developed. The principal concerns were limited awareness of the key symptoms in primary care, delayed referral and imaging, and an incorrectly reported CT scan.
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 primary-care awareness and understanding of burst-aneurysm symptoms
Wider context from the report “The inquest heard evidence that early identification of a burst aneurysm is vital if treatment is to be offered at an early enough stage to reduce the risk of death. The inquest was told that particularly in primary care the symptoms are not readily understood and awareness is often low . In Kirsty Hendry’s case she had the key symptoms that are linked to a burst aneurysm.
The evidence was that it was important awareness be raised so that all doctors and other health professionals carrying out examinations in a primary care setting should understand the key symptoms /presentation of a burst aneurysm so that appropriate referrals could be made to secondary care and CT scans be undertaken at an early stage when the probable could be easily identified and treatment options were available.
” 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 Consider Kirsty’s case further and determine next steps for raising awareness of brain aneurysm symptoms among primary care nursing professionals.
Verbatim wording from the response “My nursing colleagues for Primary Care will also be considering Kirsty’s case further, to include raising awareness of brain aneurysm symptoms among primary care nursing professionals. They will be keeping my team updated on their agreed next steps.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure primary care professionals undertake continuing professional development that includes awareness of up-to-date clinical guidance.
Verbatim wording from the response “As part of their appraisal and validation, all healthcare professionals working within Primary Care will undertake Continuing Personal Development (CPD) to keep their clinical skills up to date. This will include ensuring awareness of up-to-date clinical guidance.” 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 Primary care symptom awareness is addressed through existing NICE guidance and CPD that keeps clinicians aware of updated guidance.
Verbatim wording from the response “All healthcare professionals, including those within Primary Care, have access to and should be guided by National Institute for Health and Care Excellence (NICE) clinical guidance. In November 2022, NICE published clinical guidance NG228 on Subarachnoid haemorrhage caused by a ruptured aneurysm: diagnosis and management. The clinical guidance provides information on the diagnosis and management of aneurysm and highlights the importance of urgent investigation and the need to have a ‘high index of suspicion’ for subarachnoid haemorrhage in people who present with unexplained acute severe headache. If there is a suspicion of subarachnoid haemorrhage in people being seen outside of acute hospital settings, the guidance is to refer them to an emergency department immediately for further assessment.” Source location Response from NHS England
Open published response
17 Oct 2023 Holly May Mullan · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Delays in access to gastroenterology and gynaecology specialist appointments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 5
Action
Implement the national GIRFT rollout to review services, benchmark performance, develop evidence, and support elective-care recovery.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023. View source
Action
Enable earlier specialist advice through referral triage, advice-and-guidance, and advice-and-refer services, including direct-to-test pathways where appropriate.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023. View source
Action
Expand the Further Faster Programme to additional trusts and disseminate lessons learned across the wider NHS to reduce long referral-to-treatment waits.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023. View source
Action
Apply the Clinical Prioritisation Programme’s clinical-review expectations to waiting lists so patients with the most urgent conditions are reviewed first.
Stated completedThe respondent said that this action was complete when they made their response on 30 October 2023. View source
Action
Transform outpatient services by expanding patient choice and control, promoting patient-initiated follow-up, safe discharge with safety-net advice, and reduction of missed appointments.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023. View source See 2 more actions
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AI-generated summary
Holly May Mullan · 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
Holly May Mullan had longstanding severe abdominal pain and experienced long waits for NHS appointments with gynaecologists and gastroenterologists. She was found attached to a ligature on 7 May 2023, and the inquest heard that prolonged waiting times were causing distress, delays in diagnosis and delays in treatment for people with significant health conditions.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in access to gastroenterology and gynaecology specialist appointments
Wider context from the report “The inquest heard evidence of the distress caused to Holly and the impact on her health by the long waits to be seen by gastroenterologists and gynaecologists within the NHS . The evidence heard was that post-Covid, the waiting times to be seen in both specialties unless the referral was on the two-week cancer wait had grown significantly across England . As an illustration the inquest was told that pre-Covid, the average wait for a routine gynaecology referral was 18 weeks. Now in England the wait was often in excess of 12 months. Even an urgent referral would often involve a wait of over 40 weeks. This was leading to delays in diagnosis and treatment even in those with significant/severe health conditions.
” 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 the national GIRFT rollout to review services, benchmark performance, develop evidence, and support elective-care recovery.
Verbatim wording from the response “NHS England are also implementing the national rollout of the Getting it Right First Time (GIRFT) Programme, which is designed to improve the treatment and care of patients through reviews of services, benchmarking and developing an evidence base to support change. Through the High Volume Low Complexity programme, the GIRFT team is working with health systems and regions across England to help the NHS recover performance in elective services and reduce the backlog of patients. Gynaecology is one of six specialties being prioritised through this programme, which supports the establishment of surgical hubs for high-volume procedures and the development of standardised pathways. The GIRFT programme will work with the Royal College of Obstetricians and Gynaecologists (RCOG) and others to consider how surgical hubs can work in gynaecology as a specialty.” 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 Enable earlier specialist advice through referral triage, advice-and-guidance, and advice-and-refer services, including direct-to-test pathways where appropriate.
Verbatim wording from the response “As part of outpatient transformation, we are encouraging and enabling access to earlier expert advice through triage of referrals and by greater use of advice & guidance (A&G) or advice & refer (A&R) services. This allows patients and GPs to get the benefit of expert advice and treatment much earlier in the patient pathway. Patients who do not need to be seen in outpatients can continue to be safely managed in primary care, following specialist advice, or may be diverted direct to test where appropriate to facilitate an earlier diagnosis. This allows those that do not need to be seen in clinic to get access to clinic in a much shorter timescale and will help reduce referral to treatment times for all patients.” 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 Expand the Further Faster Programme to additional trusts and disseminate lessons learned across the wider NHS to reduce long referral-to-treatment waits.
Verbatim wording from the response “The GIRFT Further Faster Programme is also specifically looking at eradicating long waiting times from referral to treatment (RTT), in 16 different specialties. The specialties of Gastroenterology and Gynaecology both involved in the Further Faster Programme and have made good inroads into reducing long RTT waiting times in the first cohort of Further Faster Trusts (25 Trusts taking part), compared to the non-further faster Trusts. Of the 16 specialties involved in this programme, gastroenterology has shown the greatest impact (39% difference, as non-further faster trusts’” 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 Apply the Clinical Prioritisation Programme’s clinical-review expectations to waiting lists so patients with the most urgent conditions are reviewed first.
Verbatim wording from the response “As part of the further NHS response to COVID-19, NHS England introduced the Clinical Prioritisation Programme. This sets out an expectation of clinical review of waiting lists, to enable patients with the most urgent conditions to be reviewed first based on the information available (such as urgency indicated at referral or decision to admit, procedure type, specialty, and length of time that the patient has been waiting for treatment). The guidance was developed with the Academy Of Medical Royal Colleges.” 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 Transform outpatient services by expanding patient choice and control, promoting patient-initiated follow-up, safe discharge with safety-net advice, and reduction of missed appointments.
Verbatim wording from the response “The NHS is changing how it delivers outpatient services so that patients can be seen more quickly and can access and interact with services in a way that better suits them. We are giving patients and carers more control and greater choice over how and when they access care. We have recommended more use of patient initiated follow up (PIFU) pathways, which help empower patients to book their own follow-up care as and when they need it. We are encouraging services to discharge patients as soon as this is appropriate, with safety net advice, to reduce unnecessary follow up appointments. This allows those patients who do need to access appointments to be seen more quickly. We are helping services to reduce the number of missed outpatient appointments (did not attends or DNAs) to make the best use of all available appointments.” 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 cannot investigate the relevant waiting-list pathway without further particulars.
Verbatim wording from the response “It is not clear from your Report or from subsequent questions to your office if Holly received any diagnosis for the pain she was experiencing or if she was eventually seen by NHS gynaecologists or gastroenterologists. If she was on an admitted waiting list, but instead waiting for outpatients service her referral should have been triaged, although NHS England are not able to investigate this without further particulars. You may wish to contact the Trust to obtain further information.” Source location Response from NHS England
Open published response
Concerns raised 7 Failure to identify the need for genetic testing before the Pathology report View source Chronic shortage of Paediatric Pathologists View source Limited use of molecular autopsy after sudden death in childhood View source Failure of the SUDIC Protocol to reflect the development of molecular autopsy View source Limited use of molecular autopsy to detect familial genetic variants View source Insufficient time for timely Coronial and Forensic Paediatric Pathology work View source Delays in Paediatric Pathology reports View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Tyler Jay Ryan · 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
Tyler Jay Ryan, aged 11, was found collapsed in his bedroom on 12 February 2021 and died after resuscitation attempts. Genetic testing identified two RYR2 variants associated with CPVT, following earlier differing pathological opinions. The report raised concerns about delays in paediatric pathology reporting and the delayed identification of families who may need genetic testing, as well as the need for wider use of molecular autopsy and revision of the SUDIC Protocol.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to identify the need for genetic testing before the Pathology report
Wider context from the report “2. The delay in Paediatric Pathology Reports results in the delayed detection of the need for genetic testing amongst surviving siblings of children who die of Sudden Death in Childhood. Currently, it is not until the Pathologist provides a report that the need for genetic testing is identified . Reports can take up to two years to be filed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Chronic shortage of Paediatric Pathologists
Wider context from the report “1. ████████ and ████████ each gave evidence that the delay in Paediatric Pathology reports is due to a chronic shortage in recruitment and retention of Paediatric Pathologists in the UK . This shortage is systemic. Currently only 50 out of 80 national vacancies for Paediatric Pathologists are filled . Coronial and Forensic work is undertaken by these Pathologists on a private basis, in addition to their NHS work. This provides insufficient time to carry out this work in a timely fashion. There is an acute shortage of Subspeciality Paediatric Pathologists, with just one Paediatric Orthopedic Pathologist undertaking Forensic and Coronial work in the UK .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Limited use of molecular autopsy after sudden death in childhood
Wider context from the report “3. ████████ and ████████ gave evidence that more widespread use of molecular autopsy would assist in detecting genetic abnormalities in children who have died suddenly , leading to greater opportunities to prevent future deaths within their families and in other families.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 SUDIC Protocol to reflect the development of molecular autopsy
Wider context from the report “5. ████████ gave evidence that the development of the use of molecular autopsy calls for a revision of the SUDIC Protocol also known as the Kennedy Protocol .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Limited use of molecular autopsy to detect familial genetic variants
Wider context from the report “4. ████████, Consultant Clinical Geneticist gave evidence that Tyler is, to date, the only human in history to have been found to have these two RYR2 variants which is significant to his family and to the wider scientific community. Greater use of molecular autopsy would save lives within families and in other families . The detection of these variants is directly relevant to others and the prevention of future deaths .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient time for timely Coronial and Forensic Paediatric Pathology work
Wider context from the report “1. ████████ and ████████ each gave evidence that the delay in Paediatric Pathology reports is due to a chronic shortage in recruitment and retention of Paediatric Pathologists in the UK. This shortage is systemic. Currently only 50 out of 80 national vacancies for Paediatric Pathologists are filled. Coronial and Forensic work is undertaken by these Pathologists on a private basis, in addition to their NHS work . This provides insufficient time to carry out this work in a timely fashion . There is an acute shortage of Subspeciality Paediatric Pathologists, with just one Paediatric Orthopedic Pathologist undertaking Forensic and Coronial work in the UK.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in Paediatric Pathology reports
Wider context from the report “2. The delay in Paediatric Pathology Reports results in the delayed detection of the need for genetic testing amongst surviving siblings of children who die of Sudden Death in Childhood . Currently, it is not until the Pathologist provides a report that the need for genetic testing is identified. Reports can take up to two years to be filed .
” 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 Raise revision of the Sudden Unexpected Death in Children protocol with the Royal Colleges and relevant government departments.
Verbatim wording from the response “In your Report you also reference the Kennedy Guidance and the need for a revision of the Sudden Unexpected Death In Children (SUDIC) protocol. The guidance was published in November 2016 and was developed by the RCPath in collaboration with the Royal College of Paediatrics and Child Health (RCPCH). NHS England will be raising the issue of the revision with the Royal Colleges and the relevant government departments.” 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 recruitment incentives to attract pathologists into higher specialist training in paediatric and perinatal pathology.
Verbatim wording from the response “In your Report you raise a concern over the shortage of Paediatric Pathologists and the delays that this can cause to Paediatric Pathology reports. The shortage of paediatric and perinatal pathologists and the impact it has on services has been of concern for some time. This issue has been the subject of a great deal of activity relating to attracting pathologists into higher specialist training in this area with the implementation of recruitment incentives (one-off payments of £20,000) as well as supporting learning via e-learning resources.” 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 Support learning through e-learning resources for paediatric and perinatal pathology.
Verbatim wording from the response “In your Report you raise a concern over the shortage of Paediatric Pathologists and the delays that this can cause to Paediatric Pathology reports. The shortage of paediatric and perinatal pathologists and the impact it has on services has been of concern for some time. This issue has been the subject of a great deal of activity relating to attracting pathologists into higher specialist training in this area with the implementation of recruitment incentives (one-off payments of £20,000) as well as supporting learning via e-learning resources.” 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 RCPath is the appropriate organisation to comment on concerns about molecular autopsy.
Verbatim wording from the response “RCPath and they would be the appropriate organisation to provide comment on your concerns touching on molecular autopsy.” 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