12 Oct 2023 Mr Jonathan Michael McCarthy · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 4 Failure to determine the clinical importance and urgency of pre-existing community hospital appointments in light of security issues View source Failure to verify prisoners’ pre-existing community hospital appointments View source Failure to determine medical hold View source Failure to assess fitness to transfer View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mr Jonathan Michael McCarthy · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Jonathan Michael McCarthy died on 12 August 2018 at University Hospital Coventry and Warwickshire from a cardiac arrhythmia associated with scarring of the heart, while at HMP Onley. Concerns included failures to verify and assess the clinical importance of pre-existing community hospital appointments, the impact of security issues on those appointments, and whether he was fit to transfer or should have been placed on medical hold.
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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 determine the clinical importance and urgency of pre-existing community hospital appointments in light of security issues
Wider context from the report “Upon Mr McCarthy’s arrival at HMP Altcourse on 5 June 2017, it is recorded that he had an outstanding hospital appointment. There was no evidence that HMP Altcourse took any steps to verify this appointment.
Mr McCarthy was transferred to HMP Thameside on 7 May 2018. It is recorded that he had an appointment to see the cardiologist at Whittington Hospital on 13 June 2018. There was no evidence that HMP Thameside took any steps to verify this appointment. He was transferred from the prison on the next day, 14th June 2018.
It was suggested in evidence that HMP Thameside automatically re-arrange all community medical appointments for security reasons. It was clarified that the prison would only try to get a new appointment if there was a specific security concern.
There was also no evidence that Mr McCarthy had a fitness to transfer assessment at either HMP Altcourse or HMP Thameside.
1. verifying a prisoner’s pre-existing community hospital appointments.
2. determining the clinical importance/urgency of pre-existing community hospital appointments and the impact of security issues upon this assessment.
3. assessing fitness to transfer and determining medical hold.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to verify prisoners’ pre-existing community hospital appointments
Wider context from the report “Upon Mr McCarthy’s arrival at HMP Altcourse on 5 June 2017, it is recorded that he had an outstanding hospital appointment. There was no evidence that HMP Altcourse took any steps to verify this appointment.
Mr McCarthy was transferred to HMP Thameside on 7 May 2018. It is recorded that he had an appointment to see the cardiologist at Whittington Hospital on 13 June 2018. There was no evidence that HMP Thameside took any steps to verify this appointment. He was transferred from the prison on the next day, 14th June 2018.
It was suggested in evidence that HMP Thameside automatically re-arrange all community medical appointments for security reasons. It was clarified that the prison would only try to get a new appointment if there was a specific security concern.
There was also no evidence that Mr McCarthy had a fitness to transfer assessment at either HMP Altcourse or HMP Thameside.
1. verifying a prisoner’s pre-existing community hospital appointments.
2. determining the clinical importance/urgency of pre-existing community hospital appointments and the impact of security issues upon this assessment.
3. assessing fitness to transfer and determining medical hold.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to determine medical hold
Wider context from the report “Upon Mr McCarthy’s arrival at HMP Altcourse on 5 June 2017, it is recorded that he had an outstanding hospital appointment. There was no evidence that HMP Altcourse took any steps to verify this appointment.
Mr McCarthy was transferred to HMP Thameside on 7 May 2018. It is recorded that he had an appointment to see the cardiologist at Whittington Hospital on 13 June 2018. There was no evidence that HMP Thameside took any steps to verify this appointment. He was transferred from the prison on the next day, 14th June 2018.
It was suggested in evidence that HMP Thameside automatically re-arrange all community medical appointments for security reasons. It was clarified that the prison would only try to get a new appointment if there was a specific security concern.
There was also no evidence that Mr McCarthy had a fitness to transfer assessment at either HMP Altcourse or HMP Thameside.
1. verifying a prisoner’s pre-existing community hospital appointments.
2. determining the clinical importance/urgency of pre-existing community hospital appointments and the impact of security issues upon this assessment.
3. assessing fitness to transfer and determining medical hold.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to assess fitness to transfer
Wider context from the report “Upon Mr McCarthy’s arrival at HMP Altcourse on 5 June 2017, it is recorded that he had an outstanding hospital appointment. There was no evidence that HMP Altcourse took any steps to verify this appointment.
Mr McCarthy was transferred to HMP Thameside on 7 May 2018. It is recorded that he had an appointment to see the cardiologist at Whittington Hospital on 13 June 2018. There was no evidence that HMP Thameside took any steps to verify this appointment. He was transferred from the prison on the next day, 14th June 2018.
It was suggested in evidence that HMP Thameside automatically re-arrange all community medical appointments for security reasons. It was clarified that the prison would only try to get a new appointment if there was a specific security concern.
There was also no evidence that Mr McCarthy had a fitness to transfer assessment at either HMP Altcourse or HMP Thameside.
1. verifying a prisoner’s pre-existing community hospital appointments.
2. determining the clinical importance/urgency of pre-existing community hospital appointments and the impact of security issues upon this assessment.
3. assessing fitness to transfer and determining medical hold.
” Open source report
2 Oct 2023 Jack Peter Zarrop · Prevention of Future Deaths report West London
View report summary
Concerns raised 3 Lack of adequate mental health training for Custodial Nurse Practitioners seeing high-risk and complex patients in police custody View source Failure to train agency healthcare staff in the ACCT process and the threshold for opening an ACCT View source Failure of the 2003 Home Office circular to recognise suicide and self-harm risk as a core competency 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
Jack Peter Zarrop · 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
Jack Peter Zarrop, who had a history of mental-health difficulties, alcohol abuse and previous suicide attempts, died by suicide while in custody. The jury identified failures relating to referral to Liaison and Diversion services, opening an ACCT, access to relevant history, and removal of a bedsheet and closure of a hatch as main contributing factors. The report raised concerns about the use and training of Custodial Nurse Practitioners in police custody and the training of agency prison healthcare staff in the ACCT process.
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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 adequate mental health training for Custodial Nurse Practitioners seeing high-risk and complex patients in police custody
Wider context from the report “1. The use of Custodial Nurse Practitioners (CNPs) in Police custody instead of doctors. The 2003 Home Office circular appeared to envisage nurses working alongside doctors, when this is not how they are deployed. CNPs are also seeing high risk and complex patients without adequate training in mental health . The deployment in Police custody of CNPs places detained persons at risk of death in the future . The 2003 Home Office circular also does not recognise the risk of suicide and self-harm as being a core competency.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 train agency healthcare staff in the ACCT process and the threshold for opening an ACCT
Wider context from the report “2. The training of agency staff in the ACCT process and recognising the appropriate threshold to open an ACCT . The training of agency staff in ACCT does not appear to be part of the commissioning process by NHS England and individual providers do not appear to provide training to agency staff in the ACCT process . This places residents in prison at risk of death, given the high level of usage of agency healthcare staff in prison.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 2003 Home Office circular to recognise suicide and self-harm risk as a core competency
Wider context from the report “1. The use of Custodial Nurse Practitioners (CNPs) in Police custody instead of doctors. The 2003 Home Office circular appeared to envisage nurses working alongside doctors, when this is not how they are deployed. CNPs are also seeing high risk and complex patients without adequate training in mental health. The deployment in Police custody of CNPs places detained persons at risk of death in the future. The 2003 Home Office circular also does not recognise the risk of suicide and self-harm as being a core competency .
” 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 Take the report’s findings to the NHS England Health and Justice Delivery Oversight Group for oversight of the proposed training-access action.
Verbatim wording from the response “In addition, the findings in your report will be taken to the NHS England Health and Justice Delivery Oversight Group (HJＤOG) in December 2023. The HJDOG is the senior leadership forum, which holds responsibility for the oversight of delivery and continuous improvement in Health and Justice commissioned services, through both the national and regional teams, with a focus on improving health outcomes and reducing variation across England. Regional teams will be asked to give assurance at the HJDOG meeting planned for June 2024, that the proposed action has been delivered and agency and bank staff have timely access to ACCT training.” Source location Response from NHSE
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 Require regional teams to provide assurance at the planned Health and Justice Delivery Oversight Group meeting that agency and bank staff have timely access to ACCT training.
Verbatim wording from the response “In addition, the findings in your report will be taken to the NHS England Health and Justice Delivery Oversight Group (HJＤOG) in December 2023. The HJDOG is the senior leadership forum, which holds responsibility for the oversight of delivery and continuous improvement in Health and Justice commissioned services, through both the national and regional teams, with a focus on improving health outcomes and reducing variation across England. Regional teams will be asked to give assurance at the HJDOG meeting planned for June 2024, that the proposed action has been delivered and agency and bank staff have timely access to ACCT training.” Source location Response from NHSE
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 Write to Health and Justice regional teams sharing concerns and requesting action to ensure agency and bank staff access necessary joint training, including ACCT training.
Verbatim wording from the response “In response to the concerns noted, NHS England's National Director of Health & Justice, Armed Forces and Sexual Assault Services Commissioning, has written to Health & Justice regional teams sharing these concerns, asking commissioners to work with prison healthcare provider organisations and HMPPS locally, to ensure all staff, including agency and bank staff, have timely access to all joint training, including ACCT, that is necessary for them to undertake their role effectively within the prison environment. .” Source location Response from NHSE
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 overseeing effective ACCT training delivery at prison establishments, including ACCT case manager and assessor training.
Verbatim wording from the response “ACCT is the care planning process for prisoners identified as being at risk of suicide or self-harm, and training is provided by His Majesty’s Prisons and Probation Service (HMPPS). The ACCT process requires that certain actions are taken to ensure the risk of suicide and self-harm is reduced. The ACCT process is multi-disciplinary, involving” Source location Response from NHSE
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for custodial nurse practitioners in police custody settings lies with the Police Chiefs’ Council, not NHS England.
Verbatim wording from the response “Regarding the matter of concern around the use of Custodial Nurse Practitioners, this is for the Police Chief Council to respond to. NHS England does not hold responsibility for commissioning healthcare in police custody settings, therefore cannot comment.” Source location Response from NHSE
Open published response
Concerns raised 1 Insufficient availability of suitable specialist placements for autistic young adults at risk of self-harm or harm to others 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
Benjamin Henry Hazelden · 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
Benjamin Henry Hazelden died at the scene on 11 February 2022 after he assaulted two staff members, ran to a nearby train station and was hit by a train. The report identified limited availability of suitable specialist placements for young adults with autism and risks of self-harm or harm to others; he was discharged home with increased support because no suitable specialist bed was available.
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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 Insufficient availability of suitable specialist placements for autistic young adults at risk of self-harm or harm to others
Wider context from the report “1. In the course of the hearing the evidence it was clear that young adults with autism who were at risk of self-harm as well as harm to others have very limited options in terms of placements where their needs can be met . A bespoke placement had been carefully created by those involved in Ben’s care but this had taken several months to arrange. This arrangement had worked well and all involved tried to make it a success and for quite some time it was. It was however recognised that there may come a time in the future when his risks to himself and others would mean an alternative placement would be needed.
2. When Ben’s risks to himself increased further there were no suitable beds available where he could be cared for in an environment which could meet his needs . He spent several days in an acute hospital bed despite being medically fit for discharge which although, essentially a place of safety, was totally unsuited to his needs. This stay continued whilst discussions ensued regarding where he should be placed. A bed in an acute psychiatric ward was considered but not deemed appropriate to meet his needs and as there were no specialist beds available he was discharged back to his home with increased support as the best option available . Had a bed been available in a specialist unit it is likely that he would not have died when he did.
3. In the evidence provided it became clear that a lot of units where a specialist bed may have been available had been closed in the past due to concerns about the level of care following a number of investigations. This has led to a system whereby locally and nationally there are limited options for those requiring care relating to both the management of autism and self-harm or harm to others, particularly when there is an urgent need for increased support . Whilst the inquest heard there were some counties who had specialist beds they were difficult to access as they were often full and places were not always available to meet urgent needs
” Open source report
Concerns raised 2 Delays in Radiologist review of emergency chest x-rays View source Lack of guidance raising the profile of acute aortic dissection when chest pain radiates to the throat, neck or jaw 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
Chantelle Reed · 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
Chantelle Reed, who was 33 and had no significant medical history, attended hospital with back, neck and chest symptoms before returning with worsening breathlessness, chest pain, vomiting and fever. She was managed for suspected pulmonary embolism but died after becoming unconscious in the emergency department; the inquest recorded an undiagnosed Type A aortic dissection. Concerns included limited recognition of aortic dissection symptoms in emergency guidance and delays in radiological review that can leave abnormal findings unidentified until after 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 Delays in Radiologist review of emergency chest x-rays
Wider context from the report “2. The evidence also indicated that the timescale for a Radiologist to review the chest x-ray (2 days) was not unusual and that often the timescale is longer and this is due to a national shortage of Radiologists . The concern is that, to a trained Radiologist, the possibility of an aortic dissection was immediately recognised, but the review did not take place until after Chantelle had died . In an emergency situation such as this one, this delay represents on ongoing risk of future deaths .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance raising the profile of acute aortic dissection when chest pain radiates to the throat, neck or jaw
Wider context from the report “1. The evidence of the independent expert in Emergency Medicine, was that “the feature of central chest pain that radiates to the throat and jaw stands out as important and deserving attention in guidance to raise the profile of acute aortic dissection . Emergency physicians know that chest pain radiating to the neck and jaw may indicate acute coronary syndrome, but rarely appreciate this also raises the prospect of acute aortic pain . The latter is known amongst cardiologists and cardiac surgeons but it not widely known in acute medicine. I consider there is scope for those responsible for compiling guidelines to consider including this symptom to raise the profile of possible aortic dissection further ”. The expert felt that this would assist in cases such as Chantelle’s where the presentation did not have many of the usual ‘red flag’ symptoms.
” 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 NHS Long Term Workforce Plan to train, retain and reform healthcare staff across the NHS over fifteen years.
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.” 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 Trusts to increase radiology 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 Publish national image-report turnaround-time guidance, including a four-hour maximum for acutely unwell A&E patients during routine hours.
Verbatim wording from the response “NHS England published the Image report turnaround time guidance in August 2023, available here: NHS England » Diagnostic imaging reporting turnaround times. The guidance sets out the maximum turnaround times from acquisition to image reports, with a 4-hour maximum for acutely unwell patients in Accident & Emergency (A&E) during routine hours of working.” 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 Include acute aortic dissection in the GIRFT chest-pain pathway for acute settings.
Verbatim wording from the response “NHS England’s Getting It Right First Time (GIRFT) Programme also includes the possibility of aortic dissection in its chest pain pathway for acute settings: Chest-Pain-Pathway-FINAL-v2-July-2023.pdf (gettingitrightfirsttime.co.uk). GIRFT is a national programme designed to improve the treatment and care of patients through in-depth review of services, benchmarking and wide-ranging data analysis and is part of an aligned set of programmes within NHS England input into by senior clinicians.” Source location Response from NHS England
Open published response
Concerns raised 9 Failure of record-keeping systems to support direct transfer and sharing of clinical information View source Lack of consistent adoption and awareness of delayed-discharge protocols across independent providers View source Reliance of delayed-discharge protocols on home-team engagement View source Out-of-Area patients remaining away from home because of delayed discharge or repatriation View source Underfunding for local mental health beds View source Lack of a national standard process for independent-sector referrals and discharge or repatriation View source Inadequate communication between mental health care providers and relevant parties View source Variation in commissioning-body processes and communication requests View source Over-reliance by the NHS on independent providers for mental health beds View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Lauren Elizabeth Bridges · 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
Lauren Elizabeth Bridges, who was detained under the Mental Health Act and treated in out-of-area mental health placements, died on 26 February 2022 after a ligaturing incident two days earlier. The report identified concerns about delayed discharge and repatriation, the distance from home, missed opportunities to move her closer to home, and inadequate communication between relevant organisations. It also identified wider concerns about shortages of local mental health beds and reliance on independent providers.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of record-keeping systems to support direct transfer and sharing of clinical information
Wider context from the report “The jury identified inadequate and insufficient communication between Dorset Healthcare NHS Trust, The Priory and relevant parties.
I heard evidence that Dorset Healthcare NHS Trust have appointed a designated Care Co-ordinator for its Out-of-Area patients. Having a single point of contact will alleviate some of the communication issues identified.
I heard evidence from The Priory as to some of the challenges it faces when dealing with the NHS commissioning bodies, be they Hospital Trusts or Integrated Care Boards. The Priory is just one of the several independent providers of mental health care.
1. The Priory deals with 42 NHS separate commissioning bodies.
2. There are multiple software programmes for record keeping for these organisations, which makes transfer and sharing of clinical information cumbersome and difficult, as direct sharing is not possible.
3. These bodies have varying processes and requests for communication.
4. There is no national standard process for referrals into the independent sector nor for discharge/repatriation to the ‘home team’.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent adoption and awareness of delayed-discharge protocols across independent providers
Wider context from the report “The protocol is heavily reliant on engagement from, and co-operation of, the numerous NHS commissioning bodies. The protocol requires a low threshold for the escalation of delays to the appropriate manager and/or commissioner at the ‘home service’.
There are over 60 independent providers for in-patient mental health services.
The initiative taken by the Priory is to be applauded but it is just one of many independent providers for some 42 separate NHS commissioning bodies. There is a clear danger that it will not be adopted by the other independent providers , indeed there is no reason for them to be aware of its existence . In the premises, Out-of-Area delayed discharge, and its detrimental effect on a patient’s mental health, will remain a matter of concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 of delayed-discharge protocols on home-team engagement
Wider context from the report “With regard to delayed discharge/repatriation of an Out-of-Area patient I heard evidence that The Priory have devised a protocol/standing operating procedure in respect of delayed discharge, which should reduce the risks of a patient being left miles from home at all and in any event reduce the time taken to repatriate. However, it relies on the ‘home team’s’ engagement in the process .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Out-of-Area patients remaining away from home because of delayed discharge or repatriation
Wider context from the report “With regard to delayed discharge/repatriation of an Out-of-Area patient I heard evidence that The Priory have devised a protocol/standing operating procedure in respect of delayed discharge, which should reduce the risks of a patient being left miles from home at all and in any event reduce the time taken to repatriate . However, it relies on the ‘home team’s’ engagement in the process.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Underfunding for local mental health beds
Wider context from the report “This is the second inquest I have heard where the delayed discharge/repatriation of an Out-of-Area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Lauren was 20 years of age. The other inquest involved a 15 years old patient - 115 miles from home.
Both of these cases illustrate,
a) Underfunding for local mental health beds .
b) An over-reliance by the NHS on independent providers for mental health beds.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a national standard process for independent-sector referrals and discharge or repatriation
Wider context from the report “The jury identified inadequate and insufficient communication between Dorset Healthcare NHS Trust, The Priory and relevant parties.
I heard evidence that Dorset Healthcare NHS Trust have appointed a designated Care Co-ordinator for its Out-of-Area patients. Having a single point of contact will alleviate some of the communication issues identified.
I heard evidence from The Priory as to some of the challenges it faces when dealing with the NHS commissioning bodies, be they Hospital Trusts or Integrated Care Boards. The Priory is just one of the several independent providers of mental health care.
1. The Priory deals with 42 NHS separate commissioning bodies.
2. There are multiple software programmes for record keeping for these organisations, which makes transfer and sharing of clinical information cumbersome and difficult, as direct sharing is not possible.
3. These bodies have varying processes and requests for communication.
4. There is no national standard process for referrals into the independent sector nor for discharge/repatriation to the ‘home team’.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication between mental health care providers and relevant parties
Wider context from the report “The jury identified inadequate and insufficient communication between Dorset Healthcare NHS Trust, The Priory and relevant parties .
I heard evidence that Dorset Healthcare NHS Trust have appointed a designated Care Co-ordinator for its Out-of-Area patients. Having a single point of contact will alleviate some of the communication issues identified.
I heard evidence from The Priory as to some of the challenges it faces when dealing with the NHS commissioning bodies, be they Hospital Trusts or Integrated Care Boards. The Priory is just one of the several independent providers of mental health care.
1. The Priory deals with 42 NHS separate commissioning bodies.
2. There are multiple software programmes for record keeping for these organisations, which makes transfer and sharing of clinical information cumbersome and difficult, as direct sharing is not possible.
3. These bodies have varying processes and requests for communication.
4. There is no national standard process for referrals into the independent sector nor for discharge/repatriation to the ‘home team’.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Variation in commissioning-body processes and communication requests
Wider context from the report “The jury identified inadequate and insufficient communication between Dorset Healthcare NHS Trust, The Priory and relevant parties.
I heard evidence that Dorset Healthcare NHS Trust have appointed a designated Care Co-ordinator for its Out-of-Area patients. Having a single point of contact will alleviate some of the communication issues identified.
I heard evidence from The Priory as to some of the challenges it faces when dealing with the NHS commissioning bodies, be they Hospital Trusts or Integrated Care Boards. The Priory is just one of the several independent providers of mental health care.
1. The Priory deals with 42 NHS separate commissioning bodies.
2. There are multiple software programmes for record keeping for these organisations, which makes transfer and sharing of clinical information cumbersome and difficult, as direct sharing is not possible.
3. These bodies have varying processes and requests for communication.
4. There is no national standard process for referrals into the independent sector nor for discharge/repatriation to the ‘home team’.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Over-reliance by the NHS on independent providers for mental health beds
Wider context from the report “This is the second inquest I have heard where the delayed discharge/repatriation of an Out-of-Area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Lauren was 20 years of age. The other inquest involved a 15 years old patient - 115 miles from home.
Both of these cases illustrate,
a) Underfunding for local mental health beds.
b) An over-reliance by the NHS on independent providers for mental health beds .
” 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 Work towards eliminating adult acute out-of-area placements across the NHS.
Verbatim wording from the response “The NHS remains committed to eliminating the practice of adult acute Out of Area Placements. All Integrated Care Boards (ICBs) were asked to work towards eliminating the practice in NHS England’s 2023/24 Priorities and Operational Planning Guidance. An ICB is a statutory NHS organisation which is responsible for developing a plan for meeting the health needs of the population, managing the NHS budget, and arranging for the provision of health services within a given geographical area. They replace clinical commissioning groups (CCGs), taking on the NHS planning functions previously held by CCGs, as well as absorbing some planning roles from NHS England.” 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 health and care systems to operationalise inpatient mental health care localisation plans through regional and national assistance.
Verbatim wording from the response “To implement this, all ICBs have been tasked with developing 3-year plans to localise and realign inpatient mental health care, including care provided by the Independent Sector, as part of the mental health, learning disability and autism inpatient quality transformation programme launched in 2022. Health and Care systems across England are currently being supported to operationalise the guidance via 3-year plans with direct support from regional and national teams. The transformation programme is underpinned by a £36 million investment.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish guidance supporting timely, local, high-quality therapeutic inpatient care and timely discharge.
Verbatim wording from the response “In July 2023 NHS England published renewed guidance to support the commissioning and delivery of timely access to high quality therapeutic inpatient care, close to home and in the least restrictive setting possible. Key to this are the principles of: timely and purposeful admissions that are local, timely discharge, joined-up care and continuous improvement.” Source location Response from NHS England
Open published response
19 Sep 2023 Stephen William Cassidy · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Failure to integrate the Summary Care Record with SMH and primary care electronic patient records for automatic transfer of clinical information View source Lack of routine and easy access to patients’ Summary Care Records for SMH clinical staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stephen William Cassidy · 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
Stephen William Cassidy fractured his hip and was admitted to Southmead Hospital, where he was given intravenous Ceftriaxone during anaesthetic induction despite a recorded Ceftriaxone allergy. He suffered a severe anaphylactic reaction and died shortly afterwards. The principal concern was that hospital staff could not routinely or easily access or automatically receive Summary Care Record information, including allergies, creating a risk of avoidable patient harm and death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to integrate the Summary Care Record with SMH and primary care electronic patient records for automatic transfer of clinical information
Wider context from the report “a) There is no provision for clinical staff at SMH to access patients’ Summary Care Record routinely or easily;
b) This is despite provision existing for SWAS clinical staff to do so before a patient arrives at hospital;
c) There is no provision for the Summary Care Record to be integrated with SMH’s hospital electronic patient record (known as Careflow/Connect) or the primary care electronic patient record (known as EMIS – Egton Medical Information System) – such that the Ceftriaxone allergy automatically appears in SMH’s electronic patient record ;
d) As a result hospital doctors are ignorant of important clinical information on the patients they are treating;
e) This can lead to avoidable patient harm including death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of routine and easy access to patients’ Summary Care Records for SMH clinical staff
Wider context from the report “a) There is no provision for clinical staff at SMH to access patients’ Summary Care Record routinely or easily ;
b) This is despite provision existing for SWAS clinical staff to do so before a patient arrives at hospital;
c) There is no provision for the Summary Care Record to be integrated with SMH’s hospital electronic patient record (known as Careflow/Connect) or the primary care electronic patient record (known as EMIS – Egton Medical Information System) – such that the Ceftriaxone allergy automatically appears in SMH’s electronic patient record;
d) As a result hospital doctors are ignorant of important clinical information on the patients they are treating;
e) This can lead to avoidable patient harm including death.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with North Bristol Trust to identify suitable alternatives to smartcard authentication.
Verbatim wording from the response “Staff require a smartcard to authenticate to Spine services, it is however acknowledged that only a limited number of staff at NBT have and carry a smartcard. NHS England are working with NBT to identify suitable alternative solutions to the use of Smartcards.” 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 the National Care Records Service to provide integration with local clinical systems and alternative authentication methods.
Verbatim wording from the response “The implementation of National Care Records Service (NCRS) will address two of these points:” 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 Deliver programmes such as GP Connect and MIG that convey allergy information end to end in machine-processable form.
Verbatim wording from the response “NHS England is committed to other programs of work (e.g., GP Connect / MIG) which are currently delivering solutions that convey allergy information end to end in a machine processable way.” 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 Collaborate with North Bristol Trust to identify suitable options for accessing Summary Care Records.
Verbatim wording from the response “NHS England Summary Care Records team and digital safety experts within the National Patient Safety Team have worked collaboratively with North Bristol Trust to discuss and identify suitable options to access SCR.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Current SCR viewing requirements prevent clinical systems from machine-processing allergy information for automatic insertion into local patient records.
Verbatim wording from the response “The SCR viewing requirements require clinical systems and organisations that consume the SCR to only present the information as human readable and not machine processed i.e., a human must read the information, assimilate this, and transcribe relevant content in the correct way, into their local patient record.” Source location Response from NHS England
Open published response
Concerns raised 3 Failure to include Herpes Simplex as a diagnosis to consider in sepsis pathways View source Unclear advice on testing staff during infection investigations View source Lack of guidance on antiviral therapy for postpartum women with signs of systemic infection View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kimberley Sampson and Samantha Mulcahy · 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
Kimberley Sampson and Samantha Mulcahy died after developing disseminated herpes simplex infections acquired before or around delivery, with both progressing to multi-organ failure despite intensive treatment. The principal concerns were delays in recognising a viral cause and commencing antiviral therapy, alongside a lack of national guidance on antiviral treatment for women presenting with systemic infection in the postpartum or peripartum period. The investigation also found uncertainty about testing staff who had treated both women and was unable to establish whether they had a common source of infection.
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 include Herpes Simplex as a diagnosis to consider in sepsis pathways
Wider context from the report “(2) Evidence given at the inquest revealed that Herpes Simplex can be fatal if contracted in pregnancy and whilst deaths are rare there is no specific guidance in relation to treating women in the post-partum period with anti-viral therapy. It was accepted by all who gave evidence that antiviral medication would have been recognised treatment for Herpes Simplex (specifically Acyclovir). The Trust has made some minor amendments to its protocols but there is no national guidance either in place back in 2018 or currently in 2023 on prescribing antiviral medication to women who present with signs of systemic infection. Had Acyclovir been prescribed at an earlier stage it is likely to have significantly reduced the risk of death from progression of the disease. Sepsis protocols cover antibiotic therapy but not antiviral therapy. What was abundantly clear from the evidence before the court was that this is a rare but often fatal disease if contracted in the peripartum period and more needs to be done to raise awareness of it as a potential diagnosis to exclude in sepsis pathways and for early consideration of the use to Acyclovir .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unclear advice on testing staff during infection investigations
Wider context from the report “(1) The inquest heard evidence of steps having been taken to try to establish if the deaths of both women were linked and if there was a common source of infection. In both inquests the women had been treated in separate hospitals but within the same Trust and two members of staff had been involved in treating both women. The inquest heard that Public Health England were involved in the investigation following the deaths and advice on testing staff was unclear which meant neither of the members of staff involved with both women were tested . The inquest was however unable to establish if the strain of the virus was the same in both women as the evidence on this was inconsistent and on balance the evidence did not support a conclusion that both women were infected by the same source.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on antiviral therapy for postpartum women with signs of systemic infection
Wider context from the report “(2) Evidence given at the inquest revealed that Herpes Simplex can be fatal if contracted in pregnancy and whilst deaths are rare there is no specific guidance in relation to treating women in the post-partum period with anti-viral therapy . It was accepted by all who gave evidence that antiviral medication would have been recognised treatment for Herpes Simplex (specifically Acyclovir). The Trust has made some minor amendments to its protocols but there is no national guidance either in place back in 2018 or currently in 2023 on prescribing antiviral medication to women who present with signs of systemic infection . Had Acyclovir been prescribed at an earlier stage it is likely to have significantly reduced the risk of death from progression of the disease. Sepsis protocols cover antibiotic therapy but not antiviral therapy . What was abundantly clear from the evidence before the court was that this is a rare but often fatal disease if contracted in the peripartum period and more needs to be done to raise awareness of it as a potential diagnosis to exclude in sepsis pathways and for early consideration of the use to Acyclovir.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for relevant national sepsis guidance lies with the Royal College of Obstetricians and Gynaecologists.
Verbatim wording from the response “The relevant national guidance does not come under the remit of NHS England. The Royal College of Obstetricians & Gynaecologists (RCOG), who you also addressed your Report to, are one of the organisations responsible for the national guidance on diagnosing and treating sepsis during pregnancy and we note their response to you that they are in the process of updating their Green-top Guidelines on Sepsis in pregnancy (No. 64a) and Bacterial sepsis following pregnancy (No. 64b). The update will result in a new combined guideline titled Identification and management of maternal sepsis during and following pregnancy (No. 64), which will include guidance on the timely and routine identification and treatment of herpes simplex. NHS England notes that this is scheduled for publication in March 2024.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National guidance on diagnosing and treating pregnancy-related sepsis and antiviral prescribing is outside the organisation’s remit.
Verbatim wording from the response “Your second concern related to the delays in prescribing the antiviral medication Acyclovir to Kimberley and Samantha and that there was no national guidance in relation to prescribing antiviral medication in such cases, and that more needed to be done to raise awareness of the possibility of HSV to exclude in sepsis pathways.” Source location Response from NHS England
Open published response
Concerns raised 4 Failure to provide appropriate treatment and hospital admission for a seriously ill child View source Failure to escalate care in response to clearly expressed parental concerns about a deteriorating child View source Failure to recognise the severity of a seriously ill child’s condition View source Failure to seek or provide ready access to a second medical opinion when serious illness is disputed View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Riya HIRANI · 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
Riya Hirani, aged nine, was transferred to Great Ormond Street Hospital after presenting in cardiac arrest, having previously been assessed and discharged from Northwick Park Hospital. The concerns were that the severity of her illness was not recognised, despite her mother's repeated concerns, and that she was not given intravenous antibiotics, admitted, or escalated for a second opinion. Riya died five days after the cardiac arrest; her recorded cause of death included hypoxic ischaemic encephalopathy, out-of-hospital cardiac arrest, invasive group A streptococcal infection and influenza B infection.
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 appropriate treatment and hospital admission for a seriously ill child
Wider context from the report “Riya’s mother took her to hospital a full day before Riya’s fatal collapse, because she believed that Riya was very sick. Unfortunately, the junior doctor who examined and assessed Riya failed to appreciate the severity of her condition. Instead of giving her intravenous antibiotics and admitting her to hospital, he diagnosed a virus and discharged her with advice to take over the counter painkillers and a sheet describing the management of sore throats.
I intend to make a PFD report to the medical director of Northwick Park Hospital about the diagnosis and treatment of Riya’s condition. However, I am writing to you both because it seems to me that there is a fundamental issue regarding the lack of appropriate diagnosis and treatment that is apparent locally but relevant nationally.
When Riya’s mother took her to hospital, she did so because it seemed to her that this illness was qualitatively very different from any other that Riya had suffered in her nine years. In short, Riya’s mum was convinced that Riya was extremely ill, she articulated clearly and at every stage in hospital why she thought that Riya was extremely ill, and she even questioned the doctor about whether this could be a group A streptococcal infection. (There was a well publicised outbreak at the time and the hospital had actually received an alert about this.)
I heard at inquest that, even in the middle of the night, there was a consultant available to give a second opinion if this had been requested by medical personnel. However, no thought was given to seeking a second opinion. I think it highly likely that if it had been open to Riya’s family to seek a second opinion at that point, they would have done so without hesitation.
One of the reasons that coroners are local to an area is because this makes them better placed to recognise any local trends.
Although the events bringing the two children to hospital were very different, as I listened to the evidence at Riya’s inquest I noticed some striking similarities between the circumstances of Riya’s treatment and those of Martha Mills. On each occasion a parent’s articulately expressed and ultimately prescient concerns about a previously healthy but rapidly deteriorating child, did not result in appropriate escalation of care.
I heard the inquest touching Martha’s death last year. I am aware from press reports of the attempts of Martha’s mother to enable families in such a situation to have ready access to a second medical opinion. It seems to me that you should be aware of the circumstances of Riya’s death before you decide how to proceed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 escalate care in response to clearly expressed parental concerns about a deteriorating child
Wider context from the report “Riya’s mother took her to hospital a full day before Riya’s fatal collapse, because she believed that Riya was very sick. Unfortunately, the junior doctor who examined and assessed Riya failed to appreciate the severity of her condition. Instead of giving her intravenous antibiotics and admitting her to hospital, he diagnosed a virus and discharged her with advice to take over the counter painkillers and a sheet describing the management of sore throats.
I intend to make a PFD report to the medical director of Northwick Park Hospital about the diagnosis and treatment of Riya’s condition. However, I am writing to you both because it seems to me that there is a fundamental issue regarding the lack of appropriate diagnosis and treatment that is apparent locally but relevant nationally.
When Riya’s mother took her to hospital, she did so because it seemed to her that this illness was qualitatively very different from any other that Riya had suffered in her nine years. In short, Riya’s mum was convinced that Riya was extremely ill, she articulated clearly and at every stage in hospital why she thought that Riya was extremely ill, and she even questioned the doctor about whether this could be a group A streptococcal infection. (There was a well publicised outbreak at the time and the hospital had actually received an alert about this.)
I heard at inquest that, even in the middle of the night, there was a consultant available to give a second opinion if this had been requested by medical personnel. However, no thought was given to seeking a second opinion. I think it highly likely that if it had been open to Riya’s family to seek a second opinion at that point, they would have done so without hesitation.
One of the reasons that coroners are local to an area is because this makes them better placed to recognise any local trends.
Although the events bringing the two children to hospital were very different, as I listened to the evidence at Riya’s inquest I noticed some striking similarities between the circumstances of Riya’s treatment and those of Martha Mills. On each occasion a parent’s articulately expressed and ultimately prescient concerns about a previously healthy but rapidly deteriorating child, did not result in appropriate escalation of care .
I heard the inquest touching Martha’s death last year. I am aware from press reports of the attempts of Martha’s mother to enable families in such a situation to have ready access to a second medical opinion. It seems to me that you should be aware of the circumstances of Riya’s death before you decide how to proceed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the severity of a seriously ill child’s condition
Wider context from the report “Riya’s mother took her to hospital a full day before Riya’s fatal collapse, because she believed that Riya was very sick. Unfortunately, the junior doctor who examined and assessed Riya failed to appreciate the severity of her condition . Instead of giving her intravenous antibiotics and admitting her to hospital, he diagnosed a virus and discharged her with advice to take over the counter painkillers and a sheet describing the management of sore throats.
I intend to make a PFD report to the medical director of Northwick Park Hospital about the diagnosis and treatment of Riya’s condition. However, I am writing to you both because it seems to me that there is a fundamental issue regarding the lack of appropriate diagnosis and treatment that is apparent locally but relevant nationally.
When Riya’s mother took her to hospital, she did so because it seemed to her that this illness was qualitatively very different from any other that Riya had suffered in her nine years. In short, Riya’s mum was convinced that Riya was extremely ill, she articulated clearly and at every stage in hospital why she thought that Riya was extremely ill, and she even questioned the doctor about whether this could be a group A streptococcal infection. (There was a well publicised outbreak at the time and the hospital had actually received an alert about this.)
I heard at inquest that, even in the middle of the night, there was a consultant available to give a second opinion if this had been requested by medical personnel. However, no thought was given to seeking a second opinion. I think it highly likely that if it had been open to Riya’s family to seek a second opinion at that point, they would have done so without hesitation.
One of the reasons that coroners are local to an area is because this makes them better placed to recognise any local trends.
Although the events bringing the two children to hospital were very different, as I listened to the evidence at Riya’s inquest I noticed some striking similarities between the circumstances of Riya’s treatment and those of Martha Mills. On each occasion a parent’s articulately expressed and ultimately prescient concerns about a previously healthy but rapidly deteriorating child, did not result in appropriate escalation of care.
I heard the inquest touching Martha’s death last year. I am aware from press reports of the attempts of Martha’s mother to enable families in such a situation to have ready access to a second medical opinion. It seems to me that you should be aware of the circumstances of Riya’s death before you decide how to proceed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 or provide ready access to a second medical opinion when serious illness is disputed
Wider context from the report “Riya’s mother took her to hospital a full day before Riya’s fatal collapse, because she believed that Riya was very sick. Unfortunately, the junior doctor who examined and assessed Riya failed to appreciate the severity of her condition. Instead of giving her intravenous antibiotics and admitting her to hospital, he diagnosed a virus and discharged her with advice to take over the counter painkillers and a sheet describing the management of sore throats.
I intend to make a PFD report to the medical director of Northwick Park Hospital about the diagnosis and treatment of Riya’s condition. However, I am writing to you both because it seems to me that there is a fundamental issue regarding the lack of appropriate diagnosis and treatment that is apparent locally but relevant nationally.
When Riya’s mother took her to hospital, she did so because it seemed to her that this illness was qualitatively very different from any other that Riya had suffered in her nine years. In short, Riya’s mum was convinced that Riya was extremely ill, she articulated clearly and at every stage in hospital why she thought that Riya was extremely ill, and she even questioned the doctor about whether this could be a group A streptococcal infection. (There was a well publicised outbreak at the time and the hospital had actually received an alert about this.)
I heard at inquest that, even in the middle of the night, there was a consultant available to give a second opinion if this had been requested by medical personnel. However, no thought was given to seeking a second opinion . I think it highly likely that if it had been open to Riya’s family to seek a second opinion at that point, they would have done so without hesitation .
One of the reasons that coroners are local to an area is because this makes them better placed to recognise any local trends.
Although the events bringing the two children to hospital were very different, as I listened to the evidence at Riya’s inquest I noticed some striking similarities between the circumstances of Riya’s treatment and those of Martha Mills. On each occasion a parent’s articulately expressed and ultimately prescient concerns about a previously healthy but rapidly deteriorating child, did not result in appropriate escalation of care.
I heard the inquest touching Martha’s death last year. I am aware from press reports of the attempts of Martha’s mother to enable families in such a situation to have ready access to a second medical opinion. It seems to me that you should be aware of the circumstances of Riya’s death before you decide how to proceed.
” Open source report
Concerns raised 7 Failure to complete and store mental health unit handover records in SystmOne View source Lack of structured arrival handover and risk-history enquiry for detained patients View source Failure to securely store and share Queen Alexandra Hospital mental health records View source Failure to routinely flag patient risks in the Oceana records system View source Failure to properly record, store or audit paper observations and records View source Failure to integrate risk assessment tool outcomes into absconding-risk policies and operational requirements View source Lack of timely cross-local access to relevant electronic patient records View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jack FARRINGTON · 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
Jack Farrington, who had a long history of mental health difficulties and was detained under section 2 of the Mental Health Act, died on 2 January 2020 after running from an emergency department and falling from a road bridge. The report raised concerns about fragmented access to medical records, inadequate handovers and record keeping, insufficient flagging and assessment of absconding and self-harm risks, and the implementation of measures intended to keep him safe.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and store mental health unit handover records in SystmOne
Wider context from the report “I heard evidence that the staff within the secure mental health unit rely very heavily on information given at handovers at the start of a shift and they do not have time to review the patient records in detail. At the time of Jack’s death records of these handovers were not stored in the same way as other patient records and, in Jack’s case, were missing entirely. This significantly hampered the investigation and inquest.
I am pleased to hear that Solent NHS Trust have now changed their document storage policy in this regard and these records will now be added to and stored on SystmOne.
However the handover records are not currently completed within SystmOne . This gives rise to the continuing risk of this information not being correctly recorded or correctly stored . I understand that this requires a change to SystmOne which is not yet complete.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of structured arrival handover and risk-history enquiry for detained patients
Wider context from the report “I heard that there is no specific structure in place at Queen Alexandra Hospital Emergency Department for ensuring the full and accurate handover of information about a patient who arrives whilst subject to detention under the Mental Health Act. I heard evidence that the receiving staff are not required to ask about a patients history of absconding or self harm . This gives rise to the possibility of a patient’s risk not being properly assessed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 securely store and share Queen Alexandra Hospital mental health records
Wider context from the report “There were records kept during Jack’s presence at Queen Alexandra Hospital which were either not stored or had been lost prior to the inquest. This significantly hampered the investigation and restricted the information available to the jury.
I accept that the location of patients with mental health issues whilst awaiting transfer to a mental health unit has changed since Jack’s death. I also understand that mental health nursing records are now kept within an Enhanced Care Plan but this is still a paper format and therefore the risk of inadequate information sharing and failing to store records remain .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely flag patient risks in the Oceana records system
Wider context from the report “I heard in evidence that it is possible for patient risks to be ‘flagged’ within the Oceana records system to ensure that all staff are made aware of these. This was not done in Jack’s case and that this was not done as a matter of course , The Acting Medical Director was not aware of an established policy or procedure about using this existing functionality .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to properly record, store or audit paper observations and records
Wider context from the report “Solent NHS Trust still relies on paper forms for some observations and record keeping within the mental health unit . In Jack’s case these were not scanned and stored which hampered the investigation and inquest. There remains a risk that where paper records are kept information is not properly recorded, stored or audited .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 integrate risk assessment tool outcomes into absconding-risk policies and operational requirements
Wider context from the report “A ‘Mental Health Primary Disturbance Survey’ tool was used to assess Jack on his arrival at ED. This indicated that his risk level was ‘level 5+ black’ and this in turn set out a requirement of the mandatory presence of security guards. However when Jack absconded there was evidence that no security guards were present. There was evidence that clinicians made risk based decisions that such guards were not necessary.
However I heard evidence that the hospital board were not aware of this tool mandating a security presence and that the tool outcomes were not reflected in trust policies about the risk of absconding . The Acting Medical Director has stated that this tool requires assessment as to whether it is fit for purpose.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of timely cross-local access to relevant electronic patient records
Wider context from the report “I heard evidence that there is no systems or arrangements for the sharing of access to electronic medical records (such as SystmOne and RIO) outside of local areas and the Care and Health Information Exchange (CHIE) operating in the local area contains limited information.
I also received evidence that the new NHS England National Record Locator system only acts as a flag to show who holds records rather than allowing access to clinicians .
This fragmentation of patient records means that medical and mental health practitioners do not have quick access to relevant information about their patients .
” Open source report
Concerns raised 1 Lack of clinician awareness of the seriousness of Myasthenia Gravis and its interaction with Gentamicin 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
Graham Thomas John SMITH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Graham Smith, who had Myasthenia Gravis, was admitted with suspected biliary sepsis and a chest infection. He received Gentamicin, which was contraindicated for Myasthenia Gravis, and was not prescribed his usual Pyridostigmine; he subsequently developed a myasthenic crisis, respiratory failure and multi-organ dysfunction, and died after further deterioration. The principal concern was that insufficient awareness of Myasthenia Gravis and the interaction between Gentamicin and the condition could persist among clinicians more widely.
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 clinician awareness of the seriousness of Myasthenia Gravis and its interaction with Gentamicin
Wider context from the report “1. During the course of the inquest I heard evidence from the author of a Serious Investigation Report commissioned by the Trust (University Hospitals Birmingham) that the errors with regard to medication were, in part, due to a lack of awareness on the part of clinicians within the Trust as to the seriousness of Myasthenia Gravis as well as the interaction between Gentamicin and this condition .
2. I also heard evidence from the author of the SI report about a comprehensive action plan that is being put in place to raise awareness within the Trust including the development and issue of a Trust wide patient safety notice in relation to Antibiotic Prescribing in patients with Myasthenia Gravis.
3. However, given the apparent lack of awareness about Myasthenia Gravis amongst clinicians within UHB , a large hospital trust in a significant metropolitan area, I am concerned that there is a risk that a similar lack of awareness could persist amongst clinicians in other areas of the country and that consideration should be given to raising awareness more widely.
” Open source report
30 Aug 2023 Allison Vivian Jacome Aules · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Under-resourcing of CAMHS services View source Lack of consultant psychiatrist leadership within CAMHS teams View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Allison Vivian Jacome Aules · 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
Allison Aules was referred to a child and adolescent mental health service in May 2021 following concerns including self-harm, low mood and anxiety, but her referral was delayed and the eventual assessment was incomplete. She was discharged without a documented risk management plan, and was found suspended in her bedroom on 18 July 2022; the investigation states that she died on 19 July 2022 as a result of suicide, contributed to by neglect. The principal concerns were failings in care and the under-resourcing of CAMHS services, including delays in assessment and concern that continuing under-resourcing amid rising demand could result in similar deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Under-resourcing of CAMHS services
Wider context from the report “The Inquest identified multiple failings in the care provided to Allison. The failings occurred within a children and adolescent mental health service which was significantly under resourced .
The Inquest heard evidence that the under resourcing of CAMHS services is not confined to this local Trust but is a matter of National concern.
The under resourcing of CAMHS services contributed to delays in Allison being assessed by the mental health team. The delay between triage to assessment was 9 months. The Inquest heard evidence that this delay is not unusual within CAMHS teams across the country.
There was very little evidence of any consultant psychiatrist leadership within the CAMHS team. The Inquest heard of the difficulties in recruiting suitably qualified psychiatrists to CAMHS teams.
The Inquest heard that funding for CAMHS teams within the allocation of funding for general mental health is poor.
The Inquest heard that the number of children presenting to CAMHS teams is increasing significantly. The number of referrals of children to the local CAMHS team in the early 2010s was between 10 – 12 per week. The current number of referrals is in the region of 140 patients per week.
There is a concern that ongoing under resourcing of CAMHS services (whilst demand continues to increase) , will result in future similar 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 consultant psychiatrist leadership within CAMHS teams
Wider context from the report “The Inquest identified multiple failings in the care provided to Allison. The failings occurred within a children and adolescent mental health service which was significantly under resourced.
The Inquest heard evidence that the under resourcing of CAMHS services is not confined to this local Trust but is a matter of National concern.
The under resourcing of CAMHS services contributed to delays in Allison being assessed by the mental health team. The delay between triage to assessment was 9 months. The Inquest heard evidence that this delay is not unusual within CAMHS teams across the country.
There was very little evidence of any consultant psychiatrist leadership within the CAMHS team . The Inquest heard of the difficulties in recruiting suitably qualified psychiatrists to CAMHS teams .
The Inquest heard that funding for CAMHS teams within the allocation of funding for general mental health is poor.
The Inquest heard that the number of children presenting to CAMHS teams is increasing significantly. The number of referrals of children to the local CAMHS team in the early 2010s was between 10 – 12 per week. The current number of referrals is in the region of 140 patients per week.
There is a concern that ongoing under resourcing of CAMHS services (whilst demand continues to increase), will result in future similar deaths.
” 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 Increase investment in the children and young people’s mental health workforce to expand service capacity.
Verbatim wording from the response “Improving mental health support for children and young people is a priority for NHS England. The NHS Long Term Plan (LTP) sets an ambitious commitment that access will increase, with 345,000 more children aged 0-25 accessing support in 2023/24 compared to 2019. This commitment came with significant additional funding, rising to over £900m in 2023/24. We have made significant progress towards this commitment with 702,000 children and young people receiving support from the NHS in the 12 months to June 2023. This has been achieved through investment in the children and young people’s mental health workforce, which has increased by 46% since the start of the LTP, and by 70% since 2016.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local support provision and related actions must be addressed by the relevant local commissioners and providers.
Verbatim wording from the response “This response focuses on the national NHS England policy and programmes relevant to the matters of concern you have identified in your Report. The concerns you have raised relating to the provision of local support and the actions taken in providing that support to Allison would need to be addressed by the relevant local commissioners and providers.” 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 Delivery of expanded children’s mental health access and workforce ambitions is subject to future funding settlements.
Verbatim wording from the response “The NHS Long Term Workforce Plan (June 2023) sets out the importance of continued investment in the mental health workforce and in 2022, NHS England consulted on potential new access and waiting time standards including for children and young people’s mental health. Delivering these ambitions will be subject to future funding settlements and we will clarify plans in due course.” Source location Response from NHS England
Open published response
Concerns raised 5 Failure to identify conflicting medication concentration and specify administration volume before dispensing View source Failure to clearly record prescribed medication strength and administration volume View source Failure to produce an unambiguous medication prescription when available prescribing strengths differ View source Unavailability of an appropriate morphine strength as a prescribing choice on EMIS View source Failure of GP and pharmacist to communicate when prescription instructions are unclear or conflicting View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Juanita Boate Nti · 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
Juanita Boate Nti had complex congenital diseases and was receiving palliative care at home. She received twenty times the intended morphine dose after the prescription and symptom control plan failed to clearly specify the volume, and the prescription contained two different concentrations. She suffered respiratory arrest and died following an accidental morphine overdose, with concerns also identified about the EMIS prescribing system not offering the relevant morphine strength.
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 conflicting medication concentration and specify administration volume before dispensing
Wider context from the report “The hospital originally prescribed 120 micrograms of morphine sulphate 6 hourly and dispensed 100 micrograms per ml solution, but the strength and volume to be administered were not clearly recorded on the plan sent to the GP. The mother requested her GP by telephone to continue the prescription. The GP found only one strength of morphine on the EMIS prescription system, 10mg/5ml, confirmed to be the lowest strength available in the British National Formulary. He wrote this in the first line of the prescription and then confusingly further added “100 micrograms per ml solution, 120 micrograms 6hrly”.
The pharmacist did not notice that the second line contained a different concentration and dispensed the higher dose without stipulating the volume to be administered . The baby received 3mg instead of the intended 150 micrograms.
Whilst both GP and pharmacist made errors in clinical practice and did not contact each other, the error would not have occurred had another strength of morphine been a choice on EMIS. EMIS have been notified and placed the special prescription on its drug data base. The local commissioning group is conducting a project to identify other special prescriptions that are not on EMIS that may pose a similar risk to 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 Failure to clearly record prescribed medication strength and administration volume
Wider context from the report “The hospital originally prescribed 120 micrograms of morphine sulphate 6 hourly and dispensed 100 micrograms per ml solution, but the strength and volume to be administered were not clearly recorded on the plan sent to the GP . The mother requested her GP by telephone to continue the prescription. The GP found only one strength of morphine on the EMIS prescription system, 10mg/5ml, confirmed to be the lowest strength available in the British National Formulary. He wrote this in the first line of the prescription and then confusingly further added “100 micrograms per ml solution, 120 micrograms 6hrly”.
The pharmacist did not notice that the second line contained a different concentration and dispensed the higher dose without stipulating the volume to be administered. The baby received 3mg instead of the intended 150 micrograms.
Whilst both GP and pharmacist made errors in clinical practice and did not contact each other, the error would not have occurred had another strength of morphine been a choice on EMIS. EMIS have been notified and placed the special prescription on its drug data base. The local commissioning group is conducting a project to identify other special prescriptions that are not on EMIS that may pose a similar risk to 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 Failure to produce an unambiguous medication prescription when available prescribing strengths differ
Wider context from the report “The hospital originally prescribed 120 micrograms of morphine sulphate 6 hourly and dispensed 100 micrograms per ml solution, but the strength and volume to be administered were not clearly recorded on the plan sent to the GP. The mother requested her GP by telephone to continue the prescription. The GP found only one strength of morphine on the EMIS prescription system, 10mg/5ml, confirmed to be the lowest strength available in the British National Formulary. He wrote this in the first line of the prescription and then confusingly further added “100 micrograms per ml solution, 120 micrograms 6hrly” .
The pharmacist did not notice that the second line contained a different concentration and dispensed the higher dose without stipulating the volume to be administered. The baby received 3mg instead of the intended 150 micrograms.
Whilst both GP and pharmacist made errors in clinical practice and did not contact each other, the error would not have occurred had another strength of morphine been a choice on EMIS. EMIS have been notified and placed the special prescription on its drug data base. The local commissioning group is conducting a project to identify other special prescriptions that are not on EMIS that may pose a similar risk to 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 Unavailability of an appropriate morphine strength as a prescribing choice on EMIS
Wider context from the report “The hospital originally prescribed 120 micrograms of morphine sulphate 6 hourly and dispensed 100 micrograms per ml solution, but the strength and volume to be administered were not clearly recorded on the plan sent to the GP. The mother requested her GP by telephone to continue the prescription. The GP found only one strength of morphine on the EMIS prescription system, 10mg/5ml, confirmed to be the lowest strength available in the British National Formulary. He wrote this in the first line of the prescription and then confusingly further added “100 micrograms per ml solution, 120 micrograms 6hrly”.
The pharmacist did not notice that the second line contained a different concentration and dispensed the higher dose without stipulating the volume to be administered. The baby received 3mg instead of the intended 150 micrograms.
Whilst both GP and pharmacist made errors in clinical practice and did not contact each other, the error would not have occurred had another strength of morphine been a choice on EMIS . EMIS have been notified and placed the special prescription on its drug data base. The local commissioning group is conducting a project to identify other special prescriptions that are not on EMIS that may pose a similar risk to 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 Failure of GP and pharmacist to communicate when prescription instructions are unclear or conflicting
Wider context from the report “The hospital originally prescribed 120 micrograms of morphine sulphate 6 hourly and dispensed 100 micrograms per ml solution, but the strength and volume to be administered were not clearly recorded on the plan sent to the GP. The mother requested her GP by telephone to continue the prescription. The GP found only one strength of morphine on the EMIS prescription system, 10mg/5ml, confirmed to be the lowest strength available in the British National Formulary. He wrote this in the first line of the prescription and then confusingly further added “100 micrograms per ml solution, 120 micrograms 6hrly”.
The pharmacist did not notice that the second line contained a different concentration and dispensed the higher dose without stipulating the volume to be administered. The baby received 3mg instead of the intended 150 micrograms.
Whilst both GP and pharmacist made errors in clinical practice and did not contact each other , the error would not have occurred had another strength of morphine been a choice on EMIS. EMIS have been notified and placed the special prescription on its drug data base. The local commissioning group is conducting a project to identify other special prescriptions that are not on EMIS that may pose a similar risk to safety.
” 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 Undertake further actions and discussions after receiving the paediatric medicines review’s statement on next steps.
Verbatim wording from the response “The national Patient Safety Team at NHS England are aware of the issues and the Royal College of Paediatrics and Child Health (RCPCH) and the Neonatal and Paediatric Pharmacy Group (NPPG) Joint Medicines Committee is currently undertaking a ‘Review of the Management of the Supply of Unlicensed Liquid Medicines to Children’, which includes the workstreams referenced above. NHS England awaits a statement from the Group as to next steps later in November 2023, and further actions and discussions will then take place. We can update the Coroner once we have an update.” 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 Discuss liquid morphine safety with London ICB medication-safety representatives and provide regional oversight of action-plan implementation, including communications to GPs and community pharmacists.
Verbatim wording from the response “The London region Controlled Drugs Accountable Officer will also be discussing this issue with all London ICB medications safety representatives and ensure regional oversight of implementation of action plans which will include communications to GPs and community pharmacists.” Source location Response from NHS England
Open published response
16 Aug 2023 Devon Drew Turner · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 7 Failure to ensure that SATS machines are suitable and easy to use at home View source Failure to train parents to use the particular SATS machine brand issued View source Failure of SATS machine alarm volume to wake sleeping parents View source Failure to ensure the reliability of SATS machines sent home with vulnerable patients View source Failure of SATS machine alarms to sound reliably View source Failure to provide accurate SATS machine event data and analysis View source Failure of SATS machine alarms to remain active or sound when required View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Devon Drew Turner · 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
Devon Drew Turner, who had Mosaic Trisomy 9 and significant respiratory vulnerability, died at hospital on 10 May 2022 after being found unresponsive at home. The report raises concerns about the reliability, suitability, alarm function and data recording of SATS monitoring machines provided for use by vulnerable babies at home, including whether parents were adequately trained on the particular device supplied.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that SATS machines are suitable and easy to use at home
Wider context from the report “Matter of Concern 1:
3. On 25 April 2022 this second SATS machine, stopped working. It had some sort of error message on the screen. The parents contacted the community nurse team and Devon’s mother had to attend the hospital that night to pick up a new SATS machine.
4. Therefore the first concern is regarding the reliability of such SATS machines sent home with vulnerable patients.
5. If a safety plan is put in place which includes the use of a SATS machine to monitor the wellbeing of the patient, and that machine is less than at least 99% reliable, or has software issues, or is unsuitable for home use, or is complicated to use , this may result in a false sense of security from the family who will rely on the machine to alert them if the oxygen levels drop below a certain figure.
6. Therefore there is a risk that future deaths will occur if hospital trusts do not ensure that the SATS machines are reliable and easy to use and that parents are trained to use the particular brand they are issued with.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 train parents to use the particular SATS machine brand issued
Wider context from the report “Matter of Concern 1:
3. On 25 April 2022 this second SATS machine, stopped working. It had some sort of error message on the screen. The parents contacted the community nurse team and Devon’s mother had to attend the hospital that night to pick up a new SATS machine.
4. Therefore the first concern is regarding the reliability of such SATS machines sent home with vulnerable patients.
5. If a safety plan is put in place which includes the use of a SATS machine to monitor the wellbeing of the patient, and that machine is less than at least 99% reliable, or has software issues, or is unsuitable for home use, or is complicated to use, this may result in a false sense of security from the family who will rely on the machine to alert them if the oxygen levels drop below a certain figure.
6. Therefore there is a risk that future deaths will occur if hospital trusts do not ensure that the SATS machines are reliable and easy to use and that parents are trained to use the particular brand they are issued with .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 SATS machine alarm volume to wake sleeping parents
Wider context from the report “Matter of Concern 2:
8. The third machine was issued to the family on 25 April 2022, which remained with them until Devon’s death. It was manufactured by Medtronic (Model number MBB1920904). It is not known if this was the same brand as the second SATS machine mentioned above.
9. The concern is that this Medtronic machine was also either not functioning reliably or was not suitable for the home environment.
10. On 10 May 2022 Devon was given his 1am feed and the family settled down to sleep. At 4.30am Devon’s mother woke to find him unresponsive. The CPAP machine log confirms those two times.
11. The SATS machine was seized by the police on 10 May 2022.
12. Medtronic technician, ████████ made a statement dated 6/7/2022 which I append to this Report, in which he states that:
• The testing of the SATS machine revealed that it was functioning properly
• The data from the machine shows that from approximately 1.44am Devon’s oxygen saturations started to drop and continued to fall until approximately 2.00am when there was no pulse.
• The alarm would have been sounding throughout that time and that at the loss of pulse, at 2.00am a further alarm would have sounded.
• The machine alarm was at maximum volume
• There is a silence button on the machine but that it only silences the alarm for 60 seconds, after which interval the alarm would sound again throughout the whole period that the saturation levels were low.
13. Given the crucial role a SATS machine has in monitoring a vulnerable baby at home, with non-medically trained carers who need to sleep, there should be no doubt but that the alarm sound will sound reliably, that its volume will wake sleeping exhausted parents and should provide an accurate log of events.
14. The conclusions that the data from the SATS machine appear to provide do not accord with the other evidence provided to the inquest about the events in question. That gives cause for concern that either the analysis of the SATS machine has not been accurate or the SATS machine has not correctly recorded the data or that this SATS machine is not a suitable device for use at home.
15. For example, the community nurses would have noticed if the SATS machine was not working in the first weeks of Devon being at home and yet it has recorded that it was not used at all until 31 May 2022.
16. Secondly in order for the SATS machine data to have been correct about events of 10 May 2022, either both the parents would have had to sleep through an alarm sounding for at least 15 minutes at full volume as well as a second alarm after 15 minutes at the loss of pulse, or the parents would have had to have used the silence button on the alarm system every 60 seconds for that 15 minute period.
17. The SATS machine silence button was not within reach of Devon’s mother unless she sat up and reached up and over baby Devon in his cot. Devon’s father would have had to get out of bed altogether. A copy of the police photographs of the bedroom on 10 May 2022 is attached to this report. It is inconceivable that these concerned and careful parents, who had taken such an active role in Devon’s care, would have turned off this alarm in this way several times and failed to notice his respiratory distress, and when he was found unresponsive, would have forgotten that they had silenced the alarm in this way. Therefore either the SATS machine did not function as it should or was not sufficiently loud to wake either of these careful parents.
18. The potential for future deaths is that future parents will also rely on the SATS machine to alert them to a vulnerable child stopping breathing and taking action will not be alerted because either the alarm is too quiet , or it cuts out automatically before waking the parents, or it simply does not sound at all.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure the reliability of SATS machines sent home with vulnerable patients
Wider context from the report “Matter of Concern 1:
3. On 25 April 2022 this second SATS machine, stopped working. It had some sort of error message on the screen. The parents contacted the community nurse team and Devon’s mother had to attend the hospital that night to pick up a new SATS machine.
4. Therefore the first concern is regarding the reliability of such SATS machines sent home with vulnerable patients .
5. If a safety plan is put in place which includes the use of a SATS machine to monitor the wellbeing of the patient, and that machine is less than at least 99% reliable , or has software issues, or is unsuitable for home use, or is complicated to use, this may result in a false sense of security from the family who will rely on the machine to alert them if the oxygen levels drop below a certain figure.
6. Therefore there is a risk that future deaths will occur if hospital trusts do not ensure that the SATS machines are reliable and easy to use and that parents are trained to use the particular brand they are issued with.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 SATS machine alarms to sound reliably
Wider context from the report “Matter of Concern 2:
8. The third machine was issued to the family on 25 April 2022, which remained with them until Devon’s death. It was manufactured by Medtronic (Model number MBB1920904). It is not known if this was the same brand as the second SATS machine mentioned above.
9. The concern is that this Medtronic machine was also either not functioning reliably or was not suitable for the home environment.
10. On 10 May 2022 Devon was given his 1am feed and the family settled down to sleep. At 4.30am Devon’s mother woke to find him unresponsive. The CPAP machine log confirms those two times.
11. The SATS machine was seized by the police on 10 May 2022.
12. Medtronic technician, ████████ made a statement dated 6/7/2022 which I append to this Report, in which he states that:
• The testing of the SATS machine revealed that it was functioning properly
• The data from the machine shows that from approximately 1.44am Devon’s oxygen saturations started to drop and continued to fall until approximately 2.00am when there was no pulse.
• The alarm would have been sounding throughout that time and that at the loss of pulse, at 2.00am a further alarm would have sounded.
• The machine alarm was at maximum volume
• There is a silence button on the machine but that it only silences the alarm for 60 seconds, after which interval the alarm would sound again throughout the whole period that the saturation levels were low.
13. Given the crucial role a SATS machine has in monitoring a vulnerable baby at home, with non-medically trained carers who need to sleep, there should be no doubt but that the alarm sound will sound reliably , that its volume will wake sleeping exhausted parents and should provide an accurate log of events.
14. The conclusions that the data from the SATS machine appear to provide do not accord with the other evidence provided to the inquest about the events in question. That gives cause for concern that either the analysis of the SATS machine has not been accurate or the SATS machine has not correctly recorded the data or that this SATS machine is not a suitable device for use at home.
15. For example, the community nurses would have noticed if the SATS machine was not working in the first weeks of Devon being at home and yet it has recorded that it was not used at all until 31 May 2022.
16. Secondly in order for the SATS machine data to have been correct about events of 10 May 2022, either both the parents would have had to sleep through an alarm sounding for at least 15 minutes at full volume as well as a second alarm after 15 minutes at the loss of pulse, or the parents would have had to have used the silence button on the alarm system every 60 seconds for that 15 minute period.
17. The SATS machine silence button was not within reach of Devon’s mother unless she sat up and reached up and over baby Devon in his cot. Devon’s father would have had to get out of bed altogether. A copy of the police photographs of the bedroom on 10 May 2022 is attached to this report. It is inconceivable that these concerned and careful parents, who had taken such an active role in Devon’s care, would have turned off this alarm in this way several times and failed to notice his respiratory distress, and when he was found unresponsive, would have forgotten that they had silenced the alarm in this way. Therefore either the SATS machine did not function as it should or was not sufficiently loud to wake either of these careful parents.
18. The potential for future deaths is that future parents will also rely on the SATS machine to alert them to a vulnerable child stopping breathing and taking action will not be alerted because either the alarm is too quiet, or it cuts out automatically before waking the parents, or it simply does not sound at all.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accurate SATS machine event data and analysis
Wider context from the report “Matter of Concern 2:
8. The third machine was issued to the family on 25 April 2022, which remained with them until Devon’s death. It was manufactured by Medtronic (Model number MBB1920904). It is not known if this was the same brand as the second SATS machine mentioned above.
9. The concern is that this Medtronic machine was also either not functioning reliably or was not suitable for the home environment.
10. On 10 May 2022 Devon was given his 1am feed and the family settled down to sleep. At 4.30am Devon’s mother woke to find him unresponsive. The CPAP machine log confirms those two times.
11. The SATS machine was seized by the police on 10 May 2022.
12. Medtronic technician, ████████ made a statement dated 6/7/2022 which I append to this Report, in which he states that:
• The testing of the SATS machine revealed that it was functioning properly
• The data from the machine shows that from approximately 1.44am Devon’s oxygen saturations started to drop and continued to fall until approximately 2.00am when there was no pulse.
• The alarm would have been sounding throughout that time and that at the loss of pulse, at 2.00am a further alarm would have sounded.
• The machine alarm was at maximum volume
• There is a silence button on the machine but that it only silences the alarm for 60 seconds, after which interval the alarm would sound again throughout the whole period that the saturation levels were low.
13. Given the crucial role a SATS machine has in monitoring a vulnerable baby at home, with non-medically trained carers who need to sleep, there should be no doubt but that the alarm sound will sound reliably, that its volume will wake sleeping exhausted parents and should provide an accurate log of events .
14. The conclusions that the data from the SATS machine appear to provide do not accord with the other evidence provided to the inquest about the events in question. That gives cause for concern that either the analysis of the SATS machine has not been accurate or the SATS machine has not correctly recorded the data or that this SATS machine is not a suitable device for use at home.
15. For example, the community nurses would have noticed if the SATS machine was not working in the first weeks of Devon being at home and yet it has recorded that it was not used at all until 31 May 2022.
16. Secondly in order for the SATS machine data to have been correct about events of 10 May 2022, either both the parents would have had to sleep through an alarm sounding for at least 15 minutes at full volume as well as a second alarm after 15 minutes at the loss of pulse, or the parents would have had to have used the silence button on the alarm system every 60 seconds for that 15 minute period.
17. The SATS machine silence button was not within reach of Devon’s mother unless she sat up and reached up and over baby Devon in his cot. Devon’s father would have had to get out of bed altogether. A copy of the police photographs of the bedroom on 10 May 2022 is attached to this report. It is inconceivable that these concerned and careful parents, who had taken such an active role in Devon’s care, would have turned off this alarm in this way several times and failed to notice his respiratory distress, and when he was found unresponsive, would have forgotten that they had silenced the alarm in this way. Therefore either the SATS machine did not function as it should or was not sufficiently loud to wake either of these careful parents.
18. The potential for future deaths is that future parents will also rely on the SATS machine to alert them to a vulnerable child stopping breathing and taking action will not be alerted because either the alarm is too quiet, or it cuts out automatically before waking the parents, or it simply does not sound at all.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of SATS machine alarms to remain active or sound when required
Wider context from the report “Matter of Concern 2:
8. The third machine was issued to the family on 25 April 2022, which remained with them until Devon’s death. It was manufactured by Medtronic (Model number MBB1920904). It is not known if this was the same brand as the second SATS machine mentioned above.
9. The concern is that this Medtronic machine was also either not functioning reliably or was not suitable for the home environment.
10. On 10 May 2022 Devon was given his 1am feed and the family settled down to sleep. At 4.30am Devon’s mother woke to find him unresponsive. The CPAP machine log confirms those two times.
11. The SATS machine was seized by the police on 10 May 2022.
12. Medtronic technician, ████████ made a statement dated 6/7/2022 which I append to this Report, in which he states that:
• The testing of the SATS machine revealed that it was functioning properly
• The data from the machine shows that from approximately 1.44am Devon’s oxygen saturations started to drop and continued to fall until approximately 2.00am when there was no pulse.
• The alarm would have been sounding throughout that time and that at the loss of pulse, at 2.00am a further alarm would have sounded.
• The machine alarm was at maximum volume
• There is a silence button on the machine but that it only silences the alarm for 60 seconds, after which interval the alarm would sound again throughout the whole period that the saturation levels were low.
13. Given the crucial role a SATS machine has in monitoring a vulnerable baby at home, with non-medically trained carers who need to sleep, there should be no doubt but that the alarm sound will sound reliably, that its volume will wake sleeping exhausted parents and should provide an accurate log of events.
14. The conclusions that the data from the SATS machine appear to provide do not accord with the other evidence provided to the inquest about the events in question. That gives cause for concern that either the analysis of the SATS machine has not been accurate or the SATS machine has not correctly recorded the data or that this SATS machine is not a suitable device for use at home.
15. For example, the community nurses would have noticed if the SATS machine was not working in the first weeks of Devon being at home and yet it has recorded that it was not used at all until 31 May 2022.
16. Secondly in order for the SATS machine data to have been correct about events of 10 May 2022, either both the parents would have had to sleep through an alarm sounding for at least 15 minutes at full volume as well as a second alarm after 15 minutes at the loss of pulse, or the parents would have had to have used the silence button on the alarm system every 60 seconds for that 15 minute period.
17. The SATS machine silence button was not within reach of Devon’s mother unless she sat up and reached up and over baby Devon in his cot. Devon’s father would have had to get out of bed altogether. A copy of the police photographs of the bedroom on 10 May 2022 is attached to this report. It is inconceivable that these concerned and careful parents, who had taken such an active role in Devon’s care, would have turned off this alarm in this way several times and failed to notice his respiratory distress, and when he was found unresponsive, would have forgotten that they had silenced the alarm in this way. Therefore either the SATS machine did not function as it should or was not sufficiently loud to wake either of these careful parents.
18. The potential for future deaths is that future parents will also rely on the SATS machine to alert them to a vulnerable child stopping breathing and taking action will not be alerted because either the alarm is too quiet, or it cuts out automatically before waking the parents, or it simply does not sound at all .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There are no known patient-safety issues relating generally to SATS machine alarms, and no similar incidents are known.
Verbatim wording from the response “On receipt of your Report, it was shared with colleagues from NHS England’s central Patient Safety (including medical device specialists) and Children & Young People teams as well as my regional Quality colleagues in the South East. The Patient Safety Team reviewed the concerns raised and have confirmed that they are not aware of similar incidents and that there are no known patient safety issues relating to SATS machine alarms in general.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The device specification, alarm settings, home suitability and functioning fall outside NHS England’s remit and within MHRA’s regulatory remit.
Verbatim wording from the response “From your Report the underlying issue relates to the specification of the SATS machine used, its alarm settings and volume, whether it was suitable for use in a patient’s home and whether the machine in this case was working properly. These issues would fall under the remit of the Medicines and Healthcare products Regulatory Agency (MHRA), who are the regulator for all medical devices in the UK, who I note that you have also addressed your concerns to.” 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 MHRA is responsible for investigating the monitor concerns and ensuring that any identified actions are undertaken.
Verbatim wording from the response “From your Report the underlying issue relates to the specification of the SATS machine used, its alarm settings and volume, whether it was suitable for use in a patient’s home and whether the machine in this case was working properly. These issues would fall under the remit of the Medicines and Healthcare products Regulatory Agency (MHRA), who are the regulator for all medical devices in the UK, who I note that you have also addressed your concerns to.” Source location Response from NHS England
Open published response
Concerns raised 2 Failure to provide recommendations for discussing anticoagulation withholding risks and benefits with patients View source Lack of national guidance on when to recommence anticoagulation after traumatic head injury View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jeffrey MARSHALL · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jeffrey Marshall died at St Peter’s Hospital in Chertsey on 13 December 2023 after suffering an ischaemic stroke caused by thrombosis of the basilar artery, following a fall and subdural haematoma. His anticoagulation had been withheld for 47 days. The principal concern was the lack of national guidance on when to recommence anticoagulation after a head injury and the lack of guidance on discussing the risks and benefits of withholding it with patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide recommendations for discussing anticoagulation withholding risks and benefits with patients
Wider context from the report “- Mr Marshall was prescribed anticoagulation (Edoxaban) to mitigate his increased risk of developing thrombus due to atrial fibrillation and a permanent pacemaker;
- Anticoagulation was withheld following a traumatic head injury, in accordance with NICE guidance;
- There is no national guidance to assist clinicians in determining when anticoagulation should be recommenced in this scenario, nor any recommendation for clinicians to discuss the risks and benefits of withholding anticoagulation with patients to enable them to make an informed decision as to when to recommence anticoagulation .
Consideration should be given to whether any steps can be taken to address the above concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on when to recommence anticoagulation after traumatic head injury
Wider context from the report “- Mr Marshall was prescribed anticoagulation (Edoxaban) to mitigate his increased risk of developing thrombus due to atrial fibrillation and a permanent pacemaker;
- Anticoagulation was withheld following a traumatic head injury, in accordance with NICE guidance;
- There is no national guidance to assist clinicians in determining when anticoagulation should be recommenced in this scenario , nor any recommendation for clinicians to discuss the risks and benefits of withholding anticoagulation with patients to enable them to make an informed decision as to when to recommence anticoagulation.
Consideration should be given to whether any steps can be taken to address the above concerns.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review NICE’s response and consider whether NHS England must take resultant action.
Verbatim wording from the response “I note, in addition to NHS England, that your Report has been addressed to the National Institute for Health and Care Excellence (NICE). They are the appropriate organisation to respond to the Coroner’s concerns, as the provider of the relevant clinical guidance. NHS England will carefully review NICE’s response to the Coroner in due course, and consider whether any resultant actions are required from us.” 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 Individualised risk-benefit decisions may make it challenging to produce specific guidance on restarting anticoagulation after traumatic head injury.
Verbatim wording from the response “It should however be noted that there will need to be a significant degree of individualised care and decision-making in cases such as Jeffrey’s. There will need to be careful consideration of the risks of atrial fibrillation stroke versus the risk of precipitating bleeding (dependent on different patient factors), and that this could provide challenge to producing specific guidance on this issue.” 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 NICE, as the provider of relevant clinical guidance, is the appropriate organisation to respond to concerns about anticoagulation guidance.
Verbatim wording from the response “I note, in addition to NHS England, that your Report has been addressed to the National Institute for Health and Care Excellence (NICE). They are the appropriate organisation to respond to the Coroner’s concerns, as the provider of the relevant clinical guidance. NHS England will carefully review NICE’s response to the Coroner in due course, and consider whether any resultant actions are required from us.” Source location Response from NHS England
Open published response
Concerns raised 2 Failure to provide clear and consistent guidance when applying the Kaiser Permanente Score and NICE guidance View source Failure to use the Kaiser Permanente Score as part of an overall assessment of the patient 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
Baby Isabela Suciu · 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
Baby Isabela Suciu was born in hospital and later suffered a cardiac arrest at home after feeding; she did not regain consciousness and died in hospital. Concerns included the failure to escalate low temperatures for paediatric review or start antibiotics, amid conflicting Kaiser Permanente and NICE guidance. The report identified a continuing risk of confusion and avoidable delay in other neonatal units, although the omission was not shown to have caused Isabela’s death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear and consistent guidance when applying the Kaiser Permanente Score and NICE guidance
Wider context from the report “If the Newborn Early Warning Trigger and Track score had been followed the hypothermia would have triggered escalation by the midwife to paediatricians at 02.00 when the temperature was 36.3. Paediatrician ████████, advised that the KP score would not alter then, but at 06.20, the temperature of 36.2 should have triggered starting antibiotics. There was agreement amongst experts that antibiotics should have been started at 06.20 on 3rd of November. It is accepted by the doctors and Trust that this should have happened and did not because of conflict between the Kaiser Permanente Score and the NICE guidance. Whilst this omission was not shown to have caused Isabela’s death, it creates a possible risk for other hospitals using the KP scale.
Expert microbiologist ███████████ informed the court that it was not that the KP scale was inferior to NICE recommendations, but rather that there is a risk as the threshold for antibiotics is different, that doctors will think the KP score is gospel and not look at the patient as a whole and therefore miss clinical signs which should trigger starting antibiotics.
████████████████, consultant neonatology expert opined that the evidence for the use of KP pathway was thin, and it was better to follow NICE guidance as KP should only be used as part of an overall assessment. Expert neonatologist █████████████ agreed saying that the use of two guidelines was confusing .
████████ expert opinion was that there was a risk of deaths in other neonatal units and that the expert was not sure how well known the differences and apparent conflict in applying the guidelines was known. The Trust have taken a number of steps to address the risk, but there appears to remain the opportunity for confusion as the revised Newborn Early Warning Trigger and Track score indicates a different response from KP, when late onset symptoms occur after an asymptomatic period, creating a risk of avoidable delay .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to use the Kaiser Permanente Score as part of an overall assessment of the patient
Wider context from the report “If the Newborn Early Warning Trigger and Track score had been followed the hypothermia would have triggered escalation by the midwife to paediatricians at 02.00 when the temperature was 36.3. Paediatrician ████████, advised that the KP score would not alter then, but at 06.20, the temperature of 36.2 should have triggered starting antibiotics. There was agreement amongst experts that antibiotics should have been started at 06.20 on 3rd of November. It is accepted by the doctors and Trust that this should have happened and did not because of conflict between the Kaiser Permanente Score and the NICE guidance. Whilst this omission was not shown to have caused Isabela’s death, it creates a possible risk for other hospitals using the KP scale.
Expert microbiologist ███████████ informed the court that it was not that the KP scale was inferior to NICE recommendations, but rather that there is a risk as the threshold for antibiotics is different, that doctors will think the KP score is gospel and not look at the patient as a whole and therefore miss clinical signs which should trigger starting antibiotics.
████████████████, consultant neonatology expert opined that the evidence for the use of KP pathway was thin, and it was better to follow NICE guidance as KP should only be used as part of an overall assessment . Expert neonatologist █████████████ agreed saying that the use of two guidelines was confusing.
████████ expert opinion was that there was a risk of deaths in other neonatal units and that the expert was not sure how well known the differences and apparent conflict in applying the guidelines was known. The Trust have taken a number of steps to address the risk, but there appears to remain the opportunity for confusion as the revised Newborn Early Warning Trigger and Track score indicates a different response from KP, when late onset symptoms occur after an asymptomatic period, creating a risk of avoidable delay.
” Open source report
9 Aug 2023 Rohan GODHANIA · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 3 Lack of guidance for testing ammonia levels in patients presenting in extremis with an unknown cause View source Lack of clarity and consistent guidance for classifying teenagers aged 16-18 as paediatric patients or adults View source Failure of high-protein supplement and drink labels to provide adequate warnings and safety information for people with urea cycle disorders View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rohan GODHANIA · 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
Rohan GODHANIA became unwell after consuming a high-protein drink on 15 August 2020, was admitted to hospital, and died on 18 August 2020 from Ornithine Transcarbamylase Deficiency. The report identifies concerns about inconsistent NHS classification of teenagers aged 16–18 and a lack of emergency-department guidance on ammonia testing for patients presenting in extremis with an unknown cause.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for testing ammonia levels in patients presenting in extremis with an unknown cause
Wider context from the report “2. Guidance for Testing for Ammonia in Emergency Departments
The other concerning issue that requires immediate attention is the lack of guidance for testing ammonia levels in patients who present in extremis with an unknown cause . Timely and accurate diagnosis is essential in such cases to ensure appropriate treatment and prevent unnecessary deaths. The guideline should include clear protocols for conducting ammonia tests, interpreting the results and making informed clinical decisions based on the findings. The guidance should be disseminated to all emergency departments and healthcare facilities.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 and consistent guidance for classifying teenagers aged 16-18 as paediatric patients or adults
Wider context from the report “1. Age classification of Teenagers 16-18 within the NHS
There seems to be a lack of clarity and consistent guidance across the NHS regarding the appropriate classification of teenagers aged 16-18. The question of whether they should be treated as paediatric patients or adults is leading to confusion and potential disparities in the care provided. I consider that this should be urgently reviewed by NHS England and if necessary the guidance on age classification updated ensuring that all healthcare providers adhere to a unified approach emphasising the importance of consistent and appropriate care for this age group.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 high-protein supplement and drink labels to provide adequate warnings and safety information for people with urea cycle disorders
Wider context from the report “High protein supplements and drinks are easily accessible to the general public, yet their labels fail to adequately inform consumers about the potential dangers posed to individuals with urea cycle disorders, such as Ornithine Transcarbamylase (OTC) deficiency . This genetic disorder can lead to severe medical emergencies, requiring immediate medical intervention to prevent life-threatening complications. This disorder can be triggered by the sudden increased ingestion of protein.
Consideration should be given as to whether the labels should prominently display a warning about the potential risks for individuals with an undiagnosed urea cycle disorder and include clear and concise information on symptoms of this and the importance of seeking immediate medical advice .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a Patient Safety Bulletin highlighting prompt ammonia measurement and action when hyperammonaemia is identified.
Verbatim wording from the response “NHS England’s National Patient Safety Team have also undertaken work with the Royal College of Pathologists (RCPath) on the specific issue of hyperammonaemia and ammonia testing. As a result of this a Patient Safety Bulletin was issued. This highlighted the need for ‘prompt measurement of ammonia and action in the event of hyperammonaemia’.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop guidance supporting consistent, age-appropriate transition pathways and defining core staff capabilities within a 0–25 care model.
Verbatim wording from the response “NHS England’s Children and Young People’s Transformation Programme, working with key stakeholders, are developing guidance to aid the design of transition pathways that improve health outcomes for all young people. The support package will outline key principles of a 0 – 25 model of care and the core capabilities of staff” 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 Move toward a person-centred 0–25 service model for young people’s mental and physical healthcare.
Verbatim wording from the response “Most children’s hospitals/departments are not commissioned to provide secondary and tertiary services for young people over the age of 16, with the exception of some rare cancers and those over this age are therefore often treated as adult patients. To improve young people’s experience of care, outcomes and continuity of care, NHS England are committed to moving to a ‘0-25 year service model’, offering person-centred and age-appropriate care for mental and physical health needs, rather than arbitrary transitions to adult services based on age and not need. We recognise that healthcare transition should be need and complexity based, not managed solely on diagnosis or what is routinely provided.” 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 Concerns about ammonia-testing guidance should be referred to the Royal Colleges.
Verbatim wording from the response “NHS England would not be the lead organisation for the relevant clinical guidance, and you may wish to refer your concerns to the Royal Colleges. NHS England has, however, engaged with the Royal College of Emergency Medicine (RCEM) on this case, and they have advised that they will be making an amendment to their existing Acute Behavioural Disturbance guidelines to specifically mention ammonia levels, should a clinician be considering the need for a metabolic screen.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is not the lead organisation for developing guidance on ammonia testing in emergency departments.
Verbatim wording from the response “NHS England would not be the lead organisation for the relevant clinical guidance, and you may wish to refer your concerns to the Royal Colleges. NHS England has, however, engaged with the Royal College of Emergency Medicine (RCEM) on this case, and they have advised that they will be making an amendment to their existing Acute Behavioural Disturbance guidelines to specifically mention ammonia levels, should a clinician be considering the need for a metabolic screen.” Source location Response from NHS England
Open published response
Concerns raised 5 Lack of national guidance for placement of nasogastric decompression tubes View source Lack of instructions for inserting and confirming placement of nasogastric decompression tubes View source Risk of nasogastric decompression tube misplacement into the lung View source Failure to provide protocols for checking placement of nasogastric decompression tubes View source Lack of training for insertion of nasogastric decompression tubes 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
Reginald Edwin Bourn · 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
Reginald Edwin Bourn was admitted to hospital with an intestinal blockage and required a nasogastric decompression tube. The replacement tube was misplaced into his left lung, after which he aspirated gastrointestinal contents and died. The report raised concerns about the absence of national guidance, protocols and training for inserting and confirming the placement of nasogastric decompression tubes.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for placement of nasogastric decompression tubes
Wider context from the report “1. The expert and clinical evidence was that the insertion of any nasogastric tube is complicated and misplacement into a lung can occur because of the proximity of the trachea to the oesophagus.
2. Examples of nasogastric decompression tubes and nasogastric feeding tubes were provided in evidence. The feeding tubes have instructions both as to how to insert them and as to how to ensure that they are correctly placed. Decompression tubes have neither.
3. The expert evidence was that there is national guidance in relation to the placement of nasogastric feeding tubes but not nasogastric decompression tubes . However, as exemplified by this case, misplacement of either can prove fatal.
4. The clinicians who investigated the death could not find any nationally recognised protocols dealing with the use of, and training on the insertion of, nasogastric decompression tubes nor for checking whether they are appropriately placed.
5. The Healthcare Safety Investigation Branch independent report 12019/006 made recommendations in December 2020 on the placement of feeding nasogastric tubes. It found that the use of pH strips is potentially unreliable and incorrect X ray confirmation and interpretation is the most common cause of misplacement incidents.
6. One of the recommendations made was for a national standardised competency-based training programme for nasogastric tube placement and confirmation by pH testing.
7. It appears that there is no suggested training nor national guidance in relation the placement of nasogastric decompression tubes .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 instructions for inserting and confirming placement of nasogastric decompression tubes
Wider context from the report “1. The expert and clinical evidence was that the insertion of any nasogastric tube is complicated and misplacement into a lung can occur because of the proximity of the trachea to the oesophagus.
2. Examples of nasogastric decompression tubes and nasogastric feeding tubes were provided in evidence. The feeding tubes have instructions both as to how to insert them and as to how to ensure that they are correctly placed. Decompression tubes have neither .
3. The expert evidence was that there is national guidance in relation to the placement of nasogastric feeding tubes but not nasogastric decompression tubes. However, as exemplified by this case, misplacement of either can prove fatal.
4. The clinicians who investigated the death could not find any nationally recognised protocols dealing with the use of, and training on the insertion of, nasogastric decompression tubes nor for checking whether they are appropriately placed.
5. The Healthcare Safety Investigation Branch independent report 12019/006 made recommendations in December 2020 on the placement of feeding nasogastric tubes. It found that the use of pH strips is potentially unreliable and incorrect X ray confirmation and interpretation is the most common cause of misplacement incidents.
6. One of the recommendations made was for a national standardised competency-based training programme for nasogastric tube placement and confirmation by pH testing.
7. It appears that there is no suggested training nor national guidance in relation the placement of nasogastric decompression tubes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Risk of nasogastric decompression tube misplacement into the lung
Wider context from the report “1. The expert and clinical evidence was that the insertion of any nasogastric tube is complicated and misplacement into a lung can occur because of the proximity of the trachea to the oesophagus.
2. Examples of nasogastric decompression tubes and nasogastric feeding tubes were provided in evidence. The feeding tubes have instructions both as to how to insert them and as to how to ensure that they are correctly placed. Decompression tubes have neither.
3. The expert evidence was that there is national guidance in relation to the placement of nasogastric feeding tubes but not nasogastric decompression tubes. However, as exemplified by this case, misplacement of either can prove fatal .
4. The clinicians who investigated the death could not find any nationally recognised protocols dealing with the use of, and training on the insertion of, nasogastric decompression tubes nor for checking whether they are appropriately placed.
5. The Healthcare Safety Investigation Branch independent report 12019/006 made recommendations in December 2020 on the placement of feeding nasogastric tubes. It found that the use of pH strips is potentially unreliable and incorrect X ray confirmation and interpretation is the most common cause of misplacement incidents.
6. One of the recommendations made was for a national standardised competency-based training programme for nasogastric tube placement and confirmation by pH testing.
7. It appears that there is no suggested training nor national guidance in relation the placement of nasogastric decompression tubes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 protocols for checking placement of nasogastric decompression tubes
Wider context from the report “1. The expert and clinical evidence was that the insertion of any nasogastric tube is complicated and misplacement into a lung can occur because of the proximity of the trachea to the oesophagus.
2. Examples of nasogastric decompression tubes and nasogastric feeding tubes were provided in evidence. The feeding tubes have instructions both as to how to insert them and as to how to ensure that they are correctly placed. Decompression tubes have neither.
3. The expert evidence was that there is national guidance in relation to the placement of nasogastric feeding tubes but not nasogastric decompression tubes. However, as exemplified by this case, misplacement of either can prove fatal.
4. The clinicians who investigated the death could not find any nationally recognised protocols dealing with the use of, and training on the insertion of, nasogastric decompression tubes nor for checking whether they are appropriately placed .
5. The Healthcare Safety Investigation Branch independent report 12019/006 made recommendations in December 2020 on the placement of feeding nasogastric tubes. It found that the use of pH strips is potentially unreliable and incorrect X ray confirmation and interpretation is the most common cause of misplacement incidents.
6. One of the recommendations made was for a national standardised competency-based training programme for nasogastric tube placement and confirmation by pH testing.
7. It appears that there is no suggested training nor national guidance in relation the placement of nasogastric decompression tubes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of training for insertion of nasogastric decompression tubes
Wider context from the report “1. The expert and clinical evidence was that the insertion of any nasogastric tube is complicated and misplacement into a lung can occur because of the proximity of the trachea to the oesophagus.
2. Examples of nasogastric decompression tubes and nasogastric feeding tubes were provided in evidence. The feeding tubes have instructions both as to how to insert them and as to how to ensure that they are correctly placed. Decompression tubes have neither.
3. The expert evidence was that there is national guidance in relation to the placement of nasogastric feeding tubes but not nasogastric decompression tubes. However, as exemplified by this case, misplacement of either can prove fatal.
4. The clinicians who investigated the death could not find any nationally recognised protocols dealing with the use of, and training on the insertion of, nasogastric decompression tubes nor for checking whether they are appropriately placed.
5. The Healthcare Safety Investigation Branch independent report 12019/006 made recommendations in December 2020 on the placement of feeding nasogastric tubes. It found that the use of pH strips is potentially unreliable and incorrect X ray confirmation and interpretation is the most common cause of misplacement incidents.
6. One of the recommendations made was for a national standardised competency-based training programme for nasogastric tube placement and confirmation by pH testing.
7. It appears that there is no suggested training nor national guidance in relation the placement of nasogastric decompression tubes .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A national training programme for nasogastric tube insertion falls outside NHS England’s remit.
Verbatim wording from the response “As to national training provisions around insertion of nasogastric tubes, I asked my colleagues from the national Workforce, Training and Education (WTE) Directorate at NHS England to consider your Report and the concerns raised. They advised that such a training programme would not come under NHS England’s remit. Individual NHS Trusts are responsible for the implementation of locally recommended practice and protocols, including the staffing and availability of workforce. You may wish to engage with Firmley Health NHS Foundation Trust for further information on their specific practice and protocols regarding placement of nasogastric tubes.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing Royal Marsden Manual guidance is considered sufficient, so NHS England would not routinely provide national guidance on nasogastric tube insertion.
Verbatim wording from the response “Whilst NHS England would not routinely provide national guidance on the insertion of nasogastric decompression tubes, there is existing national guidance in the form of the Royal Marsden Manual, who have particular expertise in this area. The manual has a section on ‘Insertion of a nasogastric drainage tube’ which contains background information and specific procedural guidance for the insertion and removal of these tubes, including around pH testing. This is aimed at clinical nursing staff who would routinely be the staff responsible for placing nasogastric tubes in patients. The Manual is a well-known guide for nurses to deliver clinically effective, patient-focused, and evidence-based care.” 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 NICE is the statutory body responsible for developing and disseminating clinical guidance on nasogastric tube placement and confirmation.
Verbatim wording from the response “The National Institute of Health and Care Excellence (NICE) are the statutory body who lead on developing and disseminating clinical guidance and I note that you have also sent your Report to them. NHS England will carefully consider NICE’s response to you and any actions that may be required from us as a result.” Source location Response from NHS England
Open published response
2 Aug 2023 Dumile Daniel Thompson · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 5 Failure to highlight the preferred ARB recommendation for patients of Black African or African Caribbean origin in the BNF View source Failure to publish the increased ACE inhibitor angioedema risk for people of Black African or African Caribbean origin in the BNF View source Lack of frontline emergency staff training on angioedema types, risks and divergent treatment pathways View source Absence of NICE emergency management guidance or clinical knowledge summary for angioedema View source Failure to make previous medical records available to clinicians in different geographical areas or Trusts View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Dumile Daniel Thompson · 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
Dumile Daniel Thompson developed Ramipril-induced angioedema, deteriorated after an apparent initial improvement, suffered respiratory collapse causing catastrophic brain injury, and died several days later after life support was withdrawn. The principal concerns included inadequate recognition of the risks and trajectory of ACE inhibitor-induced angioedema, insufficient specialist airway reassessment and monitoring, lack of relevant guidance and training, and limited access to previous medical records affecting medication decisions.
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 highlight the preferred ARB recommendation for patients of Black African or African Caribbean origin in the BNF
Wider context from the report “The evidence, including that of Independent experts in Immunology and Adult Critical Care and Anaesthetics, highlighted that:
• National Guidance and training for front line/emergency staff did not, and still does not include specifics about the various types of angioedema (histamine/bradykinin mediated), the risk factors, and the diverging treatment pathways, including the need for specialty medicine input with certain types of angioedema.
• NICE does not currently publish guidance or a clinical knowledge summary on emergency management of angioedema.
• Those treating Mr Thompson on 23 October 2020 in the A&E department were therefore not aware of the complexity and fickle nature of ACE Induced angioedema, including the potential speed of deterioration in symptoms, even after what appeared to be initial improvement.
• ACE Inhibitor angioedema is more common, up to four to five times more, in individuals of Black African or African Caribbean origin. This increased risk factor is not published in the BNF.
• The NICE recommendation about using ARB as the preferred choice of medication in patients of Black African or African Caribbean origin is not highlighted in BNF , notwithstanding the BNF is the go-to source for medication management, contraindications, and cautions.
It also came to light that Mr Thompson had transferred geographical areas such that clinicians were unable to access his previous medical records to determine why ARB’s, an alternative to ACE Inhibitors, had been preferred by clinicians on a previous occasion. His now treating clinicians were unable to access this information because such records are not readily available to, or shared with, clinicians in a different area/Trust. The reason for this is not entirely clear and was thought to be related to data protection though there is nothing to suggest Mr Thompson withheld his consent, or would have done so.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 publish the increased ACE inhibitor angioedema risk for people of Black African or African Caribbean origin in the BNF
Wider context from the report “The evidence, including that of Independent experts in Immunology and Adult Critical Care and Anaesthetics, highlighted that:
• National Guidance and training for front line/emergency staff did not, and still does not include specifics about the various types of angioedema (histamine/bradykinin mediated), the risk factors, and the diverging treatment pathways, including the need for specialty medicine input with certain types of angioedema.
• NICE does not currently publish guidance or a clinical knowledge summary on emergency management of angioedema.
• Those treating Mr Thompson on 23 October 2020 in the A&E department were therefore not aware of the complexity and fickle nature of ACE Induced angioedema, including the potential speed of deterioration in symptoms, even after what appeared to be initial improvement.
• ACE Inhibitor angioedema is more common, up to four to five times more, in individuals of Black African or African Caribbean origin. This increased risk factor is not published in the BNF.
• The NICE recommendation about using ARB as the preferred choice of medication in patients of Black African or African Caribbean origin is not highlighted in BNF, notwithstanding the BNF is the go-to source for medication management, contraindications, and cautions.
It also came to light that Mr Thompson had transferred geographical areas such that clinicians were unable to access his previous medical records to determine why ARB’s, an alternative to ACE Inhibitors, had been preferred by clinicians on a previous occasion. His now treating clinicians were unable to access this information because such records are not readily available to, or shared with, clinicians in a different area/Trust. The reason for this is not entirely clear and was thought to be related to data protection though there is nothing to suggest Mr Thompson withheld his consent, or would have done so.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 frontline emergency staff training on angioedema types, risks and divergent treatment pathways
Wider context from the report “The evidence, including that of Independent experts in Immunology and Adult Critical Care and Anaesthetics, highlighted that:
• National Guidance and training for front line/emergency staff did not, and still does not include specifics about the various types of angioedema (histamine/bradykinin mediated), the risk factors, and the diverging treatment pathways, including the need for specialty medicine input with certain types of angioedema.
• NICE does not currently publish guidance or a clinical knowledge summary on emergency management of angioedema.
• Those treating Mr Thompson on 23 October 2020 in the A&E department were therefore not aware of the complexity and fickle nature of ACE Induced angioedema, including the potential speed of deterioration in symptoms, even after what appeared to be initial improvement.
• ACE Inhibitor angioedema is more common, up to four to five times more, in individuals of Black African or African Caribbean origin. This increased risk factor is not published in the BNF.
• The NICE recommendation about using ARB as the preferred choice of medication in patients of Black African or African Caribbean origin is not highlighted in BNF, notwithstanding the BNF is the go-to source for medication management, contraindications, and cautions.
It also came to light that Mr Thompson had transferred geographical areas such that clinicians were unable to access his previous medical records to determine why ARB’s, an alternative to ACE Inhibitors, had been preferred by clinicians on a previous occasion. His now treating clinicians were unable to access this information because such records are not readily available to, or shared with, clinicians in a different area/Trust. The reason for this is not entirely clear and was thought to be related to data protection though there is nothing to suggest Mr Thompson withheld his consent, or would have done so.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 NICE emergency management guidance or clinical knowledge summary for angioedema
Wider context from the report “The evidence, including that of Independent experts in Immunology and Adult Critical Care and Anaesthetics, highlighted that:
• National Guidance and training for front line/emergency staff did not, and still does not include specifics about the various types of angioedema (histamine/bradykinin mediated), the risk factors, and the diverging treatment pathways, including the need for specialty medicine input with certain types of angioedema.
• NICE does not currently publish guidance or a clinical knowledge summary on emergency management of angioedema.
• Those treating Mr Thompson on 23 October 2020 in the A&E department were therefore not aware of the complexity and fickle nature of ACE Induced angioedema, including the potential speed of deterioration in symptoms, even after what appeared to be initial improvement.
• ACE Inhibitor angioedema is more common, up to four to five times more, in individuals of Black African or African Caribbean origin. This increased risk factor is not published in the BNF.
• The NICE recommendation about using ARB as the preferred choice of medication in patients of Black African or African Caribbean origin is not highlighted in BNF, notwithstanding the BNF is the go-to source for medication management, contraindications, and cautions.
It also came to light that Mr Thompson had transferred geographical areas such that clinicians were unable to access his previous medical records to determine why ARB’s, an alternative to ACE Inhibitors, had been preferred by clinicians on a previous occasion. His now treating clinicians were unable to access this information because such records are not readily available to, or shared with, clinicians in a different area/Trust. The reason for this is not entirely clear and was thought to be related to data protection though there is nothing to suggest Mr Thompson withheld his consent, or would have done so.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to make previous medical records available to clinicians in different geographical areas or Trusts
Wider context from the report “The evidence, including that of Independent experts in Immunology and Adult Critical Care and Anaesthetics, highlighted that:
• National Guidance and training for front line/emergency staff did not, and still does not include specifics about the various types of angioedema (histamine/bradykinin mediated), the risk factors, and the diverging treatment pathways, including the need for specialty medicine input with certain types of angioedema.
• NICE does not currently publish guidance or a clinical knowledge summary on emergency management of angioedema.
• Those treating Mr Thompson on 23 October 2020 in the A&E department were therefore not aware of the complexity and fickle nature of ACE Induced angioedema, including the potential speed of deterioration in symptoms, even after what appeared to be initial improvement.
• ACE Inhibitor angioedema is more common, up to four to five times more, in individuals of Black African or African Caribbean origin. This increased risk factor is not published in the BNF.
• The NICE recommendation about using ARB as the preferred choice of medication in patients of Black African or African Caribbean origin is not highlighted in BNF, notwithstanding the BNF is the go-to source for medication management, contraindications, and cautions.
It also came to light that Mr Thompson had transferred geographical areas such that clinicians were unable to access his previous medical records to determine why ARB’s, an alternative to ACE Inhibitors, had been preferred by clinicians on a previous occasion. His now treating clinicians were unable to access this information because such records are not readily available to, or shared with, clinicians in a different area/Trust. The reason for this is not entirely clear and was thought to be related to data protection though there is nothing to suggest Mr Thompson withheld his consent, or would have done so.
” Open source report
Concerns raised 3 Delays in hospital handover reducing ambulance availability View source Failure to provide timely category 2 ambulance responses View source Failure by NHS Trusts to understand and embed image-reporting guidance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lee Dryden · 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
Lee Dryden had a displaced tracheotomy tube associated with emphysema, and critical scan findings on 15 December 2021 were not followed by successful contact or timely review. He suffered a cardiac arrest on 16 December 2021, resulting in a hypoxic brain injury, and died on 12 January 2022. The principal concerns were failures in communicating and acting on critical imaging findings and the delayed ambulance response to his mother's call.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in hospital handover reducing ambulance availability
Wider context from the report “2. The Ambulance Service graded Lee's mother's call to them on the 15th December 2021 as a category 2 call which has two targets as described in evidence, the first being a response time of 20 minutes call time and that 9 out of 10 calls would be responded to within 40 minutes. Yorkshire Ambulance Service were unable to respond to Lee's call until 2 hours and 26 minutes had passed. Yorkshire Ambulance Service were on their highest level of escalation at that time with significant delays at hospital handover caused or contributed to the delay in an ambulance being available to Lee .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 timely category 2 ambulance responses
Wider context from the report “2. The Ambulance Service graded Lee's mother's call to them on the 15th December 2021 as a category 2 call which has two targets as described in evidence, the first being a response time of 20 minutes call time and that 9 out of 10 calls would be responded to within 40 minutes. Yorkshire Ambulance Service were unable to respond to Lee's call until 2 hours and 26 minutes had passed . Yorkshire Ambulance Service were on their highest level of escalation at that time with significant delays at hospital handover caused or contributed to the delay in an ambulance being available to Lee.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 by NHS Trusts to understand and embed image-reporting guidance
Wider context from the report “1. There is Royal College Guidance as to how and by what means the images are reported from external organisations such as Medical Alliance to NHS Trusts however this appears to not be understood or embedded by NHS Trusts .
” 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 Improve ambulance response times for Category 2 incidents.
Verbatim wording from the response “NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic. That is why NHS England are focusing on improving ambulance performance for 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, published in January 2023. The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care services, including improving ambulance response times for Category 2 incidents, increasing ambulance capacity through growing the workforce, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase ambulance capacity by growing the workforce.
Verbatim wording from the response “NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic. That is why NHS England are focusing on improving ambulance performance for 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, published in January 2023. The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care services, including improving ambulance response times for Category 2 incidents, increasing ambulance capacity through growing the workforce, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.” 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 Speed up hospital discharges to support urgent and emergency care recovery.
Verbatim wording from the response “NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic. That is why NHS England are focusing on improving ambulance performance for 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, published in January 2023. The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care services, including improving ambulance response times for Category 2 incidents, increasing ambulance capacity through growing the workforce, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.” 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 Seek assurance from regional systems that national imaging-reporting guidance is being followed.
Verbatim wording from the response “My North East & Yorkshire (NEY) regional colleagues have also advised that they have gone out to all NEY systems for assurance that national guidance is being followed around image reporting. Systems bring together NHS organisations, local authorities and others to take collective responsibility for health and care planning services across geographical areas.” 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 Host a national webinar and make imaging-report notification guidance available to NHS staff through the Futures platform.
Verbatim wording from the response “• NHS England hosted a national webinar on 7th March 2023 with the inclusion of the above delivered by the RCR for NHS services. This guidance is also available on the NHS England Futures website, a virtual collaboration platform for NHS staff members to make change, improve and transform health and social care.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Highlight fail-safe imaging-report notification recommendations and related investigation findings in the national Patient Safety bulletin.
Verbatim wording from the response “• The Academy of Medical Royal Colleges (AoMRC) published a report on ‘Alerts and notification of imaging reports – Recommendations’ which include recommendations on fail-safe notification systems. This was highlighted by NHS England in the January 2023 national Patient Safety bulletin and followed a report from the Healthcare Safety Investigation Branch (HSIB): Failures in communication or follow-up of unexpected significant radiological findings.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish operational-resilience guidance focused on improving accident-and-emergency and ambulance handover times.
Verbatim wording from the response “In July 2023, we also published a letter to Integrated Care Boards, NHS Trusts and Primary Care Networks title Delivering operational resilience across the NHS this winter. This included focusing on improvements around Accident & Emergency handover and ambulance handover times.” Source location Response from NHS England
Open published response
Concerns raised 8 Unavailability of affordable NHS ADHD services View source Failure to communicate effectively with and listen meaningfully to families of patients with mental health difficulties View source Personality disorder provision not yet sufficiently developed as an individual, therapeutic and trauma-informed pathway View source Fragmented connectivity between mental health and physical or neurodivergence services View source Failure to incorporate family concerns and available information into ongoing treatment and clinical assessment View source Failure to brief families on neurodivergent and mental health diagnoses and their potential difficulties View source Failure to provide advice on possible medication withdrawal symptoms View source Lack of a comorbidity policy guiding staff caring for patients with mental health conditions and learning difficulties View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kirsty Clare TAYLOR · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kirsty Clare TAYLOR, aged 33, was found dead in the garage at her family home on 25 June 2022 after taking her own life by hanging in the early hours. The report identified concerns about fragmented mental and physical health services, insufficiently developed personality disorder provision, inadequate communication with and listening to families, and insufficient information and support for families of patients with neurodiversity.
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 affordable NHS ADHD services
Wider context from the report “1. It was recognised in evidence and in submission to the Court by representatives of the Trust, that there is and remains a fragmented relationship between mental health and physical health services, with little inter-service connectivity. It was recognised that ideally services for those with both mental and physical health diagnoses should be connecting in a seamless, timely and collaborative manner - specifically through the joint commissioning of services, to support patients of all ages.
Nationally it is recognised that co-morbidity, especially with ADHD (as was the case in this death), impacts on both treatment compliance and treatment response. Whilst local initiatives have been explored by SHFT and by the ICB - Project Fusion I understand is such an example - much of the development of such services falls outside of scope and commissioning. Consequently, there is a significant and pressing need for connectivity between mental health services and those services supporting neurodivergent patients.
It was noted in evidence e.g. that SHFT do not currently have a comorbidity policy that would provide guidance to staff regarding patients who have a mental health condition and a learning difficulty. There are no ADHD services within SHFT or other NHS organisations within the Southampton (or in fact the wider Hampshire) area - save for private clinics, which many cannot afford.
The facts in this case have highlighted that progress on initiatives and connectivity between services is still too little and too slow. More needs to be done, and with greater integration, if the needs and support of patients such as Kirsty Taylor are to be sufficiently and appropriately met in the future and similar deaths prevented.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 communicate effectively with and listen meaningfully to families of patients with mental health difficulties
Wider context from the report “3. I remain concerned (as it is a matter I have raised on many occasions at inquest and again as a result of the experiences of the family in this case), that communication with the families of patients with mental health difficulties is still not being effectively achieved . Nor are such families being sufficiently, effectively and meaningfully listened to or understood when they voice concerns , based on their experience of the patient outside of a treatment or assessment environment. Consequently, I am concerned that such matters are not being reflected sufficiently or frequently enough in the onward treatment of those patients or in the clinical curiosity afforded to their conditions.
There remains an over-focus on patient centric assessments and patient only responses. It is recognised that patients can present quite differently to and in the presence of their families, who know them intimately, to how they may (or may be able to) present to assessing clinicians - with or without the intent to mask their condition.
Whilst consent to share is an understandable barrier in some cases, there should not be a bar to listening to or to actively encouraging feedback and input from families, especially where a family's concerns are heightened by any sudden or marked changes in the behaviours, mood or presentation of their relative outside of the clinical/assessment environment - particularly in the case of neurodiversity.
Unless all concerns are heard and considered and all available information is taken on board, holistically, there is a continuing risk that the masking of mental health conditions and the deterioration of them may occur or that significant red flags are missed. In this case, the family's increasing desperate concerns voiced about their daughter's evident mental health deterioration in her final days went un-responded.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Personality disorder provision not yet sufficiently developed as an individual, therapeutic and trauma-informed pathway
Wider context from the report “2. Evidence before this inquest indicated that SHFT has recognised that the mental health provision for those with personality disorders must move towards an individual, therapeutic and trauma-informed approach , which is both compassionate and recovery focused. It is evident that the 'Personality Disorder Pathway' currently being developed is an important step towards that aim, enabling practitioners and services to take a more holistic and person-centred approach, reducing risk and improving outcomes. I am aware that SHFT have been encouraged to review and further develop the Pathway. I am concerned that that must occur, and at pace .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Fragmented connectivity between mental health and physical or neurodivergence services
Wider context from the report “1. It was recognised in evidence and in submission to the Court by representatives of the Trust, that there is and remains a fragmented relationship between mental health and physical health services, with little inter-service connectivity . It was recognised that ideally services for those with both mental and physical health diagnoses should be connecting in a seamless, timely and collaborative manner - specifically through the joint commissioning of services, to support patients of all ages.
Nationally it is recognised that co-morbidity, especially with ADHD (as was the case in this death), impacts on both treatment compliance and treatment response. Whilst local initiatives have been explored by SHFT and by the ICB - Project Fusion I understand is such an example - much of the development of such services falls outside of scope and commissioning. Consequently, there is a significant and pressing need for connectivity between mental health services and those services supporting neurodivergent patients .
It was noted in evidence e.g. that SHFT do not currently have a comorbidity policy that would provide guidance to staff regarding patients who have a mental health condition and a learning difficulty. There are no ADHD services within SHFT or other NHS organisations within the Southampton (or in fact the wider Hampshire) area - save for private clinics, which many cannot afford.
The facts in this case have highlighted that progress on initiatives and connectivity between services is still too little and too slow . More needs to be done, and with greater integration, if the needs and support of patients such as Kirsty Taylor are to be sufficiently and appropriately met in the future and similar deaths prevented.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 incorporate family concerns and available information into ongoing treatment and clinical assessment
Wider context from the report “3. I remain concerned (as it is a matter I have raised on many occasions at inquest and again as a result of the experiences of the family in this case), that communication with the families of patients with mental health difficulties is still not being effectively achieved. Nor are such families being sufficiently, effectively and meaningfully listened to or understood when they voice concerns, based on their experience of the patient outside of a treatment or assessment environment. Consequently, I am concerned that such matters are not being reflected sufficiently or frequently enough in the onward treatment of those patients or in the clinical curiosity afforded to their conditions .
There remains an over-focus on patient centric assessments and patient only responses. It is recognised that patients can present quite differently to and in the presence of their families, who know them intimately, to how they may (or may be able to) present to assessing clinicians - with or without the intent to mask their condition.
Whilst consent to share is an understandable barrier in some cases, there should not be a bar to listening to or to actively encouraging feedback and input from families, especially where a family's concerns are heightened by any sudden or marked changes in the behaviours, mood or presentation of their relative outside of the clinical/assessment environment - particularly in the case of neurodiversity.
Unless all concerns are heard and considered and all available information is taken on board, holistically , there is a continuing risk that the masking of mental health conditions and the deterioration of them may occur or that significant red flags are missed . In this case, the family's increasing desperate concerns voiced about their daughter's evident mental health deterioration in her final days went un-responded.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 brief families on neurodivergent and mental health diagnoses and their potential difficulties
Wider context from the report “4. Finally, I am concerned that more needs to be done to inform and assist families, particularly in cases of patients with neurodiversity. In this particular case, the evidence found, for example, that the family were never briefed on what EUPD and ADHD really meant or on the difficulties which could present as a result of their daughter’s joint diagnoses . Being unaware as to what they were to expect, they were consequently often at a loss to know how to interact with or to help her. Neither they nor their daughter received advice on possible medication withdrawal symptoms.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide advice on possible medication withdrawal symptoms
Wider context from the report “4. Finally, I am concerned that more needs to be done to inform and assist families, particularly in cases of patients with neurodiversity. In this particular case, the evidence found, for example, that the family were never briefed on what EUPD and ADHD really meant or on the difficulties which could present as a result of their daughter’s joint diagnoses. Being unaware as to what they were to expect, they were consequently often at a loss to know how to interact with or to help her. Neither they nor their daughter received advice on possible medication withdrawal symptoms.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a comorbidity policy guiding staff caring for patients with mental health conditions and learning difficulties
Wider context from the report “1. It was recognised in evidence and in submission to the Court by representatives of the Trust, that there is and remains a fragmented relationship between mental health and physical health services, with little inter-service connectivity. It was recognised that ideally services for those with both mental and physical health diagnoses should be connecting in a seamless, timely and collaborative manner - specifically through the joint commissioning of services, to support patients of all ages.
Nationally it is recognised that co-morbidity, especially with ADHD (as was the case in this death), impacts on both treatment compliance and treatment response. Whilst local initiatives have been explored by SHFT and by the ICB - Project Fusion I understand is such an example - much of the development of such services falls outside of scope and commissioning. Consequently, there is a significant and pressing need for connectivity between mental health services and those services supporting neurodivergent patients.
It was noted in evidence e.g. that SHFT do not currently have a comorbidity policy that would provide guidance to staff regarding patients who have a mental health condition and a learning difficulty . There are no ADHD services within SHFT or other NHS organisations within the Southampton (or in fact the wider Hampshire) area - save for private clinics, which many cannot afford.
The facts in this case have highlighted that progress on initiatives and connectivity between services is still too little and too slow. More needs to be done, and with greater integration, if the needs and support of patients such as Kirsty Taylor are to be sufficiently and appropriately met in the future and similar deaths 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 Explore opportunities to improve care quality for patients with higher-suicide-risk diagnoses and support compliance with NICE guidelines.
Verbatim wording from the response “As part of the strategy, NHS England and DHSC will explore opportunities to improve the quality of care for patients with specific diagnoses of conditions associated with higher rates of suicide and ensure compliance with the National Institute for Health and Care Excellence (NICE) guidelines. This includes patients with personality disorders. It is also intended that by 2024/25 all parts of the country will have introduced crisis text lines to enable easier access to crisis care for people who are neurodiverse.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue sharing national principles, guidance and positive practice on personality disorder services with health systems.
Verbatim wording from the response “As part of the NHS Long Term Plan, all systems in England have been receiving significant funding from 2021/22 to develop and roll out new models of integrated primary and community mental health care in line with the Community Mental Health Framework for the improved support of adults with severe mental illness in their community and to integrate mental, physical and social care. A key requirement of the new model of care is the provision of a dedicated community mental health offer for those with diagnosis of ‘personality disorder’ or complex emotional needs. This offer should be co-produced and person-centred, trauma-informed, and flexible care that is responsive to individuals changing needs. NHS England has shared key principles for the development of services for people with personality disorder and will continue to share guidance and positive practice with health systems.” Source location Response from NHS England
Open published response
Concerns raised 4 Lack of training guidance for Keilland’s forceps use View source Lack of guidance on the minimum annual case volume needed to maintain Keilland’s forceps skills View source Lack of clear guidance on alternative management of malrotation and asynclitism after abandonment of Keilland’s forceps View source Insufficient awareness of complications associated with Keilland’s forceps View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Finley Austin May · 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
Finley Austin May was born on 16 February 2021 after delivery using Keilland’s rotational forceps. He developed a high cervical spinal cord injury caused by the forceps and died at Hull Royal Infirmary on 16 March 2021, aged 28 days. The report raises concerns about complications associated with Keilland’s forceps, the training and skill levels needed for their use, and guidance on alternative methods where trusts no longer use them.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of training guidance for Keilland’s forceps use
Wider context from the report “(1) The Hull and East Yorkshire NHS Trust has abandoned the use of Keilland’s forceps since Finley’s death and evidence was heard that other NHS trusts have also done so, Nevertheless, some have retained them.
(2) Evidence was heard that the use of these obstetric forceps can facilitate delivery from the mid-pelvis in cases of malrotation, asynclitism and where the lie is occipito-transverse or occipito-posterior, and this is a well-accepted practice.
(3) Evidence was heard that such malpositions can be corrected manually, or by the use of the Ventouse suction apparatus, but the evidence adduced was that these alternative techniques may be inferior to the use of Keilland’s forceps in skilled and practiced hands; this might mean increased risk to both mother and baby.
(4) Continued use of Keilland’s forceps may be the most appropriate way to manage this obstetric problem but there should be increased awareness of complications associated with its use and guidance issued about the minimum number of cases per annum needed to maintain skill levels coupled with guidance for training .
(5) If NHS trusts have abandoned the use of Keilland’s forceps, clear guidance should exist about alternative methods of managing malrotation and asynclitism.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on the minimum annual case volume needed to maintain Keilland’s forceps skills
Wider context from the report “(1) The Hull and East Yorkshire NHS Trust has abandoned the use of Keilland’s forceps since Finley’s death and evidence was heard that other NHS trusts have also done so, Nevertheless, some have retained them.
(2) Evidence was heard that the use of these obstetric forceps can facilitate delivery from the mid-pelvis in cases of malrotation, asynclitism and where the lie is occipito-transverse or occipito-posterior, and this is a well-accepted practice.
(3) Evidence was heard that such malpositions can be corrected manually, or by the use of the Ventouse suction apparatus, but the evidence adduced was that these alternative techniques may be inferior to the use of Keilland’s forceps in skilled and practiced hands; this might mean increased risk to both mother and baby.
(4) Continued use of Keilland’s forceps may be the most appropriate way to manage this obstetric problem but there should be increased awareness of complications associated with its use and guidance issued about the minimum number of cases per annum needed to maintain skill levels coupled with guidance for training.
(5) If NHS trusts have abandoned the use of Keilland’s forceps, clear guidance should exist about alternative methods of managing malrotation and asynclitism.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance on alternative management of malrotation and asynclitism after abandonment of Keilland’s forceps
Wider context from the report “(1) The Hull and East Yorkshire NHS Trust has abandoned the use of Keilland’s forceps since Finley’s death and evidence was heard that other NHS trusts have also done so, Nevertheless, some have retained them.
(2) Evidence was heard that the use of these obstetric forceps can facilitate delivery from the mid-pelvis in cases of malrotation, asynclitism and where the lie is occipito-transverse or occipito-posterior, and this is a well-accepted practice.
(3) Evidence was heard that such malpositions can be corrected manually, or by the use of the Ventouse suction apparatus, but the evidence adduced was that these alternative techniques may be inferior to the use of Keilland’s forceps in skilled and practiced hands; this might mean increased risk to both mother and baby.
(4) Continued use of Keilland’s forceps may be the most appropriate way to manage this obstetric problem but there should be increased awareness of complications associated with its use and guidance issued about the minimum number of cases per annum needed to maintain skill levels coupled with guidance for training.
(5) If NHS trusts have abandoned the use of Keilland’s forceps, clear guidance should exist about alternative methods of managing malrotation and asynclitism .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 awareness of complications associated with Keilland’s forceps
Wider context from the report “(1) The Hull and East Yorkshire NHS Trust has abandoned the use of Keilland’s forceps since Finley’s death and evidence was heard that other NHS trusts have also done so, Nevertheless, some have retained them.
(2) Evidence was heard that the use of these obstetric forceps can facilitate delivery from the mid-pelvis in cases of malrotation, asynclitism and where the lie is occipito-transverse or occipito-posterior, and this is a well-accepted practice.
(3) Evidence was heard that such malpositions can be corrected manually, or by the use of the Ventouse suction apparatus, but the evidence adduced was that these alternative techniques may be inferior to the use of Keilland’s forceps in skilled and practiced hands; this might mean increased risk to both mother and baby.
(4) Continued use of Keilland’s forceps may be the most appropriate way to manage this obstetric problem but there should be increased awareness of complications associated with its use and guidance issued about the minimum number of cases per annum needed to maintain skill levels coupled with guidance for training.
(5) If NHS trusts have abandoned the use of Keilland’s forceps, clear guidance should exist about alternative methods of managing malrotation and asynclitism.
” Open source report
Concerns raised 2 Failure of VTE risk assessment criteria to include relevant risk factors View source Failure to maintain patients within the gynaeology care pathway and ensure timely surgery 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
Christine Goodfriday Nakaefeero · 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
Christine Goodfriday Nakaefeero was found unresponsive at home on 21 June 2022 and died from a pulmonary embolism caused by a deep vein thrombosis. The report raises concerns that recommended hysterectomy surgery for her uterine fibroids was not arranged, and that the VTE assessment did not account for her large fibroids and use of tranexamic acid.
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 VTE risk assessment criteria to include relevant risk factors
Wider context from the report “2. The clinicians treating Ms Nakaefeero assessed her VTE risk utilising an established algorithm based on national guidance. The assessment was undertaken appropriately but it failed to identify two risk factors which made the formation of a DVT more likely, namely, large uterine fibroids and the use of tranexamic acid. I have concerns that the omission of these factors in the assessment criteria limited the effectiveness of the risk assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain patients within the gynaeology care pathway and ensure timely surgery
Wider context from the report “1. Ms Nakaefeero was assessed at a Gynae-oncology clinic in early 2019. The patient was diagnosed as not suffering from any form of cancer and was therefore referred on to the “benign” gynaeology team.
Ms Nakaefeero was advised that it was likely that the most effective treatment for her condition was a hysterectomy. It was expected that the likely wait for this treatment would be 6 months.
Ms Nakaefeero was not allocated an appointment and therefore had not received the necessary surgery by the time of her death in June 2022. Had the surgery been undertaken it is probable that she would not have developed a pulmonary embolism.
Although the trust has investigated these circumstances and implemented change, no clear explanation could be offered for why the deceased slipped out of this care pathway. I am not satisfied that the risk of re-occurrence has been properly addressed.
” Open source report
21 Jul 2023 Albert Dovey · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Delays in processing ambulances at hospital emergency departments View source Delays in treatment of elderly frail patients following a fall View source Delays in ambulance attendance for patients requiring clinical assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Albert Dovey · 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
Albert Dovey suffered an accidental fall at home and was admitted to hospital with rhabdomyolysis, acute kidney injury, heart failure and a fractured clavicle. He became gravely frail and died at Tameside General Hospital on 4 February 2023. The inquest heard concerns about delays in ambulance attendance, ambulance processing at hospital and clinical assessment, with evidence that delays in treating elderly frail patients after a fall increased the risk of 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 Delays in processing ambulances at hospital emergency departments
Wider context from the report “The inquest heard evidence that in relation to Mr Dovey there had been delays in him being assessed by clinicians due to delays in the ambulance attending after he was found on the floor and due to delays for ambulances to be processed at the hospital . The ambulance Mr Dovey was in a queue behind other ambulances waiting to unload patients into A and E .
The inquest heard evidence that delays in treatment of elderly frail patients following a fall gave rise to an increased risk of death. In Mr Dovey’s case the delays were due to the sustained pressure on services across Greater Manchester which had been ongoing for months at the time of Mr Dovey’s death. The pressure was due to demand against availability of resources.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 treatment of elderly frail patients following a fall
Wider context from the report “The inquest heard evidence that in relation to Mr Dovey there had been delays in him being assessed by clinicians due to delays in the ambulance attending after he was found on the floor and due to delays for ambulances to be processed at the hospital. The ambulance Mr Dovey was in a queue behind other ambulances waiting to unload patients into A and E.
The inquest heard evidence that delays in treatment of elderly frail patients following a fall gave rise to an increased risk of death. In Mr Dovey’s case the delays were due to the sustained pressure on services across Greater Manchester which had been ongoing for months at the time of Mr Dovey’s death. The pressure was due to demand against availability of resources .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance attendance for patients requiring clinical assessment
Wider context from the report “The inquest heard evidence that in relation to Mr Dovey there had been delays in him being assessed by clinicians due to delays in the ambulance attending after he was found on the floor and due to delays for ambulances to be processed at the hospital. The ambulance Mr Dovey was in a queue behind other ambulances waiting to unload patients into A and E.
The inquest heard evidence that delays in treatment of elderly frail patients following a fall gave rise to an increased risk of death. In Mr Dovey’s case the delays were due to the sustained pressure on services across Greater Manchester which had been ongoing for months at the time of Mr Dovey’s death. The pressure was due to demand against availability of resources.
” 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 Improve ambulance response times through the urgent and emergency care recovery plan.
Verbatim wording from the response “performance for 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, published in January 2023. The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care (UEC) services, including improving ambulance response times, increasing ambulance capacity through growing the workforce, improving flow through hospitals, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase ambulance capacity by growing the workforce.
Verbatim wording from the response “performance for 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, published in January 2023. The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care (UEC) services, including improving ambulance response times, increasing ambulance capacity through growing the workforce, improving flow through hospitals, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.” 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 Achieve Ambulance Response Programme standards across the North West region.
Verbatim wording from the response “Within the North West, ambulance performance is reviewed regularly via the Strategic Partnership and Transformation Board, a joint committee between NWAS and the Integrated Care Boards in the region. We acknowledge that there remains work to be done to improve NWAS performance but are committed to achieving the ARP standards in the region.” 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 Improve patient flow through hospitals.
Verbatim wording from the response “performance for 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, published in January 2023. The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care (UEC) services, including improving ambulance response times, increasing ambulance capacity through growing the workforce, improving flow through hospitals, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.” 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 Speed up hospital discharges.
Verbatim wording from the response “performance for 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, published in January 2023. The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care (UEC) services, including improving ambulance response times, increasing ambulance capacity through growing the workforce, improving flow through hospitals, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.” Source location Response from NHS England
Open published response
21 Jul 2023 Marion Nickson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to maintain observable bay nursing because of insufficient staff time and competing ward demands View source Lack of staff understanding and prioritisation of the risk of leaving high-risk patients unobserved View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Marion Nickson · 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
Marion Nickson was admitted to hospital after a fall and later died following an unwitnessed fall in hospital that caused a brain bleed. The principal concern was that observable bay nursing failed because staff left the bay to deal with other tasks, with insufficient staffing, understanding of the risks, and prioritisation of patient observation contributing to the problem.
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 observable bay nursing because of insufficient staff time and competing ward demands
Wider context from the report “The inquest heard evidence that to deal with the risk of falls in patients deemed to be high risk the concept of observable bay nursing had been introduced at both Trusts. At both Trusts Mrs Nickson fell whilst unobserved due to the challenges of maintaining the bays as observed bays . The challenge for both trusts had arisen where staff were required to deal with issues out of the bay and had left the bay area . The cause of that was multifactorial and included a lack of understanding of the risk presented by leaving the bay and a need for the staff to complete other urgent tasks due to the demand on ward staff .
The inquest heard that preventing in patient falls to reduce avoidable deaths was recognised as being important and that across the NHS bays of this nature were seen as a way to reduce the risk. However they would only work if staff had the time and there were cultural changes amongst staff where it was recognised that observing patients had to be seen as a priority and not something that could be left to fit around other demands. The evidence was clear that if observable bays could not function as intended then across the NHS there would continue to be avoidable falls and consequential deaths. If bay nursing could not effectively delivered due to resourcing then other options to keep patients safe needed to be explored by Acute Trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of staff understanding and prioritisation of the risk of leaving high-risk patients unobserved
Wider context from the report “The inquest heard evidence that to deal with the risk of falls in patients deemed to be high risk the concept of observable bay nursing had been introduced at both Trusts. At both Trusts Mrs Nickson fell whilst unobserved due to the challenges of maintaining the bays as observed bays. The challenge for both trusts had arisen where staff were required to deal with issues out of the bay and had left the bay area. The cause of that was multifactorial and included a lack of understanding of the risk presented by leaving the bay and a need for the staff to complete other urgent tasks due to the demand on ward staff.
The inquest heard that preventing in patient falls to reduce avoidable deaths was recognised as being important and that across the NHS bays of this nature were seen as a way to reduce the risk. However they would only work if staff had the time and there were cultural changes amongst staff where it was recognised that observing patients had to be seen as a priority and not something that could be left to fit around other demands . The evidence was clear that if observable bays could not function as intended then across the NHS there would continue to be avoidable falls and consequential deaths. If bay nursing could not effectively delivered due to resourcing then other options to keep patients safe needed to be explored by Acute Trusts.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Long Term Workforce Plan priorities to improve training, staff retention and workforce sustainability for inpatient care.
Verbatim wording from the response “You also raised the issue of appropriate levels of resourcing within observable nursing bays. In June this year, the NHS published its Long Term Workforce Plan, setting out” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide and publicise FallSafe training covering observation, inpatient-fall risk reduction and post-fall management.
Verbatim wording from the response “The topic of observation is covered in the e-learning training module ‘FallSafe’ produced by the RCP and NHS England. The module is freely available and is widely publicised and used across the NHS and covers the knowledge needed to identify and reduce patient and environmental risk factors to assist with reducing inpatient falls as well as post fall management.” Source location Response from NHS England
Open published response
20 Jul 2023 Marianne Erika Oldham · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure of Emergency Department capacity to provide timely clinical assessment View source Shortage of radiographers and radiologists causing delays in scan performance and reporting View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Marianne Erika Oldham · 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
Marianne Erika Oldham was admitted to Tameside General Hospital with vomiting and abdominal pain and was diagnosed with a perforated sigmoid colon after a prolonged delay in clinical assessment and imaging. She deteriorated, was treated conservatively, and died from peritonitis. The report identified concerns about delays linked to Emergency Department demand, staffing shortages, and shortages of radiographers and radiologists.
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 Emergency Department capacity to provide timely clinical assessment
Wider context from the report “The inquest heard evidence that the very significant delay for Mrs Oldham to be seen by a clinician was due to the demand on Emergency Department Services . The inquest was told that delays of this length (9 hours) for patients who had been triaged to be seen within 60 minutes were not uncommon throughout the winter period across Greater Manchester and more widely .
The demand was due to the volume of patients and the number of staff available to see and treat them . The delay was compounded by the shortage of radiographers and radiologists nationally meaning that even when a decision is taken for a scan it can take some time (9 an hour in this case) for it to take place and then reported on.
In the time that Mrs Oldham was waiting to be seen she deteriorated very significantly meaning that by the time it was understood what the issue was she was very unwell and did not respond to conservative treatment which was all she was well enough for by that point.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 radiographers and radiologists causing delays in scan performance and reporting
Wider context from the report “The inquest heard evidence that the very significant delay for Mrs Oldham to be seen by a clinician was due to the demand on Emergency Department Services. The inquest was told that delays of this length (9 hours) for patients who had been triaged to be seen within 60 minutes were not uncommon throughout the winter period across Greater Manchester and more widely.
The demand was due to the volume of patients and the number of staff available to see and treat them. The delay was compounded by the shortage of radiographers and radiologists nationally meaning that even when a decision is taken for a scan it can take some time (9 an hour in this case) for it to take place and then reported on .
In the time that Mrs Oldham was waiting to be seen she deteriorated very significantly meaning that by the time it was understood what the issue was she was very unwell and did not respond to conservative treatment which was all she was well enough for by that point.
” 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 Address unwarranted performance variation in the most challenged local systems.
Verbatim wording from the response “The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care (UEC) services, including improving ambulance response times, increasing ambulance capacity through the workforce, improving flow through hospitals, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish national winter operational-resilience guidance addressing emergency department waits, crowding, flow and hospital length of stay.
Verbatim wording from the response “In July 2023, we also published a letter to Integrated Care Boards, NHS Trusts and Primary Care Networks titled Delivering operational resilience across the NHS this winter. This includes focusing on reducing waiting times for patients and crowding in A&E departments, improving flow, and reducing length of stay in hospital settings.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Long Term Workforce Plan to improve training, staff retention, workforce reform and sustainable staffing.
Verbatim wording from the response “Nationally, there are clear requirements placed on NHS Trusts to ensure that the right skill mix of medics and other professional groups are in place to respond to the anticipated demand throughout a day. This includes the expectation that senior decision makers are available to support more junior doctors and that diagnostics can occur in line with best practice and clinical standards set by the National Institute for Clinical Excellence (NICE) and other bodies such as Royal Colleges and Faculties. It is, however, acknowledged that resourcing remains an issue across the NHS, with local services reporting over 112,000 vacancies. In June this year, the NHS published its Long Term Workforce Plan, setting out how we will ensure that staffing is put on a sustainable footing over the next fifteen years to improve patient care.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Speed up hospital discharges to reduce length of stay and improve flow.
Verbatim wording from the response “The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care (UEC) services, including improving ambulance response times, increasing ambulance capacity through the workforce, improving flow through hospitals, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.” 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 Improve patient flow through hospitals to reduce emergency department delays.
Verbatim wording from the response “The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care (UEC) services, including improving ambulance response times, increasing ambulance capacity through the workforce, improving flow through hospitals, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS Trusts are responsible for ensuring appropriate staffing, senior clinical support and diagnostic provision for anticipated demand.
Verbatim wording from the response “Nationally, there are clear requirements placed on NHS Trusts to ensure that the right skill mix of medics and other professional groups are in place to respond to the anticipated demand throughout a day. This includes the expectation that senior decision makers are available to support more junior doctors and that diagnostics can occur in line with best practice and clinical standards set by the National Institute for Clinical Excellence (NICE) and other bodies such as Royal Colleges and Faculties. It is, however, acknowledged that resourcing remains an issue across the NHS, with local services reporting over 112,000 vacancies. In June this year, the NHS published its Long Term Workforce Plan, setting out how we will ensure that staffing is put on a sustainable footing over the next fifteen years to improve patient care.” 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