4 Feb 2019 Mrs Maureen Brown · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 2 Failure of the electronic transfer system to support recording and transmission of all information necessary for an effective handover View source National transfer policy failing to require all information necessary for an effective handover View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mrs Maureen Brown · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Maureen Brown was admitted to the Royal Derby Hospital with an infection and was identified as being at high risk of falls. Information from her daughter about her confusion and previous fall was not included in the electronic handover, and Mrs Brown subsequently fell from her bed and suffered a fatal subdural haemorrhage. The report raised concerns that electronic transfer information can omit relevant information needed for effective handover and that national policy still treats it as the only information necessary for transfer.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of the electronic transfer system to support recording and transmission of all information necessary for an effective handover
Wider context from the report “1. Evidence emerged during the inquest that the electronic transfer information is the only information that the receiving ward is given before a patient is transferred . Other relevant information, that is necessary for an effective handover to take place, can be missed as the electronic transfer system limits how much information can be recorded .
2. Evidence was heard regarding the steps that the Royal Derby Hospital has made to remedy this issue. However, the national policy still states that the only piece of information necessary for a transfer is the electronic transfer information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation National transfer policy failing to require all information necessary for an effective handover
Wider context from the report “1. Evidence emerged during the inquest that the electronic transfer information is the only information that the receiving ward is given before a patient is transferred. Other relevant information, that is necessary for an effective handover to take place, can be missed as the electronic transfer system limits how much information can be recorded.
2. Evidence was heard regarding the steps that the Royal Derby Hospital has made to remedy this issue. However, the national policy still states that the only piece of information necessary for a transfer is the electronic transfer information .
” 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 Trusts or providers are responsible for robust handover and transfer procedures for inter-hospital transfers, rather than national policy.
Verbatim wording from the response “There is no national policy for a Minimum Dataset for inter-hospital transfers, as was the case in Mrs Brown’s care, and where these occur it would be incumbent on the Trust or provider to ensure they have robust handover and transfer of information procedures. My Regional Colleagues have had assurance from the Trust of the changes they have made and the response to learning that has been implemented.” Source location 2020-0021-Response-from-NHS-England-and-NHS-Improvement-Redacted
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 A national minimum dataset exists for inter-provider hospital transfers, contrary to the concern that only electronic transfer information is required.
Verbatim wording from the response “In your report you express concern that “the national policy still states the only piece of information necessary for a transfer is the electronic transfer information”. I am assured by my colleagues at NHSX that there is a national Minimum Dataset (MDS) for transfers of patients between hospitals; Inter-Provider Transfer Administrative Minimum Data Set. This is overseen by NHS Digital. This does not relate to transfers of patients between wards within a single healthcare provider (a Trust in this case) and in such circumstances Trusts would be expected to have their own policies and protocols to govern the minimum data provided between departments to facilitate an effective transfer of patient information, following relevant clinical standards. On that basis, the actions taken by University Hospitals Of Derby And Burton NHS Foundation Trust would be relevant to your concerns.” Source location 2020-0021-Response-from-NHS-England-and-NHS-Improvement-Redacted
Open published response
Concerns raised 24 Failure to supervise staff delegated to provide asthma care View source Failure to provide coordinated long-term asthma management beyond immediate attack stabilisation View source Failure to objectively assess severity and progress during acute asthma attacks View source Lack of an agreed primary-care asthma management protocol View source Failure to inform the family of the child’s risk of poor asthma outcomes View source Failure to recognise and act on chronic asthma with recurrent severe attacks View source Failure to assign overall responsibility for asthma care View source Inadequate asthma safety-netting advice and reliance on unlicensed high-dose salbutamol weaning plans View source Failure to consider referral to a specialist respiratory or severe asthma service View source Failure to analyse recurrent asthma events and the underlying chronic condition View source Failure to maintain up-to-date coded records of asthma history and hospital correspondence View source Lack of a long-term asthma management plan View source Failure to provide an appropriately trained pre-discharge asthma review View source Failure to provide post-attack asthma follow-up View source Lack of a coordinated record of asthma-related attendances View source Failure to provide a written personal asthma self-management plan View source Failure to initiate referral to a specialist respiratory service View source Failure to alert health visitors or safeguarding services to missed routine appointments View source Failure to provide a written personalised asthma action plan View source Failure to communicate changed asthma medication to primary care View source Provision of potentially dangerous advice to manage an asthma attack at home View source Failure to adjust asthma medication despite recurrent attacks View source Failure to recognise asthma risk factors for future attacks and death View source Failure to provide detailed asthma patient education and coordinated long-term management View source See 21 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
Sophie Holman · 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
Sophie Holman, a 10-year-old girl with chronic asthma, died on 13 December 2017 after collapsing during a severe asthma attack while being taken to hospital. The report identifies concerns about inadequate long-term management, fragmented records, failure to recognise the cumulative severity and risks of her asthma, lack of a coordinated asthma action plan and safety-netting, and missed opportunities for specialist referral.
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 supervise staff delegated to provide asthma care
Wider context from the report “In the primary care practice there was:
a) No clear agreed practice protocol for managing asthma
b) The medical records did not contain an up to date summary of current and past problems; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded. As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma
c) A failure to recognise the risks of future poor outcome such as:
i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice
ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life
d) No clear supervision of junior doctors and nurses delegated to provide asthma care
e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines
f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines
g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013
h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery
i) Potentially dangerous advice on occasions: in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack
j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance
k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks
l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 coordinated long-term asthma management beyond immediate attack stabilisation
Wider context from the report “1) The medical management of this child’s asthma attacks on the innumerable occasions she presented to her general practice and hospital was concerned solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 objectively assess severity and progress during acute asthma attacks
Wider context from the report “In the primary care practice there was:
a) No clear agreed practice protocol for managing asthma
b) The medical records did not contain an up to date summary of current and past problems; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded. As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma
c) A failure to recognise the risks of future poor outcome such as:
i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice
ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life
d) No clear supervision of junior doctors and nurses delegated to provide asthma care
e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines
f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines
g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013
h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery
i) Potentially dangerous advice on occasions: in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack
j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance
k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks
l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of an agreed primary-care asthma management protocol
Wider context from the report “In the primary care practice there was:
a) No clear agreed practice protocol for managing asthma
b) The medical records did not contain an up to date summary of current and past problems; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded. As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma
c) A failure to recognise the risks of future poor outcome such as:
i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice
ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life
d) No clear supervision of junior doctors and nurses delegated to provide asthma care
e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines
f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines
g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013
h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery
i) Potentially dangerous advice on occasions: in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack
j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance
k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks
l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 inform the family of the child’s risk of poor asthma outcomes
Wider context from the report “2) There was:
a. No coordinated record of these occasions
b. No analysis of the frequency or circumstances of these events
c. No analysis of the underlying chronic asthma condition
d. No appreciation of the risk factors for future attacks and death due to asthma in this child
e. No long-term management plan for the care of this child despite innumerable attendances for attacks and failure of the parents to bring the child on occasions for routine hospital and practice appointments
f. No evidence of provision of a written personal acute asthma self-management plan recommended in the UK BTS/SIGN asthma guidelines
g. No evidence that the family were informed of the risks of poor outcome evidence in this child’s history
h. No evidence that anyone considered referring this child as recommended in the NRAD, to a respiratory specialist or severe asthma service for investigation, characterisation of the nature and phenotype of this child’s asthma so that a long-term management and treatment plan could be formulated and implemented
i. No clear understanding or awareness by the health professionals caring for Sophie of the current UK asthma guidelines, the recommendations of the NRAD or of the prescribing advice in the British National Formulary for the management of asthma
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and act on chronic asthma with recurrent severe attacks
Wider context from the report “In the secondary care there was:
a) Failure to recognise and act upon the underlying chronic condition punctuated by a number of severe attacks with life threatening features one of which was a near-fatal attack where Sophie was ‘blue and unresponsive’ with an oxygen saturation of 86% (2.7.2012)
b) Failure to recognise the need for and initiate referral of this child to a specialist respiratory service as recommended in the NRAD recommendations
c) Failure to take appropriate action when it was known that the family had a home nebuliser
d) Failure to implement the recommendations in the NICE Quality Statement 25, and BTS/SIGN guideline to ensure a pre-discharge review of the child’s asthma by an appropriately trained individual
e) Failure to effectively communicate changed medication in 2013 of the child to the general practitioner
f) Implementation of a hospital policy whereby this child was discharged from secondary care three times because of failure of the parents to bring the child to planned outpatient appointments
g) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-evidence based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to assign overall responsibility for asthma care
Wider context from the report “3) As in the case of two recent child asthma deaths resulting in Regulation 28 statements (Michael Uriely and Tamara Mills), despite the presence of numerous health professionals involved no single individual or organisation took overall responsibility for assuming management of her care overall .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 asthma safety-netting advice and reliance on unlicensed high-dose salbutamol weaning plans
Wider context from the report “In the primary care practice there was:
a) No clear agreed practice protocol for managing asthma
b) The medical records did not contain an up to date summary of current and past problems; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded. As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma
c) A failure to recognise the risks of future poor outcome such as:
i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice
ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life
d) No clear supervision of junior doctors and nurses delegated to provide asthma care
e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines
f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines
g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013
h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery
i) Potentially dangerous advice on occasions: in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack
j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance
k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks
l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to consider referral to a specialist respiratory or severe asthma service
Wider context from the report “2) There was:
a. No coordinated record of these occasions
b. No analysis of the frequency or circumstances of these events
c. No analysis of the underlying chronic asthma condition
d. No appreciation of the risk factors for future attacks and death due to asthma in this child
e. No long-term management plan for the care of this child despite innumerable attendances for attacks and failure of the parents to bring the child on occasions for routine hospital and practice appointments
f. No evidence of provision of a written personal acute asthma self-management plan recommended in the UK BTS/SIGN asthma guidelines
g. No evidence that the family were informed of the risks of poor outcome evidence in this child’s history
h. No evidence that anyone considered referring this child as recommended in the NRAD, to a respiratory specialist or severe asthma service for investigation, characterisation of the nature and phenotype of this child’s asthma so that a long-term management and treatment plan could be formulated and implemented
i. No clear understanding or awareness by the health professionals caring for Sophie of the current UK asthma guidelines, the recommendations of the NRAD or of the prescribing advice in the British National Formulary for the management of asthma
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to analyse recurrent asthma events and the underlying chronic condition
Wider context from the report “2) There was:
a. No coordinated record of these occasions
b. No analysis of the frequency or circumstances of these events
c. No analysis of the underlying chronic asthma condition
d. No appreciation of the risk factors for future attacks and death due to asthma in this child
e. No long-term management plan for the care of this child despite innumerable attendances for attacks and failure of the parents to bring the child on occasions for routine hospital and practice appointments
f. No evidence of provision of a written personal acute asthma self-management plan recommended in the UK BTS/SIGN asthma guidelines
g. No evidence that the family were informed of the risks of poor outcome evidence in this child’s history
h. No evidence that anyone considered referring this child as recommended in the NRAD, to a respiratory specialist or severe asthma service for investigation, characterisation of the nature and phenotype of this child’s asthma so that a long-term management and treatment plan could be formulated and implemented
i. No clear understanding or awareness by the health professionals caring for Sophie of the current UK asthma guidelines, the recommendations of the NRAD or of the prescribing advice in the British National Formulary for the management of asthma
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain up-to-date coded records of asthma history and hospital correspondence
Wider context from the report “In the primary care practice there was:
a) No clear agreed practice protocol for managing asthma
b) The medical records did not contain an up to date summary of current and past problems ; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded . As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma
c) A failure to recognise the risks of future poor outcome such as:
i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice
ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life
d) No clear supervision of junior doctors and nurses delegated to provide asthma care
e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines
f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines
g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013
h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery
i) Potentially dangerous advice on occasions: in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack
j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance
k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks
l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 long-term asthma management plan
Wider context from the report “2) There was:
a. No coordinated record of these occasions
b. No analysis of the frequency or circumstances of these events
c. No analysis of the underlying chronic asthma condition
d. No appreciation of the risk factors for future attacks and death due to asthma in this child
e. No long-term management plan for the care of this child despite innumerable attendances for attacks and failure of the parents to bring the child on occasions for routine hospital and practice appointments
f. No evidence of provision of a written personal acute asthma self-management plan recommended in the UK BTS/SIGN asthma guidelines
g. No evidence that the family were informed of the risks of poor outcome evidence in this child’s history
h. No evidence that anyone considered referring this child as recommended in the NRAD, to a respiratory specialist or severe asthma service for investigation, characterisation of the nature and phenotype of this child’s asthma so that a long-term management and treatment plan could be formulated and implemented
i. No clear understanding or awareness by the health professionals caring for Sophie of the current UK asthma guidelines, the recommendations of the NRAD or of the prescribing advice in the British National Formulary for the management of asthma
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an appropriately trained pre-discharge asthma review
Wider context from the report “In the secondary care there was:
a) Failure to recognise and act upon the underlying chronic condition punctuated by a number of severe attacks with life threatening features one of which was a near-fatal attack where Sophie was ‘blue and unresponsive’ with an oxygen saturation of 86% (2.7.2012)
b) Failure to recognise the need for and initiate referral of this child to a specialist respiratory service as recommended in the NRAD recommendations
c) Failure to take appropriate action when it was known that the family had a home nebuliser
d) Failure to implement the recommendations in the NICE Quality Statement 25, and BTS/SIGN guideline to ensure a pre-discharge review of the child’s asthma by an appropriately trained individual
e) Failure to effectively communicate changed medication in 2013 of the child to the general practitioner
f) Implementation of a hospital policy whereby this child was discharged from secondary care three times because of failure of the parents to bring the child to planned outpatient appointments
g) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-evidence based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide post-attack asthma follow-up
Wider context from the report “In the primary care practice there was:
a) No clear agreed practice protocol for managing asthma
b) The medical records did not contain an up to date summary of current and past problems; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded. As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma
c) A failure to recognise the risks of future poor outcome such as:
i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice
ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life
d) No clear supervision of junior doctors and nurses delegated to provide asthma care
e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines
f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines
g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013
h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery
i) Potentially dangerous advice on occasions: in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack
j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance
k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks
l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 coordinated record of asthma-related attendances
Wider context from the report “2) There was:
a. No coordinated record of these occasions
b. No analysis of the frequency or circumstances of these events
c. No analysis of the underlying chronic asthma condition
d. No appreciation of the risk factors for future attacks and death due to asthma in this child
e. No long-term management plan for the care of this child despite innumerable attendances for attacks and failure of the parents to bring the child on occasions for routine hospital and practice appointments
f. No evidence of provision of a written personal acute asthma self-management plan recommended in the UK BTS/SIGN asthma guidelines
g. No evidence that the family were informed of the risks of poor outcome evidence in this child’s history
h. No evidence that anyone considered referring this child as recommended in the NRAD, to a respiratory specialist or severe asthma service for investigation, characterisation of the nature and phenotype of this child’s asthma so that a long-term management and treatment plan could be formulated and implemented
i. No clear understanding or awareness by the health professionals caring for Sophie of the current UK asthma guidelines, the recommendations of the NRAD or of the prescribing advice in the British National Formulary for the management of asthma
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a written personal asthma self-management plan
Wider context from the report “2) There was:
a. No coordinated record of these occasions
b. No analysis of the frequency or circumstances of these events
c. No analysis of the underlying chronic asthma condition
d. No appreciation of the risk factors for future attacks and death due to asthma in this child
e. No long-term management plan for the care of this child despite innumerable attendances for attacks and failure of the parents to bring the child on occasions for routine hospital and practice appointments
f. No evidence of provision of a written personal acute asthma self-management plan recommended in the UK BTS/SIGN asthma guidelines
g. No evidence that the family were informed of the risks of poor outcome evidence in this child’s history
h. No evidence that anyone considered referring this child as recommended in the NRAD, to a respiratory specialist or severe asthma service for investigation, characterisation of the nature and phenotype of this child’s asthma so that a long-term management and treatment plan could be formulated and implemented
i. No clear understanding or awareness by the health professionals caring for Sophie of the current UK asthma guidelines, the recommendations of the NRAD or of the prescribing advice in the British National Formulary for the management of asthma
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to initiate referral to a specialist respiratory service
Wider context from the report “In the secondary care there was:
a) Failure to recognise and act upon the underlying chronic condition punctuated by a number of severe attacks with life threatening features one of which was a near-fatal attack where Sophie was ‘blue and unresponsive’ with an oxygen saturation of 86% (2.7.2012)
b) Failure to recognise the need for and initiate referral of this child to a specialist respiratory service as recommended in the NRAD recommendations
c) Failure to take appropriate action when it was known that the family had a home nebuliser
d) Failure to implement the recommendations in the NICE Quality Statement 25, and BTS/SIGN guideline to ensure a pre-discharge review of the child’s asthma by an appropriately trained individual
e) Failure to effectively communicate changed medication in 2013 of the child to the general practitioner
f) Implementation of a hospital policy whereby this child was discharged from secondary care three times because of failure of the parents to bring the child to planned outpatient appointments
g) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-evidence based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to alert health visitors or safeguarding services to missed routine appointments
Wider context from the report “5) The child’s parents failed on occasion to bring the child to routine appointments; however there was no communication by any health professional alerting the health visitors or safeguarding team regarding this . On the other hand, the child’s asthma attacks were treated in hospital and general practice ‘as an acute illness’, without detailed patient education or a co-ordinated long-term management plan. There were thus little evidence of any patient education – particularly aimed at ensuring that the child’s parents were aware of the fact that she was at risk of poor outcome even asthma death according to her risk factors; perhaps explained the behaviour of her parents.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 a written personalised asthma action plan
Wider context from the report “In the primary care practice there was:
a) No clear agreed practice protocol for managing asthma
b) The medical records did not contain an up to date summary of current and past problems; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded. As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma
c) A failure to recognise the risks of future poor outcome such as:
i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice
ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life
d) No clear supervision of junior doctors and nurses delegated to provide asthma care
e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines
f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines
g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013
h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery
i) Potentially dangerous advice on occasions: in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack
j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance
k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks
l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 changed asthma medication to primary care
Wider context from the report “In the secondary care there was:
a) Failure to recognise and act upon the underlying chronic condition punctuated by a number of severe attacks with life threatening features one of which was a near-fatal attack where Sophie was ‘blue and unresponsive’ with an oxygen saturation of 86% (2.7.2012)
b) Failure to recognise the need for and initiate referral of this child to a specialist respiratory service as recommended in the NRAD recommendations
c) Failure to take appropriate action when it was known that the family had a home nebuliser
d) Failure to implement the recommendations in the NICE Quality Statement 25, and BTS/SIGN guideline to ensure a pre-discharge review of the child’s asthma by an appropriately trained individual
e) Failure to effectively communicate changed medication in 2013 of the child to the general practitioner
f) Implementation of a hospital policy whereby this child was discharged from secondary care three times because of failure of the parents to bring the child to planned outpatient appointments
g) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-evidence based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Provision of potentially dangerous advice to manage an asthma attack at home
Wider context from the report “In the primary care practice there was:
a) No clear agreed practice protocol for managing asthma
b) The medical records did not contain an up to date summary of current and past problems; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded. As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma
c) A failure to recognise the risks of future poor outcome such as:
i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice
ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life
d) No clear supervision of junior doctors and nurses delegated to provide asthma care
e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines
f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines
g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013
h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery
i) Potentially dangerous advice on occasions : in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack
j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance
k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks
l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 adjust asthma medication despite recurrent attacks
Wider context from the report “In the primary care practice there was:
a) No clear agreed practice protocol for managing asthma
b) The medical records did not contain an up to date summary of current and past problems; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded. As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma
c) A failure to recognise the risks of future poor outcome such as:
i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice
ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life
d) No clear supervision of junior doctors and nurses delegated to provide asthma care
e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines
f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines
g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013
h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery
i) Potentially dangerous advice on occasions: in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack
j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance
k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks
l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 asthma risk factors for future attacks and death
Wider context from the report “2) There was:
a. No coordinated record of these occasions
b. No analysis of the frequency or circumstances of these events
c. No analysis of the underlying chronic asthma condition
d. No appreciation of the risk factors for future attacks and death due to asthma in this child
e. No long-term management plan for the care of this child despite innumerable attendances for attacks and failure of the parents to bring the child on occasions for routine hospital and practice appointments
f. No evidence of provision of a written personal acute asthma self-management plan recommended in the UK BTS/SIGN asthma guidelines
g. No evidence that the family were informed of the risks of poor outcome evidence in this child’s history
h. No evidence that anyone considered referring this child as recommended in the NRAD, to a respiratory specialist or severe asthma service for investigation, characterisation of the nature and phenotype of this child’s asthma so that a long-term management and treatment plan could be formulated and implemented
i. No clear understanding or awareness by the health professionals caring for Sophie of the current UK asthma guidelines, the recommendations of the NRAD or of the prescribing advice in the British National Formulary for the management of asthma
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide detailed asthma patient education and coordinated long-term management
Wider context from the report “5) The child’s parents failed on occasion to bring the child to routine appointments; however there was no communication by any health professional alerting the health visitors or safeguarding team regarding this. On the other hand, the child’s asthma attacks were treated in hospital and general practice ‘as an acute illness’, without detailed patient education or a co-ordinated long-term management plan . There were thus little evidence of any patient education – particularly aimed at ensuring that the child’s parents were aware of the fact that she was at risk of poor outcome even asthma death according to her risk factors; perhaps explained the behaviour of her parents.
” 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 national asthma policy and existing clinical guidelines, including the National Review of Asthma Deaths report, to determine appropriate national and local actions.
Verbatim wording from the response “I can confirm that improving the quality of care will be a key focus for the new CYP Transformation Board, and we will prioritise action on conditions such as asthma where our clinical outcomes are unacceptable. This work will start from April 2019 and bring together key stakeholders from across the NHS and the wider public sector. The board will be led by the Chief Executive of Birmingham Women’s and Children’s Hospital. I can confirm that we will include a review of national asthma policy and existing clinical guidelines, including the 2014 NRAD (National Review of Asthma Deaths) report⁴, in order to determine appropriate actions to be taken on both a national and local level to establish better consistency. This may include but will not limited to:” Source location 2019-0035-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Contact the Royal Colleges of General Practitioners and Paediatrics and Child Health to discuss raising professional awareness of active childhood-asthma management and care plans.
Verbatim wording from the response “In addition to the CYP Transformation Board and Programme being established shortly, I can confirm we will also contact the Royal College of General Practice and the Royal College of Paediatrics and Child Health, to discuss what more can be done to raise awareness amongst healthcare professionals about the need to actively manage childhood asthma and the importance of asthma care plans.” Source location 2019-0035-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve access to specialist paediatric care in community settings.
Verbatim wording from the response “We will also be working to improve access to specialist paediatric care in the community, as we know this will have a positive impact. Also through the clinical networks we will continue to share examples of best practice from areas that are” Source location 2019-0035-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share examples of effective asthma-service practice through the clinical networks.
Verbatim wording from the response “We will also be working to improve access to specialist paediatric care in the community, as we know this will have a positive impact. Also through the clinical networks we will continue to share examples of best practice from areas that are” Source location 2019-0035-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop integrated care models connecting services and information for children and young people.
Verbatim wording from the response “NHS England published the NHS Long Term Plan² in January 2019. Within the plan we committed to focusing on the health and care of children and young people, and to launch a ‘Children and Young People’s (CYP) Transformation Board’. As part of this we will work to develop new models of integrated care that will bring together services and connect vital information for children and young people. We are particularly keen to focus on continuing healthcare needs and from autumn 2019 we will roll out CYP clinical networks for long-term conditions focusing on asthma, epilepsy and diabetes. These CYP networks will link to primary care networks³ whilst focusing specifically on the needs of children, young people and their families and the improvement of services by sharing best clinical practices and supporting the integration of paediatric skills across services.” Source location 2019-0035-Response-by-NHS-England
Open published response
11 Jan 2019 Elizabeth Rose CURTIS · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1 Failure to incorporate patients' mobility into assessment of well-being View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Elizabeth Rose CURTIS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Elizabeth Rose Curtis was admitted to hospital with a urinary tract infection and delirium, was treated with antibiotics and haloperidol, developed aspiration pneumonia, and died on 31 March 2018. The inquest noted that she was prescribed 2.5mg of haloperidol instead of the intended 0.25mg. A substantive concern was how patients’ mobility and frailty should be assessed as indicators of wellbeing and possible deterioration in hospital.
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 incorporate patients' mobility into assessment of well-being
Wider context from the report “A patient's mobility became an issue at the inquest and how this can help with assessing a patient's wellness.
I was advised by ████████ at the Royal United Hospital, Bath, who gave evidence at this inquest that she was introducing to the hospital a mobility scale due to the impact that mobility or indeed frailty has on assessing well-being of patients when in hospital .
████████ has indicated that this is a simple scale noting a patient's best mobility in the previous 24hrs. and is recorded alongside the NEWS score . Often mobility is the first symptom demonstrating a decline in health . I am told that the Royal United Hospital have adopted this scale.
For further details in relation to this I would suggest that you contact ████████ Consultant Geriatrician, at Royal United Hospital NHS Foundation Trust her email is ████████. I have also suggested that she write to you to outline her “mobility scale”, hence I have copied her into this report.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A national mobility-score field on NEWS2 is not preferred; comprehensive specialty-tailored assessment and review alongside NEWS2 is considered better.
Verbatim wording from the response “The Royal College of Physicians, who lead on the National Early Warning Score (NEWS2) are very supportive of the need to assess, monitor and act on a range of other signs and symptoms and test results that indicate a patient is either not improving as fast as expected or is getting unexpectedly less well. They believe this is best done by comprehensive assessment and review tailored to patient specialities alongside NEWS2, rather adding a mobility score as an additional field on NEWS2 charts nationally; but we will keep them updated on any significant findings from the work at Royal United Hospital Bath NHS Foundation Trust.” Source location 2019-0018-Response-by-NHS-Improvement
Open published response
Concerns raised 1 Delays in transferring prisoners to secure hospitals under s.47 of the Mental Health Act 1983 View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Miss Kirsty Walker · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Miss Kirsty Walker died in hospital on 27 September 2015 after being found unresponsive in prison with a ligature tied around her neck. She had a history of self-harm and had engaged in 235 acts of self-harm during her imprisonment, including 215 involving ligatures. The report raised concern that prisoners were taking well over 14 days to transfer to secure hospitals under section 47 of the Mental Health Act 1983, presenting a risk of further 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 Delays in transferring prisoners to secure hospitals under s.47 of the Mental Health Act 1983
Wider context from the report “I am concerned that the average time to transfer a prisoner to a secure hospital under s.47 of the Mental Health Act 1983 is well in excess of the 14 days envisaged by the 2009 Bradley Report and presents a risk of further 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 Submit revised prisoner transfer and remission guidance for public consultation.
Verbatim wording from the response “NHS England has regard to the above Good Practice Guide in relation to transfer times from prison to mental health inpatient services and is now responsible for reviewing the Good Practice Guide. The aim of the review is to provide for more clinically informed timescales for the transfer and remission of prisoners to and from mental health hospital. This revised document has been developed with stakeholders and is currently being prepared in readiness for public consultation which is anticipated to take place early in 2019.” Source location 2018-0396-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the revised prisoner transfer and remission guidance nationally after consultation.
Verbatim wording from the response “As above a review of the Good Practice Guidance 2011 has taken place, led by NHS England. The revised guidance will be submitted for public consultation prior to implementation nationally, and will consider the whole process of referral, assessment, transfer and remission.” Source location 2018-0396-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop improved performance management through increased collection and analysis of transfer pathway data.
Verbatim wording from the response “2. Improved performance management through increased and improved collection and analysis of data;” Source location 2018-0396-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct demand and capacity reviews for adult high-, medium- and low-secure mental health services.
Verbatim wording from the response “3. A demand and capacity review in relation to adult high, medium and low-secure services;” Source location 2018-0396-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the review of guidance on prisoner transfer and remission under sections 47 and 48 of the Mental Health Act.
Verbatim wording from the response “NHS England has regard to the above Good Practice Guide in relation to transfer times from prison to mental health inpatient services and is now responsible for reviewing the Good Practice Guide. The aim of the review is to provide for more clinically informed timescales for the transfer and remission of prisoners to and from mental health hospital. This revised document has been developed with stakeholders and is currently being prepared in readiness for public consultation which is anticipated to take place early in 2019.” Source location 2018-0396-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out nationally the provider-led management of adult medium- and low-secure service budgets and whole-pathway responsibility.
Verbatim wording from the response “4. An initiative was proposed in December 2015 and then piloted from 2016, where mental health care providers were encouraged to take on the management of tertiary budgets for adult medium and low secure services and were able to work in partnership with other providers to enable the local system to be responsive and take ownership of the whole pathway including where that related to prison transfers. In February 2018 it was agreed that this approach would be rolled out nationally;” Source location 2018-0396-Response-by-NHS-England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a prison transfer service within a secure inpatient service to provide dedicated transfer and remission capacity.
Verbatim wording from the response “Another example of good practice is the development of a prison transfer service within a secure inpatient service. This service focuses specifically on transfers from prison, enabling timely transfers and remission where appropriate to ensure that particular capacity is used exclusively for this patient group.” Source location 2018-0396-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct annual audits benchmarking prisoner transfer and remission data, including the current audit cycle.
Verbatim wording from the response “1. An annual audit benchmarking data in relation to the transfer and remission process;” Source location 2018-0396-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate identified good-practice examples from prison-to-mental-health transfer pathways nationally.
Verbatim wording from the response “In respect to the improved performance management and capability that is being developed in this area, good practice examples relating to the pathway between prisons and respective mental health inpatient services are being identified in some parts of the country and processes to disseminate and share this information nationally is a specific focus.” Source location 2018-0396-Response-by-NHS-England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Mental Health Act sets no transfer deadline, and the proposed 14-day target was guidance rather than an accepted statutory requirement.
Verbatim wording from the response “The provisions of the MHA 1983 do not stipulate a timescale within which prisoner transfers from prison to mental health inpatient services must take place.” Source location 2018-0396-Response-by-NHS-England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Secondary mental health providers and CCGs hold responsibility for planning or commissioning relevant local mental health pathways and beds.
Verbatim wording from the response “Under the HSCA 2012, NHS England has responsibility for the commissioning of healthcare in prisons and the commissioning of adult secure mental health beds, amongst other specialist mental health services. More recently NHS England has devolved responsibility to secondary MH providers in respect of managing budgets and planning for their local populations. These New Care Models (NCMs) comprise of a lead provider arrangement or a collaborative of providers who are responsible for planning the pathway for their local populations in terms of adult medium and low secure services. Clinical Commissioning Groups (CCGs) are responsible for the commissioning of other mental health services, including psychiatric intensive care units (PICU).” Source location 2018-0396-Response-by-NHS-England
Open published response
Concerns raised 2 Lack of NHS Pathways questions about recent surgical or interventional procedures for patients reporting severe abdominal pain View source Failure to obtain triage information directly from the patient or record why the patient cannot speak View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mrs. Susan Longden · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs. Susan Longden underwent a routine surveillance colonoscopy on 31 January 2018 and later developed severe abdominal pain. After NHS 111 triage arranged a doctor call rather than a Category 3 ambulance, she became unresponsive, suffered cardiac arrests and was pronounced deceased after arrival at hospital. The concerns included the NHS Pathways algorithm not asking about recent procedures, insufficient emphasis on speaking directly with the patient when the caller is someone else, and previous concerns raised with the organisation.
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 NHS Pathways questions about recent surgical or interventional procedures for patients reporting severe abdominal pain
Wider context from the report “(1) The NHS Pathways algorithm does not include a question with regard to recent surgical or interventional procedures where a patient is reporting severe abdominal pain . The close association in time between such a procedure and the onset of symptoms may well be significant in ensuring prompt action is taken to investigate the cause of the 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 obtain triage information directly from the patient or record why the patient cannot speak
Wider context from the report “(2) Where the caller to NHS 111 is not the patient then the Health Advisor continues to follow the algorithm by obtaining information from the caller and not the patient . There should be greater emphasis on trying to speak with the patient and the information provided reason(s) why the patient cannot came to the telephone . The information provided by the patient themselves and the manner in which that information is provided may well affect the outcome of the triage process.
” 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 Review abdominal pain pathways with Royal College subject-matter experts, including whether to add recent-procedure questions to the severe-pain section.
Verbatim wording from the response “NHS Pathways regularly review the algorithms and our abdominal pain pathways are currently undergoing a review with our external subject matter experts from the Royal Colleges. This review will include the severe pain section specifically, and inclusion of a question asking about a recent surgical procedure or intervention has specifically been requested for review as part of this work. I can further reassure HM Coroner that this comprehensive review of our abdominal pain algorithms will be concluded by 1st May 2019, and that any changes to NHS Pathways will be implemented later this year, pending successful safety testing.” Source location 2018-0394-Response-by-NHS-Digital
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 Training materials, competency assessments and mandatory audits are considered sufficient to require speaking directly with patients where safe and appropriate.
Verbatim wording from the response “We therefore consider that the NHS Pathways training materials and licence requirements sufficiently address the need and importance of call handlers speaking directly to patients and recognise that 111 and 999 providers should continue to reinforce this with the call handlers.” Source location 2018-0394-Response-by-NHS-Digital
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 For severe abdominal pain, urgent primary-care referral and symptom-based questions are considered sufficient without asking about recent procedures.
Verbatim wording from the response “We acknowledge that we do not specifically include a question about recent procedures within the sub-section of the abdominal pain algorithm where callers describe severe pain. This is because, at present, any patient describing severe pain will, as a minimal response, be referred to primary care urgently regardless of such background. Before this backstop is reached, other questions are asked, looking to identify key symptoms that warrant prompt action to investigate their cause, including ambulance dispatch.” Source location 2018-0394-Response-by-NHS-Digital
Open published response
18 Dec 2018 John Anthony Delahaye · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 5 Failure to conduct a welfare check on cell unlock View source Failure to ensure healthcare attendance at ACCT reviews View source Unreliable recording of relevant past and current medical conditions View source Lack of clarity in the in possession medication risk assessment question View source Failure to use the in possession medication risk assessment 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
John Anthony Delahaye · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Anthony Delahaye was found dead in his cell at HMP Birmingham on 5 March 2018 after taking an insulin overdose. The report identified concerns about the clarity and use of medication risk assessments, incomplete medical records, the absence of healthcare involvement in ACCT reviews, and the failure to carry out a welfare check when his cell was unlocked.
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 conduct a welfare check on cell unlock
Wider context from the report “4. On the morning of the 5th March 2018 Mr. Delahaye’s cell had been unlocked at approximately 07:50. It is likely that he was already dead at this time (and had been so for some hours) but he was not found because the prison custody officer who unlocked his cell did not look into the cell or seek any kind of acknowledgement from Mr. Delahaye. It was acknowledged by the relevant PCO and by the Safer Custody Manager that unlock ought to have involved a welfare check. The Safer Custody Manager’s evidence is that the need for a welfare check on unlock has been emphasised to senior managers and leads through a bilateral document covered at formal briefings. However, it was not clear how this is then communicated down to the individual custody officers and how they are being audited to make sure they are conducting a welfare check on unlock. The absence of a welfare check creates a risk that a prisoner in need of life saving assistance at the time of unlock is not identified.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 healthcare attendance at ACCT reviews
Wider context from the report “3. No member of the healthcare team was present at any of Mr. Delahaye’s ACCT reviews. It was identified during the inquest that a member of either the mental health team, primary care or the drug/alcohol service ought to have been present at the first review at least. It was the evidence of a first line manager who had involvement in the ACCT that a member of the custodial team had contacted healthcare and asked them to attend but this was not documented and the healthcare team maintained they were unaware of the date of the first review. Whilst the ACCT book provides a checklist of actions to be undertaken at various times it does not include making healthcare aware of the first review. As this is a national Ministry of Justice form, HMP Birmingham can’t change it but a failure to inform healthcare of an ACCT review could result in useful knowledge or expertise not being available to the ACCT team and could put lives at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unreliable recording of relevant past and current medical conditions
Wider context from the report “2. During the inquest it emerged that the mental health nurse who assessed Mr. Delahaye on the 2nd January 2018 and the GP who assessed him for in possession medication on the 29th January 2018, had not identified from his notes all relevant past medical conditions. It emerged that whilst the System One records (a case management system used across the prison estate) has the facility to provide a summary of significant past and current medical conditions, it is not reliable at HMP Birmingham because conditions are not consistently given the correct ‘read code’ . Evidence from the NHS England clinical reviewer, ████████, was that this problem is not unique to HMP Birmingham and is found in other prison healthcare teams and requires a change of culture and practice to bring the system for read coding into line with that in the community. The absence of a reliable source for quickly identifying relevant past and current medical conditions puts lives at risk from misinformed decision making.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 in the in possession medication risk assessment question
Wider context from the report “1. There is confusion surrounding the meaning of the following question from NHS England’s national clinical template for in possession Risk Assessments in the Secure Estate : “Have you had problems in the last 6 months with not taking, or not remembering to take your medicines as prescribed?” The Risk Assessment had not been used in the assessment for Mr. Delahaye’s in possession modification on the 29th January 2018 when it ought to have been. However, during the course of considering what the outcome would have been if the risk assessment had been undertaken, more than one clinician interpreted the question as pertaining only to consideration of incidents where medication had not been taken. It was the Coroner’s view that the question is also asking about incidents where medication may have been taken but not “as prescribed” thus encompassing an overdose (accidental or deliberate). The question is not clear and this creates a risk that the score generated may be incorrect and in possession medication may be authorised where it ought not to be, putting lives at risk.
2. During the inquest it emerged that the mental health nurse who assessed Mr. Delahaye on the 2nd January 2018 and the GP who assessed him for in possession medication on the 29th January 2018, had not identified from his notes all relevant past medical conditions. It emerged that whilst the System One records (a case management system used across the prison estate) has the facility to provide a summary of significant past and current medical conditions, it is not reliable at HMP Birmingham because conditions are not consistently given the correct ‘read code’. Evidence from the NHS England clinical reviewer, ████████, was that this problem is not unique to HMP Birmingham and is found in other prison healthcare teams and requires a change of culture and practice to bring the system for read coding into line with that in the community. The absence of a reliable source for quickly identifying relevant past and current medical conditions puts lives at risk from misinformed decision making.
3. No member of the healthcare team was present at any of Mr. Delahaye’s ACCT reviews. It was identified during the inquest that a member of either the mental health team, primary care or the drug/alcohol service ought to have been present at the first review at least. It was the evidence of a first line manager who had involvement in the ACCT that a member of the custodial team had contacted healthcare and asked them to attend but this was not documented and the healthcare team maintained they were unaware of the date of the first review. Whilst the ACCT book provides a checklist of actions to be undertaken at various times it does not include making healthcare aware of the first review. As this is a national Ministry of Justice form, HMP Birmingham can’t change it but a failure to inform healthcare of an ACCT review could result in useful knowledge or expertise not being available to the ACCT team and could put lives at risk.
4. On the morning of the 5th March 2018 Mr. Delahaye’s cell had been unlocked at approximately 07:50. It is likely that he was already dead at this time (and had been so for some hours) but he was not found because the prison custody officer who unlocked his cell did not look into the cell or seek any kind of acknowledgement from Mr. Delahaye. It was acknowledged by the relevant PCO and by the Safer Custody Manager that unlock ought to have involved a welfare check. The Safer Custody Manager’s evidence is that the need for a welfare check on unlock has been emphasised to senior managers and leads through a bilateral document covered at formal briefings. However, it was not clear how this is then communicated down to the individual custody officers and how they are being audited to make sure they are conducting a welfare check on unlock. The absence of a welfare check creates a risk that a prisoner in need of life saving assistance at the time of unlock is not identified.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 in possession medication risk assessment
Wider context from the report “1. There is confusion surrounding the meaning of the following question from NHS England’s national clinical template for in possession Risk Assessments in the Secure Estate: “Have you had problems in the last 6 months with not taking, or not remembering to take your medicines as prescribed?” The Risk Assessment had not been used in the assessment for Mr. Delahaye’s in possession modification on the 29th January 2018 when it ought to have been. However, during the course of considering what the outcome would have been if the risk assessment had been undertaken, more than one clinician interpreted the question as pertaining only to consideration of incidents where medication had not been taken. It was the Coroner’s view that the question is also asking about incidents where medication may have been taken but not “as prescribed” thus encompassing an overdose (accidental or deliberate). The question is not clear and this creates a risk that the score generated may be incorrect and in possession medication may be authorised where it ought not to be, putting lives at risk.
2. During the inquest it emerged that the mental health nurse who assessed Mr. Delahaye on the 2nd January 2018 and the GP who assessed him for in possession medication on the 29th January 2018, had not identified from his notes all relevant past medical conditions. It emerged that whilst the System One records (a case management system used across the prison estate) has the facility to provide a summary of significant past and current medical conditions, it is not reliable at HMP Birmingham because conditions are not consistently given the correct ‘read code’. Evidence from the NHS England clinical reviewer, ████████, was that this problem is not unique to HMP Birmingham and is found in other prison healthcare teams and requires a change of culture and practice to bring the system for read coding into line with that in the community. The absence of a reliable source for quickly identifying relevant past and current medical conditions puts lives at risk from misinformed decision making.
3. No member of the healthcare team was present at any of Mr. Delahaye’s ACCT reviews. It was identified during the inquest that a member of either the mental health team, primary care or the drug/alcohol service ought to have been present at the first review at least. It was the evidence of a first line manager who had involvement in the ACCT that a member of the custodial team had contacted healthcare and asked them to attend but this was not documented and the healthcare team maintained they were unaware of the date of the first review. Whilst the ACCT book provides a checklist of actions to be undertaken at various times it does not include making healthcare aware of the first review. As this is a national Ministry of Justice form, HMP Birmingham can’t change it but a failure to inform healthcare of an ACCT review could result in useful knowledge or expertise not being available to the ACCT team and could put lives at risk.
4. On the morning of the 5th March 2018 Mr. Delahaye’s cell had been unlocked at approximately 07:50. It is likely that he was already dead at this time (and had been so for some hours) but he was not found because the prison custody officer who unlocked his cell did not look into the cell or seek any kind of acknowledgement from Mr. Delahaye. It was acknowledged by the relevant PCO and by the Safer Custody Manager that unlock ought to have involved a welfare check. The Safer Custody Manager’s evidence is that the need for a welfare check on unlock has been emphasised to senior managers and leads through a bilateral document covered at formal briefings. However, it was not clear how this is then communicated down to the individual custody officers and how they are being audited to make sure they are conducting a welfare check on unlock. The absence of a welfare check creates a risk that a prisoner in need of life saving assistance at the time of unlock is not identified.
” Open source report
30 Nov 2018 Mr Bradley Fraser Brown · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3 Lack of national guidance on late prison transfers and cut-off points View source Failure to provide clinicians with access to transferring prisoners’ full healthcare records View source Inadequate weekend mental health staffing and risk assessment for late prison transfers 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
Mr Bradley Fraser Brown · 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 Bradley Fraser Brown was a serving prisoner who died in prison on 14 August 2017 after being found suspended by a ligature from a cell light fitting. The report identifies concerns about his late weekend transfer, limited access to healthcare records and assessments, reduced weekend healthcare provision, and the absence of national guidance on late prison transfers.
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 on late prison transfers and cut-off points
Wider context from the report “1. Late transfer of Prisoners between Prisons - on Fridays/at a weekend puts Prisoners at increased risk of death as adequate mental health/risk assessments cannot be conducted. There are no mental health nurses available to assess/monitor prisoners over the weekend, thus making late transfers unsafe. The same concern applies, in principle, to public/bank holidays.
There are different levels of healthcare at the weekends as compared to weekdays. This gives cause for concern given the inherent susceptibilities with which prisoners frequently present.
Transfer itself creates vulnerability that requires additional support, intervention and care and is of particular concern where the transferring prisoner is being held in isolation within the Care and Separation Unit (CSU or ‘Seg’ as it is colloquially known).
By virtue of the very different prison regime at the weekends (increased lock up periods/isolation in cells, fewer staff on duty, reduced activities) timely risk assessment is critical in the prevention of self-harm leading to death.
Late transfer also risks inadequate assessment where the clinician concerned cannot access the prisoner’s full healthcare record, thus substantially reducing the amount of key information available to them. Where the transferring prisoner has not been seen by Healthcare, other clinicians such as mental health nurses cannot access the healthcare record database.
There is no national guidance in relation to late transfers/cut-off points etc.
2. Commissioning of Mental Health/Healthcare Services:
As commissioners for healthcare services within prisons, the above concerns are also being brought to the attention of NHS England, for action.
These issues are not unique to the Prison involved in Mr Brown’s case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 clinicians with access to transferring prisoners’ full healthcare records
Wider context from the report “1. Late transfer of Prisoners between Prisons - on Fridays/at a weekend puts Prisoners at increased risk of death as adequate mental health/risk assessments cannot be conducted. There are no mental health nurses available to assess/monitor prisoners over the weekend, thus making late transfers unsafe. The same concern applies, in principle, to public/bank holidays.
There are different levels of healthcare at the weekends as compared to weekdays. This gives cause for concern given the inherent susceptibilities with which prisoners frequently present.
Transfer itself creates vulnerability that requires additional support, intervention and care and is of particular concern where the transferring prisoner is being held in isolation within the Care and Separation Unit (CSU or ‘Seg’ as it is colloquially known).
By virtue of the very different prison regime at the weekends (increased lock up periods/isolation in cells, fewer staff on duty, reduced activities) timely risk assessment is critical in the prevention of self-harm leading to death.
Late transfer also risks inadequate assessment where the clinician concerned cannot access the prisoner’s full healthcare record, thus substantially reducing the amount of key information available to them. Where the transferring prisoner has not been seen by Healthcare, other clinicians such as mental health nurses cannot access the healthcare record database.
There is no national guidance in relation to late transfers/cut-off points etc.
2. Commissioning of Mental Health/Healthcare Services:
As commissioners for healthcare services within prisons, the above concerns are also being brought to the attention of NHS England, for action.
These issues are not unique to the Prison involved in Mr Brown’s case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 weekend mental health staffing and risk assessment for late prison transfers
Wider context from the report “1. Late transfer of Prisoners between Prisons - on Fridays/at a weekend puts Prisoners at increased risk of death as adequate mental health/risk assessments cannot be conducted . There are no mental health nurses available to assess/monitor prisoners over the weekend, thus making late transfers unsafe . The same concern applies, in principle, to public/bank holidays.
There are different levels of healthcare at the weekends as compared to weekdays . This gives cause for concern given the inherent susceptibilities with which prisoners frequently present.
Transfer itself creates vulnerability that requires additional support, intervention and care and is of particular concern where the transferring prisoner is being held in isolation within the Care and Separation Unit (CSU or ‘Seg’ as it is colloquially known).
By virtue of the very different prison regime at the weekends (increased lock up periods/isolation in cells, fewer staff on duty, reduced activities ) timely risk assessment is critical in the prevention of self-harm leading to death .
Late transfer also risks inadequate assessment where the clinician concerned cannot access the prisoner’s full healthcare record, thus substantially reducing the amount of key information available to them. Where the transferring prisoner has not been seen by Healthcare, other clinicians such as mental health nurses cannot access the healthcare record database.
There is no national guidance in relation to late transfers/cut-off points etc.
2. Commissioning of Mental Health/Healthcare Services:
As commissioners for healthcare services within prisons, the above concerns are also being brought to the attention of NHS England, for action.
These issues are not unique to the Prison involved in Mr Brown’s case.
” Open source report
30 Nov 2018 Thomas Nicol · Prevention of Future Deaths report Hertfordshire
View report summary
Concerns raised 1 Delays in transferring prisoners in acute mental health crisis to suitable secure hospitals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Thomas Nicol · 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
Thomas Nicol, a serving prisoner at HMP The Mount, was found hanging in his cell on 21 September 2015 and died in hospital on 25 September 2015. The report raised concern that the weeks-to-months taken to transfer prisoners in acute mental health crisis to suitable secure hospitals potentially puts lives at risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring prisoners in acute mental health crisis to suitable secure hospitals
Wider context from the report “That the length of time taken to transfer prisoners in acute mental health crisis to a suitable secure hospital potentially puts lives at risk
” 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 Use audit findings to identify delays, develop best practice and improve escalation processes, including through a standardised information template.
Verbatim wording from the response “These audits permit scrutiny on a national and local level and have helped to develop a better understanding of any obstacles leading to delays in the timely assessment and if appropriate, transfer and/or remission of prisoners to and from mental health in-patient services. This knowledge is being used to build on best practice and identify areas for further service development. For example, a previous audit led to the examination of the escalation process to be applied regionally and nationally to those persons for whom an assessment and / or referral remained outstanding. The audit indicated that gaps in the information required to facilitate the escalation of care incurred a delay in its processing. As a result, a template was developed confirming” Source location 2018-0375-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake a strategic demand-and-capacity review of adult high-secure services.
Verbatim wording from the response “4. Demand and capacity service reviews in relation to adult high secure services;” Source location 2018-0375-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement nationally the revised integrated prison mental-health service specification, including seven-day provision, quality standards and local transfer-remission navigator functions.
Verbatim wording from the response “In March 2018 NHS England published a new integrated prison mental health service specification which significantly revised the previous specifications. It included provision for more flexible mental health services with seven days a week provision to ensure that those in mental health care are able to access the appropriate support even at the weekends. It also, for the first time, included the Royal College of Psychiatrists Quality Network for Prison Mental Health Services (QNMHPS) standard for mental health care in prisons. These standards were written with mental health” Source location 2018-0375-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the adult high-secure service specification through stakeholder co-design and co-production.
Verbatim wording from the response “In relation to high secure services, a similar demand and capacity review will be undertaken as part of strategic commissioning work and the current specification is being reviewed via the established NHS England processes of co-design and co-production. This review is in its early stages and NHS England aims to publish the results of this review during 2019/20.” Source location 2018-0375-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the Good Practice Guidance to clarify and standardise transfer and remission processes.
Verbatim wording from the response “In addition, improved performance management and capability is being developed in this area. Good practice examples relating to the pathway in some parts of the country within prison and respective mental health in-patient services are being identified and processes to disseminate and share this information nationally is a specific focus. For example, a national transfer and remission best practice conference is scheduled to take place on 19 March 2019 which will allow NHS England to present its findings and service expectations to local commissioners and providers alike, particularly in relation to escalation processes. In addition, responsibility for reviewing the Good Practice Guidance 2011 has been passed to NHS England, which is revising this document in order to clarify and standardise the transfer process.” Source location 2018-0375-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct and maintain national annual audits benchmarking prisoner mental-health transfers and remissions.
Verbatim wording from the response “1. An annual audit benchmarking data in relation to transfers and remissions;” Source location 2018-0375-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop improved performance management and capability for the prisoner mental-health transfer pathway.
Verbatim wording from the response “2. Improved performance management and capability;” Source location 2018-0375-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct demand-and-capacity reviews and reconfigure adult low- and medium-secure services to improve geographical access, capacity and throughput.
Verbatim wording from the response “3. Demand and capacity service reviews in relation to adult low and medium secure services, an initiative to increase local ownership of the pathway through collaborative commissioning and the development of new forensic community models of care;” Source location 2018-0375-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Identify and disseminate national good-practice examples and service expectations through a scheduled transfer and remission conference.
Verbatim wording from the response “In addition, improved performance management and capability is being developed in this area. Good practice examples relating to the pathway in some parts of the country within prison and respective mental health in-patient services are being identified and processes to disseminate and share this information nationally is a specific focus. For example, a national transfer and remission best practice conference is scheduled to take place on 19 March 2019 which will allow NHS England to present its findings and service expectations to local commissioners and providers alike, particularly in relation to escalation processes. In addition, responsibility for reviewing the Good Practice Guidance 2011 has been passed to NHS England, which is revising this document in order to clarify and standardise the transfer process.” Source location 2018-0375-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Submit the revised transfer and remission guidance for public consultation before national implementation.
Verbatim wording from the response “The proposed guidance will be submitted for public consultation prior to implementation nationally.” Source location 2018-0375-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pilot specialist forensic community-care models and collaborative commissioning approaches to increase local ownership of the pathway.
Verbatim wording from the response “3. Demand and capacity service reviews in relation to adult low and medium secure services, an initiative to increase local ownership of the pathway through collaborative commissioning and the development of new forensic community models of care;” Source location 2018-0375-Response-by-NHS-England
Open published response
Concerns raised 1 Failure to ensure prison healthcare staff possessing diazepam are trained or authorised to administer it 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
Daniel Paul Mark Stokes · 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
Daniel Paul Mark Stokes, an inmate at HM Prison Lindholme, died on 30 November 2015 after reportedly taking MDMA, acting erratically, becoming physically agitated and suffering cardiac arrest. A concern was raised that prison healthcare staff possessed diazepam but were not trained or authorised to administer it, indicating a possible failure to have proper systems in place.
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 prison healthcare staff possessing diazepam are trained or authorised to administer it
Wider context from the report “Part of the evidence in this case related to the attendance of prison healthcare staff who were in the possession of diazepam, but not trained/authorised to administer it . Whilst there may be good reason for this (ie so that diazepam is available at the scene of an incident if someone attends who is so trained/authorised) nonetheless, the jury which considered the case clearly considered that this amounts to a failure to have proper systems in place .
” Open source report
26 Oct 2018 Timothy Alastair Mason · Prevention of Future Deaths report Kent (North-West)
View report summary
Concerns raised 6 Unclear staff instructions for Emergency Department management of patients with symptoms suggestive of sepsis View source Failure to provide Men ACWY vaccination to eligible patients View source Inadequate systems for providing and monitoring Men ACWY vaccination View source Failure to correctly diagnose and treat patients with suspected sepsis View source Failure to carry out required tests for patients with symptoms suggestive of sepsis View source Discharge of very unwell patients before required tests are carried out View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Timothy Alastair Mason · 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
Timothy Alastair Mason became unwell over several days, attended Tunbridge Wells Hospital twice on 16 March 2018, and died later that day after treatment. The inquest recorded the medical cause of death as meningococcal septicaemia and identified concerns about failure to diagnose and treat him, his discharge while seriously unwell, and his not receiving the Men ACWY vaccination. Further concerns related to staff instructions and training and the systems for offering, recording and monitoring vaccination.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unclear staff instructions for Emergency Department management of patients with symptoms suggestive of sepsis
Wider context from the report “(1) The reasons for the failure to correctly diagnose and treat Timothy on the 16th March 2018 at 03.30. What staff instructions were given to the doctors and nurses in the Emergency Department at the hospital for dealing with patients with symptoms suggestive of sepsis and what tests should have been carried out and why they were not done.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Men ACWY vaccination to eligible patients
Wider context from the report “(5) How it happened that Timothy did not receive the Men ACWY vaccination and what systems are in place to ensure patients do receive the vaccination, how this is provided and monitored by NHS England and whether this is adequate or should be improved to avoid patients failing to receive the vaccine.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 systems for providing and monitoring Men ACWY vaccination
Wider context from the report “(5) How it happened that Timothy did not receive the Men ACWY vaccination and what systems are in place to ensure patients do receive the vaccination , how this is provided and monitored by NHS England and whether this is adequate or should be improved to avoid patients failing to receive the vaccine .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 correctly diagnose and treat patients with suspected sepsis
Wider context from the report “(1) The reasons for the failure to correctly diagnose and treat Timothy on the 16th March 2018 at 03.30. What staff instructions were given to the doctors and nurses in the Emergency Department at the hospital for dealing with patients with symptoms suggestive of sepsis and what tests should have been carried out and why they were not done.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out required tests for patients with symptoms suggestive of sepsis
Wider context from the report “(1) The reasons for the failure to correctly diagnose and treat Timothy on the 16th March 2018 at 03.30. What staff instructions were given to the doctors and nurses in the Emergency Department at the hospital for dealing with patients with symptoms suggestive of sepsis and what tests should have been carried out and why they were not done .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Discharge of very unwell patients before required tests are carried out
Wider context from the report “(2) Why was Timothy discharged home on the morning of the 16th March 2018 when he was clearly very unwell and tests had not been carried out .
” 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 Continue offering opportunistic Men ACWY vaccination to eligible people up to age 25 during 2019/20.
Verbatim wording from the response “During 2018/19 GP practices have continued to opportunistically offer the vaccine to anyone up to the age of 25. This includes those who may have missed the opportunity to be immunised as part of the schools-based programme.” Source location 2018-0351-Response-by-NHS-England-1
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 Undertake a national review of vaccination and immunisation arrangements, including call-and-recall expectations.
Verbatim wording from the response “In 2019/20 NHS England, will continue to offer the opportunistic service and has committed to undertake a national review of the vaccination and immunisations arrangements (https://www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf) which will include a review and clarification of the expectations around call/recall arrangements, reducing the risk of this incident recurring.” Source location 2018-0351-Response-by-NHS-England-1
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Write to local practices asking them to verify Men ACWY alert activation and invite eligible patients.
Verbatim wording from the response “As a result of this incident, the practice has acted to ensure that the vaccination has been offered to all eligible patients. I can also confirm that the practice has now switched on the necessary alerts prompting the offer for patients who have not received the Men ACWY vaccination. The practice has also written to EMIS requesting that Men ACWY is added to the list of vaccines flagged up in the alert box as a routine. All local practices have been written to and asked to check that the Men ACWY vaccination alert is activated and patients invited from the relevant cohort.” Source location 2018-0351-Response-by-NHS-England-1
Open published response
Concerns raised 4 Unrestricted internet availability of potentially dangerous and addictive drugs View source Failure to perform further checks when filling prescriptions for potentially dangerous and addictive drugs in UK pharmacies View source Failure to access the patient’s medical records before prescribing potentially dangerous and addictive drugs View source Failure to contact the patient’s regular medical practitioner before prescribing potentially dangerous and addictive drugs View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jennifer Anne Lacey · 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
Jennifer Anne Lacey was found deceased in a hotel room in Morden on 4 June 2018, having consumed a large amount of alcohol and 210 tramadol tablets. The concerns were that potentially dangerous and addictive drugs were freely available over the internet, could be prescribed without contact with the patient’s regular doctor or access to medical records, and might be dispensed by UK pharmacies without further checks.
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 Unrestricted internet availability of potentially dangerous and addictive drugs
Wider context from the report “1. That such potentially dangerous and addictive drugs are so freely available over the internet .
2. That they can be prescribed without any contact with the patient’s regular medical practitioner or access to the patient’s medical records.
3. That such prescriptions of such potentially dangerous and addictive drugs may be being filled in UK pharmacies without any further checks.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 perform further checks when filling prescriptions for potentially dangerous and addictive drugs in UK pharmacies
Wider context from the report “1. That such potentially dangerous and addictive drugs are so freely available over the internet.
2. That they can be prescribed without any contact with the patient’s regular medical practitioner or access to the patient’s medical records.
3. That such prescriptions of such potentially dangerous and addictive drugs may be being filled in UK pharmacies without any further checks .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 access the patient’s medical records before prescribing potentially dangerous and addictive drugs
Wider context from the report “1. That such potentially dangerous and addictive drugs are so freely available over the internet.
2. That they can be prescribed without any contact with the patient’s regular medical practitioner or access to the patient’s medical records .
3. That such prescriptions of such potentially dangerous and addictive drugs may be being filled in UK pharmacies without any further checks.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to contact the patient’s regular medical practitioner before prescribing potentially dangerous and addictive drugs
Wider context from the report “1. That such potentially dangerous and addictive drugs are so freely available over the internet.
2. That they can be prescribed without any contact with the patient’s regular medical practitioner or access to the patient’s medical records.
3. That such prescriptions of such potentially dangerous and addictive drugs may be being filled in UK pharmacies without any further checks.
” 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 with other health regulators to address patient-safety risks from remote consultations and distance-selling medicine supply.
Verbatim wording from the response “With regard to this case, and based on the information provided within the Regulation 28, it appears that this death was not the result of services provided by NHS, but from services outside of the NHS. It is unclear whether this doctor or company were registered and the site from which the deceased obtained the consultation, prescription and medication. Nevertheless, the provision of remote consultations and the supply of medicines through distance selling remains a concern. We are working with other health regulators who have a greater role in responding to this challenge.” Source location 2018-0315-Response-by-NHS-England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure NHS online consultations provide safe, secure access to an appropriate clinician connected with the patient’s GP practice.
Verbatim wording from the response “These issues are important for NHS England and we will ensure that NHS online consultations provide a safe and secure way for patients to discuss their health concerns with an appropriate clinician connected to their own GP practice and place centred around their needs. NHS England has adopted a robust system of quality assurance, safety and security standards so that patients and clinicians can feel confident in using online consultations.” Source location 2018-0315-Response-by-NHS-England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The death appears unrelated to NHS services because the consultation, prescription and medication were obtained outside the NHS.
Verbatim wording from the response “With regard to this case, and based on the information provided within the Regulation 28, it appears that this death was not the result of services provided by NHS, but from services outside of the NHS. It is unclear whether this doctor or company were registered and the site from which the deceased obtained the consultation, prescription and medication. Nevertheless, the provision of remote consultations and the supply of medicines through distance selling remains a concern. We are working with other health regulators who have a greater role in responding to this challenge.” Source location 2018-0315-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CQC and MHRA are better placed to explain and address online prescribing safety work.
Verbatim wording from the response “NHS England remains committed to improving the safety of controlled drugs and online prescribing. We will continue to work across the system with key partners nationally, regionally and locally to ensure patient safety. We would also suggest that contact is made directly with the CQC and MRHA would be better placed should you wish to understand the work in this area further.” Source location 2018-0315-Response-by-NHS-England
Open published response
Concerns raised 8 Inadequate NHS services for adults with ASD View source Lack of education for parents caring for children with ASD View source Severe shortage of inpatient psychiatric beds for children and adolescents View source Over-reliance on questionnaires impeding correct diagnosis View source Lack of support for parents caring for children with ASD View source Reduced training time for doctors causing delays in diagnosis and misdiagnosis View source NHS commissioning structure biased against services for chronic incurable conditions and ASD View source Over-reliance on questionnaires causing underestimation of self-harm risk View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Maximilien Conrad Kohler · 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
Maximilien Conrad Kohler, known as Max, was found hanging by a belt from a pull-up bar at his home on 5 May 2018 and died despite resuscitation. The report identified concerns about delayed or incorrect diagnosis, over-reliance on questionnaires in assessing diagnosis and self-harm risk, limited services and support for people with ASD and their parents, and shortages of NHS inpatient psychiatric beds for children and adolescents.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequate NHS services for adults with ASD
Wider context from the report “6. That services for adults with ASD are even less well provided for by the NHS than those for children .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 education for parents caring for children with ASD
Wider context from the report “4. That there is a lack of support and education available for parents caring for children with ASD .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Severe shortage of inpatient psychiatric beds for children and adolescents
Wider context from the report “5. That there is a severe shortage of inpatient psychiatric beds for children and adolescents in the NHS .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 on questionnaires impeding correct diagnosis
Wider context from the report “2. That over reliance in the current fashion on questionnaires used in diagnostics and management may impede rather than assist doctors and other clinicians, firstly to arrive at the correct diagnosis in the first place , and secondly to cause or contribute to underestimation or proper evaluation of the risk of self -harm in particular.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 support for parents caring for children with ASD
Wider context from the report “4. That there is a lack of support and education available for parents caring for children with ASD .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Reduced training time for doctors causing delays in diagnosis and misdiagnosis
Wider context from the report “1. That delays in diagnosis and misdiagnosis in medicine due to reduced time in training for doctors in general and psychiatry in particular , may imperil the lives of vulnerable patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation NHS commissioning structure biased against services for chronic incurable conditions and ASD
Wider context from the report “3. That the NHS care commissioning structure is biased against the commissioning of services for chronic incurable conditions in general and ASD in particular .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 on questionnaires causing underestimation of self-harm risk
Wider context from the report “2. That over reliance in the current fashion on questionnaires used in diagnostics and management may impede rather than assist doctors and other clinicians, firstly to arrive at the correct diagnosis in the first place, and secondly to cause or contribute to underestimation or proper evaluation of the risk of self -harm in particular .
” Open source report
9 Oct 2018 Tom Cribley · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 12 Failure to document important clinical findings View source Insufficient clinical staff training in identifying and treating sepsis View source Failure to escalate monitoring and management after grossly abnormal blood results View source Failure of senior leadership ownership of training programme implementation and review View source Failure to maintain systematic and monitored ongoing sepsis training View source Failure to complete full PIT STOP reviews View source Failure to hand over clinical concerns to relevant clinical staff View source Failure to escalate and convey the severity of deterioration to the Critical Care Team View source Failure to review an initial diagnosis when the patient deteriorates View source Delays in escalating NEWS to medical staff View source Delays in administering antibiotic therapy during clinical deterioration View source Failure to repeat observations hourly in accordance with the NEWS policy View source See 9 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
Tom Cribley · 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
Tom Cribley attended Aintree hospital on 18 February 2017 with vomiting, diarrhoea and a rash, and was later diagnosed with meningococcal sepsis. The report identifies concerns including failures to document and escalate the rash and deteriorating observations, inadequate handovers and reassessment, delayed recognition of abnormal blood results, and delayed antibiotic treatment. Tom did not recover and died on 20 February 2017.
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 document important clinical findings
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage . The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 clinical staff training in identifying and treating sepsis
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 monitoring and management after grossly abnormal blood results
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results , the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 senior leadership ownership of training programme implementation and review
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board . This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 systematic and monitored ongoing sepsis training
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness .
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 full PIT STOP reviews
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review , the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 hand over clinical concerns to relevant clinical staff
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers , the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 and convey the severity of deterioration to the Critical Care Team
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team , who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 review an initial diagnosis when the patient deteriorates
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate , the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 escalating NEWS to medical staff
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 administering antibiotic therapy during clinical deterioration
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 repeat observations hourly in accordance with the NEWS policy
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy . The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report
4 Oct 2018 Bradley Jordache Morgan · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Excessive staff caseloads in mental health services View source Chronic underfunding of mental health services View source Failure to provide needed follow-up review in mental health care View source Breakdown in communication between mental health care teams and individuals 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
Bradley Jordache Morgan · 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
Bradley Jordache Morgan was declared dead on 13 May 2018 after falling from the eighth-floor balcony of his home; the medical cause of death was multiple blunt injuries. He had a history of mental illness and was considered at high risk of suicide and self-harm, but was not reviewed by the community mental health team after a missed appointment. Concerns included communication and follow-up failures, excessive staff caseloads, and underfunding of mental health services creating a risk to life.
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 Excessive staff caseloads in mental health services
Wider context from the report “3. Despite the comprehensive action plan evidence was given by the Medical Director of the Birmingham Women’s and Children’s NHS Foundation Trust that she was concerned that even with the processes and training identified in the action plan similar circumstances could arise again due to the pressures placed on staff who carry caseloads well in excess of the national average as a result of demand on the service .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Chronic underfunding of mental health services
Wider context from the report “4. The evidence given was that chronic underfunding of mental health services is creating a risk to life .
5. The strain on the systems of Mental Health Services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health NHS Foundation Trust has become apparent to the Birmingham and Solihull Coroners in recent months. Consequently this report to prevent future death is being made in conjunction with reports to prevent future deaths arising from 6 other investigations into deaths between May and August 2018 that demonstrate a risk that future deaths will occur as a result of under-funding .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 needed follow-up review in mental health care
Wider context from the report “1. Investigation into Mr. Morgan’s mental health care provided by Forward Thinking Birmingham identified gross failings following an appointment on the 15th December 2017 where despite an obvious need for follow up there was a breakdown in communication between teams and individuals that meant he was not reviewed again before his death in May.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Breakdown in communication between mental health care teams and individuals
Wider context from the report “1. Investigation into Mr. Morgan’s mental health care provided by Forward Thinking Birmingham identified gross failings following an appointment on the 15th December 2017 where despite an obvious need for follow up there was a breakdown in communication between teams and individuals that meant he was not reviewed again before his death in May.
” Open source report
4 Oct 2018 Michael Paul Wheeler · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 6 Unavailability of inpatient mental health beds for patients requiring inpatient treatment View source Underfunding of mental health services View source Failure of home treatment teams to visit all patients requiring a visit each day View source Failure to provide psychiatrist review and treatment planning for patients with acute paranoid or aggressive presentations View source Lack of planned follow-up review for mental health patients View source Unavailability of urgent psychiatrist review through home treatment teams View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Michael Paul Wheeler · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Paul Wheeler died after jumping from a fourth-floor window at his brother’s home on 26 July 2018, following increasing paranoia and bizarre behaviour. The principal concerns were that he was not reviewed by a psychiatrist, had no treatment plan, and had no planned review on 26 July; broader concerns were raised about pressures on mental health services, including the availability of urgent psychiatric reviews and inpatient beds.
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 inpatient mental health beds for patients requiring inpatient treatment
Wider context from the report “2. The Coroner is aware, although not from evidence obtained in respect of Mr. Wheeler’s case as the inquest is yet to take place, that inpatient beds within the BSMHFT who are currently operating at 109% capacity and are often not available . Consequently, patients who would otherwise have been offered in-patient treatment, are having to be managed by the HTTs . Partly as a consequence of this but partly due to other pressures the demand on the HTTs is often too great to enable them to visit all patients requiring a visit in any one day. One particular problem in the Birmingham and Solihull area is that the occurrence of psychosis is more than 3 times higher than the national average. It is understood that the Trust is exploring options to expand its HTT service but funding is required.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 of mental health services
Wider context from the report “4. Although evidence at inquest has yet to be heard there is a concern that this case, along with several other cases being investigated by the Birmingham and Solihull Coroners’ jurisdiction may arise from underfunding of mental health services .
5. The strain on the systems of mental health services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health NHS Foundation Trust has become apparent to the Birmingham and Solihull Coroners in recent months. Consequently this report to prevent future death is being made in conjunction with reports to prevent future deaths arising from 6 other investigations into deaths between May and August 2018 that demonstrate a risk that future deaths will occur as a result of under-funding .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 home treatment teams to visit all patients requiring a visit each day
Wider context from the report “2. The Coroner is aware, although not from evidence obtained in respect of Mr. Wheeler’s case as the inquest is yet to take place, that inpatient beds within the BSMHFT who are currently operating at 109% capacity and are often not available. Consequently, patients who would otherwise have been offered in-patient treatment, are having to be managed by the HTTs. Partly as a consequence of this but partly due to other pressures the demand on the HTTs is often too great to enable them to visit all patients requiring a visit in any one day . One particular problem in the Birmingham and Solihull area is that the occurrence of psychosis is more than 3 times higher than the national average. It is understood that the Trust is exploring options to expand its HTT service but funding is required.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 psychiatrist review and treatment planning for patients with acute paranoid or aggressive presentations
Wider context from the report “1. Mr. Wheeler’s family have provided evidence that he was extremely paranoid by the 24th of July 2018 and this was causing him to act irrationally and at times aggressively, they were very fearful for his safety and reported this to the mental health nurses he saw on the 24th and 25th. Despite these concerns Mr. Wheeler was not reviewed by a Psychiatrist and therefore his condition went undiagnosed with no treatment plan. Furthermore it is noted that there was no plan to review Mr. Wheeler at all on the 26th July 2018.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 planned follow-up review for mental health patients
Wider context from the report “1. Mr. Wheeler’s family have provided evidence that he was extremely paranoid by the 24th of July 2018 and this was causing him to act irrationally and at times aggressively, they were very fearful for his safety and reported this to the mental health nurses he saw on the 24th and 25th. Despite these concerns Mr. Wheeler was not reviewed by a Psychiatrist and therefore his condition went undiagnosed with no treatment plan. Furthermore it is noted that there was no plan to review Mr. Wheeler at all on the 26th July 2018 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 urgent psychiatrist review through home treatment teams
Wider context from the report “3. The fact that at the current time HTT cannot always provide urgent medical review by a psychiatrist creates a risk to life .
” Open source report
4 Oct 2018 Stephen Peter Jackson · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Failure to provide timely mental health follow-up after hospital discharge View source Failure to answer calls to mental health professionals View source Failure to send mental health appointments View source Under-funding of mental health services View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Stephen Peter Jackson · 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 Peter Jackson was found deceased at home on 11 August 2018 after sending his mother a text message saying “sorry”; drugs paraphernalia and a suicide note were present, and the provisional cause of death was a diamorphine overdose. The report raised concerns that he was not seen by mental health clinicians after his GP requested an urgent appointment, despite reported low mood and negative thoughts, and that delays and possible under-funding of mental health services posed a risk of future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely mental health follow-up after hospital discharge
Wider context from the report “1. On the 1st August 2018 Mr. Jackson attended his GP and expressed frustration that following his discharge from hospital on the 23rd July 2018. He had not been contacted by the home treatment team and his GP wrote to the Kingstanding and Erdington Home Treatment Team that same day asking them to expedite his appointment , reporting that Mr. Jackson continued to have low mood and negative thoughts and merited an urgent appointment.
2. Mr. Jackson was not seen by mental health clinicians following the GP request.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 answer calls to mental health professionals
Wider context from the report “3. Mr. Jackson wrote a very detailed suicide note within which he refers to feeling unsupported by professionals who did not send him appointments or answers his calls , the context would support this being a reference to mental health professionals.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 send mental health appointments
Wider context from the report “3. Mr. Jackson wrote a very detailed suicide note within which he refers to feeling unsupported by professionals who did not send him appointments or answers his calls, the context would support this being a reference to mental health professionals.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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-funding of mental health services
Wider context from the report “4. Although evidence at inquest has yet to be heard there is a concern that this case, along with several other cases being investigated by the Birmingham and Solihull Coroners’ jurisdiction, future deaths may arise due to under-funding of mental health services .
5. The strain on the systems of mental health services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health Trust has become apparent to the Birmingham and Solihull Coroners in recent months. Consequently this report to prevent future death is being made in conjunction with reports to prevent future deaths arising from 6 other investigations into deaths between May and August 2018 that demonstrate a risk that future deaths will occur as a result of under-funding .
6. In addition to this report letters are enclosed from the Medical Directors of both Trusts setting out their concerns.
” Open source report
4 Oct 2018 William Peter Edge · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Failure of home treatment teams to visit all patients requiring a visit when required View source Unavailability of inpatient mental health beds View source Underfunding of mental health services 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
William Peter Edge · 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
William Peter Edge was found hanging in the shed at his home in Birmingham on 18 August 2018, after an ambulance crew attempted resuscitation. He had depression, a history of self-harm, and had attempted to hang himself the previous day before being assessed and discharged with a referral to the home treatment team. Concerns included the home treatment team being unable to return when his wife reported that he was in imminent danger, and wider pressures on inpatient beds and home treatment services, including a stated risk to life when patients cannot be attended as required.
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 home treatment teams to visit all patients requiring a visit when required
Wider context from the report “3. The Coroner is aware, although not from evidence obtained in respect of Mr. Edge’s case as the inquest is yet to take place, that inpatient beds within the BSMHFT are currently operating at 109% capacity and are often not available. Consequently patients who would otherwise have been offered in-patient treatment are having to be managed by the HTTs, partly as a consequence of this but partly due to other pressures the demand on the HTTs is often too great to enable them to visit all patients requiring a visit in any one day which in turn is putting pressure on out of hours services. It is understood that the Trust is exploring options to expand its HTT service but funding is required.
4. The fact that at the current time HTTs cannot attend patients when required creates a risk to life .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unavailability of inpatient mental health beds
Wider context from the report “3. The Coroner is aware, although not from evidence obtained in respect of Mr. Edge’s case as the inquest is yet to take place, that inpatient beds within the BSMHFT are currently operating at 109% capacity and are often not available . Consequently patients who would otherwise have been offered in-patient treatment are having to be managed by the HTTs , partly as a consequence of this but partly due to other pressures the demand on the HTTs is often too great to enable them to visit all patients requiring a visit in any one day which in turn is putting pressure on out of hours services. It is understood that the Trust is exploring options to expand its HTT service but funding is required.
4. The fact that at the current time HTTs cannot attend patients when required creates a risk to life.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Underfunding of mental health services
Wider context from the report “5. Although evidence at inquest has yet to be heard there is a concern that this case, along with several other cases being investigated by the Birmingham and Solihull Coroners’ jurisdiction may arise from underfunding of mental health services .
6. The strain on the systems of mental health services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health NHS Foundation Trust has become apparent to the Birmingham and Solihull Coroners in recent months. Consequently this report to prevent future death is being made in conjunction with reports to prevent future deaths arising from 6 other investigations into deaths between May and August 2018 that demonstrate a risk that future deaths will occur as a result of under-funding .
” Open source report
4 Oct 2018 Michael William Cooper · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 7 Out-of-area mental health beds disrupting patient support and continuity of care View source Strain on mental health service systems View source Lack of available inpatient mental health beds View source Insufficient Care Coordinator capacity to review patient histories and assess risk View source Under-funding of mental health services View source Insufficient funding to maintain staff and resources under service demand View source Delays in Care Programme Approach follow-up appointments 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
Michael William Cooper · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael William Cooper was found dead at home on 22 June 2018 from constriction by a ligature around the neck. The report describes concerns about the lack of face-to-face follow-up and immediate action despite indications of high suicide risk, as well as shortages of inpatient beds, team capacity and funding in mental health services.
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 Out-of-area mental health beds disrupting patient support and continuity of care
Wider context from the report “1. The Home Treatment Team advised on the 13th March 2018 that Mr. Cooper should be admitted for inpatient mental health treatment. However, this could not happen on the day as there was no bed available. The lack of inpatient beds is a known resource issue within the Birmingham and Solihull Mental Health NHS Foundation Trust, which the Trust is currently working to address through numerous new initiatives. In the absence of an inpatient bed, Mr. Cooper was managed with medication and home treatment team visiting twice a day. Whilst awaiting admission, he was offered an out-of-area bed on the 16th March 2018 but he declined this as he felt it would be detrimental to him to be so far from his wife and family. The Coroner is aware, although this was not an issue that came out in evidence in this case, that placing patients in out of area beds not only causes difficulty for maintaining the patient's support and visits from family and friends which can be prejudicial to their mental health, but also affects their continuity of care thus creating a risk to life .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Strain on mental health service systems
Wider context from the report “5. The strain on the systems of mental health services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health NHS Foundation Trust has become apparent to the Birmingham and Solihull Coroners in recent months. Consequently this report to prevent future death is being made in conjunction with reports to prevent future deaths arising from 6 other investigations into deaths between May and August 2018 that demonstrate a risk that future deaths will occur as a result of under-funding.
6. In addition to this report, letters are enclosed from the Medical Directors of both Trusts setting out their 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 available inpatient mental health beds
Wider context from the report “1. The Home Treatment Team advised on the 13th March 2018 that Mr. Cooper should be admitted for inpatient mental health treatment. However, this could not happen on the day as there was no bed available . The lack of inpatient beds is a known resource issue within the Birmingham and Solihull Mental Health NHS Foundation Trust, which the Trust is currently working to address through numerous new initiatives. In the absence of an inpatient bed, Mr. Cooper was managed with medication and home treatment team visiting twice a day. Whilst awaiting admission, he was offered an out-of-area bed on the 16th March 2018 but he declined this as he felt it would be detrimental to him to be so far from his wife and family. The Coroner is aware, although this was not an issue that came out in evidence in this case, that placing patients in out of area beds not only causes difficulty for maintaining the patient's support and visits from family and friends which can be prejudicial to their mental health, but also affects their continuity of care thus creating a risk to life.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient Care Coordinator capacity to review patient histories and assess risk
Wider context from the report “3. When Mr. Cooper was established on the Care Programme Approach, his Care Co-ordinator did not have the capacity to review his notes prior to her first visit and therefore did not have a clear understanding of his complex history . Care Co-ordinators within Birmingham and Solihull Mental Health Trust are currently carrying a caseload of more than 30 patients . The NICE guidelines for the Care Programme Approach advises that a Care Coordinator should have caseload of 15 patients. Without the time to familiarise themselves with their patients’ histories Care Co-ordinators cannot make informed assessments of their risk which puts lives at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Under-funding of mental health services
Wider context from the report “5. The strain on the systems of mental health services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health NHS Foundation Trust has become apparent to the Birmingham and Solihull Coroners in recent months. Consequently this report to prevent future death is being made in conjunction with reports to prevent future deaths arising from 6 other investigations into deaths between May and August 2018 that demonstrate a risk that future deaths will occur as a result of under-funding .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 funding to maintain staff and resources under service demand
Wider context from the report “4. Despite a detailed root cause analysis investigation with a comprehensive action plan arising from Mr. Cooper’s case, without increased funding similar circumstances could arise again due to the pressures placed on staff and resources arising from demand for the service .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 Care Programme Approach follow-up appointments
Wider context from the report “2. An appointment following referral onto the Care Programme Approach on the 18th April 2018 was outside the two week timeframe specified in the Care Programme Approach Policy . This was due to capacity issues within the team and was not an isolated occurrence . Consequently a patient requiring follow up within 2 weeks may be left unsupported which creates a risk to life.
” 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 Ensure commissioned and provided services deliver high-quality risk assessment continuously, 24 hours a day, seven days a week.
Verbatim wording from the response “b. Risk assessment: this needs to be available and of high quality 24 hours a day, 7 days a week. We will ensure services are commissioned and provided to ensure this occurs in order to provide safe and effective care. Provider and the CCG will identify any cases where risk assessment has not been provided in a timely manner for patients and also investigate where the outcome of that risk assessment is inadequate. This will be undertaken by the CCG and providers at established monthly quality review meetings.” Source location NHS-England-Response.pdf
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 Funding is not the sole cause of the identified failures, and the link between funding and the deaths cannot currently be validated.
Verbatim wording from the response “5. Funding: In 2017/18 provided additional investment in mental health services above the contract value amounting to £4,611,000 for BSMHFT (3.7% increase) and £6,235,000 for FTB (22.6% increase). In 2018/19 the CCG provided additional investment in BSMHFT amounting to £3,117,000 (2.4% increase) and FTB amounting to £2,881,000 (9.3% increase). Further funding discussions are ongoing but at present the CCG is unable to validate a link between funding and the deaths presented. However, the CCG continuously monitors this position and demand in order to ensure it is responsive to any increase in demand where funding would be either the sole, or contributory solution.” Source location NHS-England-Response.pdf
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 Clinical Commissioning Group will lead the shared demand analysis needed to assess demand, capacity and funding constraints.
Verbatim wording from the response “Funding alone is not the issue but there is agreement that in order to answer the question of the likely attribution of funding constraint on risk within services, all stakeholders need to be party to a shared demand analysis (with an extended invitation to partners from health and Justice, local authority and schools) and a ‘Suicide prevention strategy’. The Demand analysis will be led by the CCG and the Suicide prevention strategy will be led by the Director of Public Health.” Source location NHS-England-Response.pdf
Open published response
3 Oct 2018 Simon Anthony Graham · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 6 Failure of support workers to complete suicide prevention training View source Under-funding of mental health services creating a risk of future deaths View source Continuation of lone working during emergencies View source Use of unqualified support workers for suicide risk assessments View source Absence of a scoring system or guide for suicide risk assessments View source Failure to maintain accurate room-key labelling View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Simon Anthony Graham · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Simon Anthony Graham, who had recently attempted suicide by overdose, died by suspension from a ligature at a respite centre on 4 May 2018. The report raised concerns about lone working, delays caused by incorrectly labelled room keys, unqualified support workers undertaking suicide risk assessments, and incomplete suicide prevention training.
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 support workers to complete suicide prevention training
Wider context from the report “5. Concern 4: Future Care & Social Care Association have identified that support workers should undertake suicide prevention training. I heard evidence that some support workers have still not undertaken this training despite lone working and support workers continuing to undertake suicide risk assessments.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Under-funding of mental health services creating a risk of future deaths
Wider context from the report “6. The strain on the systems of Mental Health Services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health NHS Foundation Trust has become apparent to the Birmingham and Solihull Coroners in recent months. Consequently this report to prevent future death is being made in conjunction with reports to prevent future deaths arising from 6 other investigations into deaths between May and August 2018 that demonstrate a risk that future deaths will occur as a result of under-funding .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Continuation of lone working during emergencies
Wider context from the report “2. Concern 1: At any one time only one support worker is working . The death of Simon Graham identified a number of concerns arising from lone working during an emergency:
A) Upon concern being raised by Simon Graham’s wife, the support worker was prevented from promptly checking on his wellbeing because he was with another resident at the medicine cupboard. He had to finish with the other resident and ensure the medicine cupboard was left secure. This caused a delay of about 10-15 minutes before the support worker could check on Simon Graham. Further delay was then caused by confusion over rooms – see below.
B) After forcing entry and finding Simon Graham hanging and in cardiac arrest the support worker got him down and commenced CPR. He had to call for help from other residents but no one came. He had to break-off CPR for at least 80 seconds when he ran down three flights of stairs to answer the door thinking it was an ambulance (it was in fact the deceased’s wife). I heard evidence that the lone working still exists because the current financial contract with the NHS is insufficient to cover the cost of a second support worker, despite Future Care & Social Care Association wanting to end lone working.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Use of unqualified support workers for suicide risk assessments
Wider context from the report “4. Concern 3: When a new patient arrives an unqualified support worker completes a suicide risk assessment based on a) the written observations/risk assessment from mental health Drs/nurses faxed over with the referral and b) talking directly to the resident about their intentions. There is no score system or guide to assist support workers. The support worker who completed the risk assessment for Simon Graham was unable to explain what makes him competent to undertake such an assessment and said in terms that he believes they should be undertaken by a mental health nurse. I heard evidence that unqualified support workers are continuing to undertake suicide risk assessments .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Absence of a scoring system or guide for suicide risk assessments
Wider context from the report “4. Concern 3: When a new patient arrives an unqualified support worker completes a suicide risk assessment based on a) the written observations/risk assessment from mental health Drs/nurses faxed over with the referral and b) talking directly to the resident about their intentions. There is no score system or guide to assist support workers. The support worker who completed the risk assessment for Simon Graham was unable to explain what makes him competent to undertake such an assessment and said in terms that he believes they should be undertaken by a mental health nurse. I heard evidence that unqualified support workers are continuing to undertake suicide risk assessments.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate room-key labelling
Wider context from the report “3. Concern 2: Support workers were using keys to check on residents in their rooms knowing that they were labelled incorrectly . The fact Simon Graham’s room key was incorrectly labelled added to the delayed entry to the room and emergency first aid. I heard evidence that after the death of Simon Graham all keys were checked to ensure they were labelled correctly. However, Future Care & Social Care Association want to implement a key fob system, to avoid any confusion and provide quick access in an emergency, but this has still not been implemented. Further funding would be required to implement a key fob system.
” Open source report
19 Sep 2018 Sufia Begum · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Lack of doctors’ awareness of the BNF mobile device app for identifying potential drug interactions 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
Sufia Begum · 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
Sufia Begum was admitted to Queen Elizabeth Hospital with vomiting, confusion and generalised weakness after being prescribed clarithromycin while taking verapamil. She died on 24 April 2018 from multiorgan failure and calcium channel blocker toxicity, with the inquest concluding that she died from an unrecognised adverse drug interaction. The principal concern was that not all doctors were aware of the BNF mobile device app, identified as a useful tool for detecting potential drug interactions.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of doctors’ awareness of the BNF mobile device app for identifying potential drug interactions
Wider context from the report “1. I heard evidence at the inquest that the most useful tool to identify potential drug interactions was the BNF mobile device APP. The author of the RCA confirmed that not all doctors were aware of the APP. An alert to all NHS Trusts and GPs would provide this valuable information which may prevent a future death from an unknown drug interaction.
” Open source report
Concerns raised 6 Lack of assessment of care needs and provision across supporting services View source Failure to coordinate and provide appropriate mental health support for people affected by the incident View source Lack of access to guidance and information about health consequences of hazardous-site exposure View source Lack of structured health screening for people exposed to smoke and dust inhalation View source Risk of respiratory illness after smoke, particulate and poison inhalation View source Potential asbestos exposure causing late-onset health conditions View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Fatemeh Afrasiabi and 70 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
The report concerns people who died in the Grenfell Tower fire, where it was considered likely that almost all deaths resulted from smoke inhalation, although this evidence had not yet been tested in court. Concerns included the absence of a structured health-screening programme for survivors, first responders and site workers exposed to smoke, dust and potentially asbestos, together with the risk of later physical and mental health problems going unnoticed.
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 assessment of care needs and provision across supporting services
Wider context from the report “8. It may be that the provision of some care services, for physical or psychological damage may be provided by occupational health services outside the NHS, however a scale and risk assessment of need and care provision needs to be undertaken to minimise persons affected slipping through the net and being lost from appropriate supportive services .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate and provide appropriate mental health support for people affected by the incident
Wider context from the report “7. That the NHS needs to oversee and co-ordinate and provide appropriate mental health support for all those affected by their involvement in the incident , be they survivors, bereaved, local residents or first responders or other workers involved in the aftermath. The potential impact of this disaster is very wide ranging.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of access to guidance and information about health consequences of hazardous-site exposure
Wider context from the report “6. That survivors and first responders and site workers, need to be given access to guidance and/ or information that would help them to understand what could be the health consequences of being exposed to the hazardous environment of the site of the fire.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 health screening for people exposed to smoke and dust inhalation
Wider context from the report “1. That no structured health screening programme is in place for those who were exposed to risks of smoke and dust inhalation during the Grenfell Tower fire.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 respiratory illness after smoke, particulate and poison inhalation
Wider context from the report “2. That those subject to smoke and dust inhalation are at risk of developing health conditions in particular respiratory illness after particulate and poison inhalation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Potential asbestos exposure causing late-onset health conditions
Wider context from the report “3. That there may have been exposure to asbestos during and after the fire that could possibly cause late onset health issues such as mesothelioma .
” Open source report
Concerns raised 3 Failure to ensure that the GP is informed View source Failure to check patients’ appropriate access to medication before self-certification View source Toxicity of amitriptyline when taken in excessive amounts or with other medication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Karl James Willis · 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
Karl James Willis was found deceased at home, with toxicology showing amitriptyline at a concentration within the reported fatal range and morphine sufficient to increase its toxicity. The inquest recorded the medical cause of death as aspiration pneumonitis and amitriptyline and morphine toxicity, with a conclusion of misadventure. Concerns included online access to amitriptyline without adequate checks, the ability to provide inaccurate information, and the option not to inform the patient’s GP.
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 the GP is informed
Wider context from the report “(3) Permitting the patient the option of not having the GP informed removes an otherwise effective safeguard . The GP had worked with extreme care and supported the patient over many months to try and reduce his excessive reliance on polypharmacy.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to check patients’ appropriate access to medication before self-certification
Wider context from the report “(2) Permitting the patient to “self certify” without any checks he can appropriately access this medication can allow the patient to give inaccurate answers , and therefore the questionnaire is open to deliberate abuse by those most vulnerable who have addiction problems
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Toxicity of amitriptyline when taken in excessive amounts or with other medication
Wider context from the report “(1) Amitriptyline is well recognised to have toxic effects when taken in excessive amounts or in conjunction with other medication
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Private consultations, private-only clinicians and online prescribing fall outside the Board’s jurisdiction or control.
Verbatim wording from the response “In choosing to access private health care, a patient is stepping outside the NHS, as a result, the Board has no jurisdiction over private consultations and none of the Board’s powers relating to community pharmacy, prescriptions or regulation would apply.” Source location 2018-0256-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The provider could not share consultation details with the patient’s GP because there was no legal justification to breach confidentiality.
Verbatim wording from the response “You finally highlight the concern that Karl was given an option to refuse to have the details of his consultation with the private on-line provider to be shared with his own GP. We have checked the website for the provider which has been involved in this case and note that it is recommended that information is shared with a patient’s own GP. As you will appreciate, whilst most often in a patient’s best interest information to be shared, the bar at which it is appropriate for confidentiality to be breached is set high and in the tragic circumstance of Karl Willis, there would have been no legal justification to have breached his confidentiality and informed his GP or anyone else involved in his care.” Source location 2018-0256-Response-by-NHS-England
Open published response
21 Aug 2018 Kiarah Faith Adora Allen · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Insufficient nursing and clinical staffing for very sick babies 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
Kiarah Faith Adora Allen · 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
Kiarah Faith Adora Allen was born extremely prematurely and died after an inadvertent total parenteral nutrition fluid overload during a change of treatment, which led to severe metabolic complications and cardiac failure. The report identified unsafe staffing levels, failure to follow the correct procedure, and failure to learn from a previous similar incident. The principal concern was that staffing levels were insufficient when the neonatal unit was full.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient nursing and clinical staffing for very sick babies
Wider context from the report “1. I heard evidence in the inquest that at the time this incident occurred there were unsafe levels of nursing and clinical staff . The funding provided for nurses assumed the unit was only 85% full. Therefore when the unit was full, there were insufficient numbers of nurses and doctors . Consideration needs to be given to providing additional funding to enable the unit to be appropriately staffed for the very sick babies they care for.
” Open source report
Concerns raised 2 Unclear mental health care pathways for professionals after discharge View source Lack of triage of GP appointment requests for likely clinical difficulty 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
Graeme Robert Mathieson · 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
Graeme Robert Mathieson died following an intentional overdose of prescribed medication. The inquest concluded suicide and identified gross failures to provide basic medical attention while he was in a dependent position, which caused or contributed to the outcome. Concerns included time constraints affecting recognition of his serious psychiatric condition, confusion about mental-health care pathways, and weaknesses in transfer processes.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unclear mental health care pathways for professionals after discharge
Wider context from the report “It became apparent during the course of the inquest that a number of professionals (both GPs and care coordinators) were confused or unclear about the correct pathway for ████████ to follow once he had been wrongly discharged from the local CM HT . I indicated that I felt it may be beneficial for Livewell Southwest to add a ‘Professionals’ tab or page to its website so that doctors and other professionals could refer to it in the event of uncertainty. I suggested that it may be sensible for a doctor representing GPs locally to sit down with an individual from Livewell Southwest to ensure that any areas of ongoing confusion were recognised and appropriately addressed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 triage of GP appointment requests for likely clinical difficulty
Wider context from the report “At page 20 of my judgement I found that at the appointment on 10 August 2016 the time constraints under which ████████ was obliged to work meant that he was faced with trying to achieve the impossible. I said that I was sure that the very real constraints of time had had a direct impact on the outcome of the appointment. I said that it would have been better if the likely difficulties in this regard had been recognised at the point that Mr Matheson or his sister had asked to have an appointment . If there had been some sort of triage system in place , as I understand to be the case in other practices, this could have been recognised from the outset.
I am aware that while some GP practices operate triage system there are plenty of others that do not . I think it may be beneficial for the facts of this case to be shared with all GPs in the area as a learning exercise. What I want to ensure, as far as possible, is that another GP is not placed in the same situation as ████████ on 10 August 2016 with the nearly inevitable conclusion that a patient’s serious psychiatric condition is not recognised .
” Open source report
16 Jul 2018 Sheila Winifred Ridgway · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1 Lack of a system for communication between treating specialty consultants about potential ongoing risks of simultaneous specialty-specific treatments 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
Sheila Winifred Ridgway · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sheila Winifred Ridgway was treated for arterial disease in both legs and later developed a painful, cold, pulseless right leg after stopping dual antiplatelet therapy before a planned loop ECG recorder procedure. She subsequently developed diarrhoea, deteriorating renal function, low blood pressure and multi-organ failure due to sepsis, and died after escalation of treatment was considered futile. The principal concern was inadequate communication between specialty consultants about ongoing risks and treatment requirements.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for communication between treating specialty consultants about potential ongoing risks of simultaneous specialty-specific treatments
Wider context from the report “1) Communication between specialty consultants – lack of any system to ensure that communication occurs between the treating consultants as to the necessity for identifying and documenting any potential ongoing risks when specialty specific treatments are being contemplated or planned for the different specialities simultaneously
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations