Concerns raised 1 Lack of guidance on steps to take when high serum clozapine levels are returned View source
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AI-generated summary
Mr Turner · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Turner was a 63-year-old man who was found deceased at his home on 18 April 2025; a postmortem identified citalopram toxicity as the cause of death. The concern raised was that there was no local or national guidance on what steps to take when a high serum level is returned in patients monitored while taking clozapine.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on steps to take when high serum clozapine levels are returned
Wider context from the report “1. That when a high serum level is returned in patients being monitored as they are taking clozapine, there is no guidance, locally or nationally as to what steps should be taken .
” 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 Write to all Mental Health Chief Pharmacists requesting local clozapine clinics review and update plasma-level monitoring information and support materials.
Verbatim wording from the response “In response to this case, NHS England has written to all Mental Health Chief Pharmacists in England to ask them to work with their local clozapine clinics to review the information and support materials that they use. This is to help ensure the safe and appropriate use of plasma level monitoring within their Trusts, and ensure these are up to date and embedded locally.” Source location 2026-0065 - Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Interpretation of clozapine plasma levels is assigned to individual trusts, based on general guidance and local clinical circumstances.
Verbatim wording from the response “In summary, the interpretation of clozapine plasma levels should be individualised at trust level, based on the general guidance contained in all the above information.” Source location 2026-0065 - Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing national and local guidance is considered sufficient to support decisions on high clozapine plasma levels.
Verbatim wording from the response “In the majority of NHS trusts clozapine treatment will be undertaken though a dedicated clozapine clinic where the overall safe prescribing and associated monitoring will be undertaken.” Source location 2026-0065 - Response from NHS England
Open published response
12 Jan 2026 Amy Grace Pugh · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 1 Lack of access to important mental health records from partner NHS mental health institutions View source
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AI-generated summary
Amy Grace Pugh · 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
Amy Grace Pugh took an overdose of drugs around midnight on 10 April 2024 and died on the morning of 11 April 2024; the inquest could not determine her intent. Concerns included clinical staff being unable to access important mental-health records from partner NHS institutions and overnight observations that did not involve entering her room or physically examining her.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of access to important mental health records from partner NHS mental health institutions
Wider context from the report “Following Amy’s admission to Avondale Unit on 8th April 2024, clinical staff were unable to access important records pertaining to Amy’s mental health from partner NHS mental health institutions and this compromised her assessment and subsequent management. The approved findings of fact are attached.
” 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 the Summary Care Record Programme to support wider access to relevant patient information.
Verbatim wording from the response “NHS England is aware of the challenge in sharing medical records between providers and the variability between areas using different technologies. We are also aware that use of the SCR is variable across different care settings. We are therefore working across the health system to support greater integration and awareness of record sharing between providers. We are also working with the SCR Programme to support wider access to relevant patient information.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work across the health system to support greater integration and awareness of record sharing between providers.
Verbatim wording from the response “NHS England is aware of the challenge in sharing medical records between providers and the variability between areas using different technologies. We are also aware that use of the SCR is variable across different care settings. We are therefore working across the health system to support greater integration and awareness of record sharing between providers. We are also working with the SCR Programme to support wider access to relevant patient information.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual NHS trusts are responsible for procuring, implementing and locally converging their electronic patient record systems.
Verbatim wording from the response “NHS England is committed to improving the maturity and quality of Electronic Patient Records (EPRs) across all NHS Trusts. NHS England has provided funding to ensure all NHS Trusts have an EPR implemented. It is, however, up to individual NHS Trusts to effectively procure and implement their chosen EPR system, and to agree and progress any convergence of EPR systems within their local systems.” Source location Response from NHS England
Open published response
Concerns raised 2 Lack of national pathway guidance for call handlers on assessing whether someone is breathing and whether CPR is required View source Lack of national pathway guidance for call handlers on assessing how cold the body is View source
Responses linked to these concerns
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AI-generated summary
Drew John GREAVES-PIMBLETT · 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
Drew John Graves-Pimblett, aged 26 and with a history of epilepsy, was found unresponsive and not breathing at home on 22 March 2025. An ambulance was initially stood down after telephone triage, but police later commenced CPR and Drew was pronounced deceased. The inquest concluded that he died from Sudden Unexpected Death in Epilepsy (SUDEP), related to epilepsy and natural causes. The principal concern was that call handlers lacked sufficient guidance and did not ask probing questions about breathing, body temperature, turning Drew over, or stiffness before deciding that resuscitation would not be effective.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of national pathway guidance for call handlers on assessing whether someone is breathing and whether CPR is required
Wider context from the report “Though a telephone triage is always challenging and subjective, there appears to be a gap in the national pathways for call handlers . Consideration as to further guidance and assistance to call handlers on probing questioning for fundamental aspects such as breathing and where and how to best show how cold the body is. If someone is not breathing to ask how they know and/or techniques such as head to the chest, where to take a pulse etc. for the call handler to make a more informed decision as to whether someone is breathing and if CPR is required . When a call is made to NWAS, often it is by someone not thinking straight and so specific questions on breathing and general presentation may be of assistance in assessing the call .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 pathway guidance for call handlers on assessing how cold the body is
Wider context from the report “Though a telephone triage is always challenging and subjective, there appears to be a gap in the national pathways for call handlers . Consideration as to further guidance and assistance to call handlers on probing questioning for fundamental aspects such as breathing and where and how to best show how cold the body is . If someone is not breathing to ask how they know and/or techniques such as head to the chest, where to take a pulse etc. for the call handler to make a more informed decision as to whether someone is breathing and if CPR is required. When a call is made to NWAS, often it is by someone not thinking straight and so specific questions on breathing and general presentation may be of assistance in assessing the call.
” 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 Provide CPR Toolkit Training to NHS Pathways health advisors, including the ‘No, No, Go’ approach and telephone-guided CPR initiation.
Verbatim wording from the response “Also, of relevance to this particular case, in terms of additional training regarding the assessment of consciousness and breathing, health advisors utilising NHS Pathways who have completed the core training are provided with ‘CPR Toolkit Training’. This encompasses what is called the ‘No, No, Go’ approach where, if the patient is not conscious or not breathing (either normally or at all), health advisors are trained to proceed immediately to the initiation of cardiopulmonary resuscitation (CPR) as presented by the system. This additional training seeks to ensure that health advisors are supported to proceed quickly to the required life supporting advice.” Source location Response from NHS England
Open published response
7 Jan 2026 Joshua Lee Allcock · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 4 Use of insensitive Capillary Refill Time testing for dehydration assessment View source Lack of clear national guidance on autism assessment View source Failure to provide onward referral to dieticians experienced in autism and ARFID View source Risk of dehydration among autistic children in similar circumstances View source See 1 more concern
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AI-generated summary
Joshua Lee Allcock · 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
Joshua Lee Allcock, a five-year-old boy with complex medical needs and a limited diet, developed severe dehydration after entering foster care and died on 3 January 2023 despite hospital treatment. Concerns included the lack of a formal autism diagnosis and related dietary support, variation in autism assessment practice, and the potential for the capillary refill time test to provide misleading reassurance when assessing dehydration in children with similar circumstances.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Use of insensitive Capillary Refill Time testing for dehydration assessment
Wider context from the report “5. The expert evidence also indicated that the Capillary Refill Time (CRT) test used to assess dehydration by checking peripheral blood flow is a very insensitive test and can provide misleading reassurance . Therefore, my concern is that young children with similar circumstances to Joshua maybe at risk when assessing levels of dehydration . NHS England may wish to consider reviewing their guidance for 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 Lack of clear national guidance on autism assessment
Wider context from the report “2. My concern is that Joshua was never formally diagnosed with Autism and there appears to be nationally, a variation in practice before an assessment for autism can be made . Some areas specify 3 years of age or above but there is no clear national guidance .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 onward referral to dieticians experienced in autism and ARFID
Wider context from the report “3. Regrettably, without a formal diagnosis of autism being made, there was no onward referral to dieticians with experience of autism and therefore an understanding of the link between autism and Avoidant restrictive food intake disorder (ARFID) .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 dehydration among autistic children in similar circumstances
Wider context from the report “4. In addition, I heard expert evidence that Joshua’s death wasn’t an isolated incident and another autistic child died in very similar circumstances by developing dehydration .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish guidance for commissioners and providers on children’s eating disorder services, including ARFID care and reasonable adaptations for additional needs.
Verbatim wording from the response “In January 2026, NHS England published guidance for commissioners and providers on eating disorder services for Children and Young People (CYP) including those with ARFID.” Source location 2026-0012 - Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce national framework and operational guidance requiring access to autism assessments for people of all ages.
Verbatim wording from the response “NHS England has produced a national framework and operational guidance for autism assessments. Whilst the national framework states that “the traits that characterise autism emerge during the pre-school years, yet diagnoses given before 2 years of age are less stable than those given after this age”, the operational guidance suggests that Integrated Care Boards (ICBs) should ensure that all ages can access autism assessments: “check that people of all ages can access an autism assessment in the area”.” Source location 2026-0012 - Response from NHS England
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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 Assessment of dehydration is a basic professional competency, so NHS England does not publish dedicated guidance on it.
Verbatim wording from the response “Assessment of dehydration is on the curriculum of undergraduate and relevant postgraduate medical courses and the emphasis is not on reliance on a single indicator. NHS England does not publish guidance on the assessment of dehydration as it is in the basic domain of medical professionals to know this. Publication of further guidance is unlikely to result in increased recognition. However, I note that your Report has been addressed to other health organisations, including Walsall Healthcare NHS Trust and Birchill’s Medical Centre. They may be able to provide further information around the local guidance on assessing dehydration and the use of CRT tests.” Source location 2026-0012 - Response from NHS England
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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 National autism assessment guidance exists and does not impose a minimum assessment age.
Verbatim wording from the response “NHS England has produced a national framework and operational guidance for autism assessments. Whilst the national framework states that “the traits that characterise autism emerge during the pre-school years, yet diagnoses given before 2 years of age are less stable than those given after this age”, the operational guidance suggests that Integrated Care Boards (ICBs) should ensure that all ages can access autism assessments: “check that people of all ages can access an autism assessment in the area”.” Source location 2026-0012 - Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Further national dehydration guidance is unlikely to increase recognition because clinicians are taught to use multiple assessment indicators.
Verbatim wording from the response “Capillary Refill Time (CRT) is a moderately effective but imperfect clinical sign for diagnosing dehydration in a child. A prolonged CRT (>2 seconds) is a strong indicator of dehydration, but its sensitivity is variable, so a normal CRT does not reliably exclude dehydration. It is one of the most useful individual signs, but a combination of signs (such as skin turgor, respiratory pattern, and capillary refill considered together) is more accurate than any single sign alone.” Source location 2026-0012 - Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CRT is moderately effective and useful as one sign, but should not be used alone to assess dehydration.
Verbatim wording from the response “Capillary Refill Time (CRT) is a moderately effective but imperfect clinical sign for diagnosing dehydration in a child. A prolonged CRT (>2 seconds) is a strong indicator of dehydration, but its sensitivity is variable, so a normal CRT does not reliably exclude dehydration. It is one of the most useful individual signs, but a combination of signs (such as skin turgor, respiratory pattern, and capillary refill considered together) is more accurate than any single sign alone.” Source location 2026-0012 - Response from NHS England
Open published response
6 Jan 2026 Robert Shaun GRACEY · Prevention of Future Deaths report Greater Lincolnshire
View report summary
Concerns raised 3 Lack of an ABD protocol between police forces and the local ambulance service View source Allocation of ABD referrals to only a category 2 response in the absence of police restraint View source Lack of an NHS Pathways allocation pathway for ABD View source
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AI-generated summary
Robert Shaun GRACEY · 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
Robert Shaun Gracey died in hospital on 29 September 2021 after police restraint and transportation following behaviour associated with cocaine use. The jury found that the effects of cocaine, restraint and struggle against restraint contributed to his death. Concerns included the absence of a Lincolnshire protocol for treating suspected excited delirium as a medical emergency, inadequate police training and monitoring, and delays or shortcomings in medical response and de-escalation.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of an ABD protocol between police forces and the local ambulance service
Wider context from the report “1. Despite a very clear recommendation made in a letter dated 24 July 2019 by DAC Twist on behalf of the NPCC that "police forces have established ABD protocols with their local ambulance service so that suspected ABD incidents are treated as medical emergencies (i.e. Cat 1, with a response time of 8 minutes)", there is still no such protocol in Lincolnshire .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Allocation of ABD referrals to only a category 2 response in the absence of police restraint
Wider context from the report “3. Under the current NHS Pathways system a referral for ABD will only be allocated a category 2 response in the absence of police restraint .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 NHS Pathways allocation pathway for ABD
Wider context from the report “2. Under the current NHS Pathways system, ABD does not have its own allocation pathway .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue reviewing the ambulance response categorisation for ABD through NHS England and relevant ambulance-sector governance bodies.
Verbatim wording from the response “The categorisation of 999 calls is managed through a specific process within NHS England. The mapping of triage outcomes to response categories is undertaken by an expert group which has representatives from both NHS Pathways and MPDS ambulance trusts. The coding groups engage with the ambulance sector within England and consider reviews triggered by coroner, patient safety concerns identified by the ambulance services or changes in national guidance. This group makes recommendations to the NHS England Emergency Call Prioritisation Advisory Group (ECPAG) for implementation across all NHS England ambulance service providers. This ensures appropriate prioritisation, equity of access and uniformity of response across the English ambulance services.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue monitoring ABD incidents to develop the NHS Pathways system and associated user training in response to emerging evidence.
Verbatim wording from the response “Additional Training” Source location Response from NHS England
Open published response
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation ABD can receive Category 1 where life-threatening symptoms are present; otherwise Category 2 is a medical emergency with possible local upgrading.
Verbatim wording from the response “Under the current NHS Pathways system, a referral for ABD will only be allocated a Category 2 ambulance response in the absence of police restraint” Source location Response from NHS England
Open published response
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation East Midlands Ambulance Service is responsible for responding directly to the concerns and revising relevant clinical presentation protocols with system partners.
Verbatim wording from the response “NHS England’s Midlands regional colleagues have reached out to Derby and Derbyshire Integrated Care Board (ICB) who has advised that East Midlands Ambulance Service will be responding directly to the concerns you raised. The Trust has confirmed that, as part of the learning and actions arising from this process, a review of all existing Memorandums of Understanding (MOUs) is underway to ensure appropriate governance arrangements are in place for each agreement. Through their Mental Health lead, the Trust is also working collaboratively with system partners to revise the relevant clinical presentation protocols.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A dedicated ABD allocation pathway is unnecessary because NHS Pathways assesses symptoms rather than allocating patients by diagnosis.
Verbatim wording from the response “Under the current NHS Pathways system, ABD does not have its own allocation pathway” Source location Response from NHS England
Open published response
Concerns raised 2 Inconsistent assessment, triage and ambulance categorisation of urgent breathing complaints across MPDS and NHS Pathways View source Failure of NHS Pathways to interrogate declared cyanosis as a trigger for Category 1 ineffective-breathing disposition View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Theo Gordon Tuikubulau · 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
Theo Gordon Tuikubulau, a three-year-old boy, died on 8 July 2022 from sepsis arising from an invasive Group A streptococcal infection. The report identified variation between the MPDS and NHS Pathways triage systems in assessing respiratory distress and cyanosis in children under five, resulting in different ambulance response categories for similar symptoms. The report stated that this two-tiered system continued to exist while work to review and align the systems had not yet occurred.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inconsistent assessment, triage and ambulance categorisation of urgent breathing complaints across MPDS and NHS Pathways
Wider context from the report “The difference in assessment and triage of calls under these two systems appears to create a two-tiered system of assessment and ambulance categorisation in the Devon area (and potentially nationally). It appears that similar breathing complaints requiring urgent medical attention will result in a different ambulance disposition depending on whether the call is triaged via MPDS (used by the 999 provider in Devon) or NHS Pathways (used by the 111 provider in Devon).
As a result of the evidence heard at the inquest I considered it likely that my duty to prevent future deaths was engaged in this case. However, I was conscious that I did not hear evidence directly from those responsible for the NHS Pathways or MPDS systems during the inquest.
I therefore requested further information from both of the organisations responsible for NHS Pathways and MPDS about why there appears to be a two tier system in Devon (and potentially nationally) which would result in a different ambulance categorisation (category 1 under MPDS and category 2 under NHS Pathways) when a caller describes breathing difficulties such as "fighting for breath", "turning blue", or "gasping".
Further I asked that if this two tier system does exist, either in Devon, nationally or both, for further information about what is being done to address those differences in call assessment, triage and ambulance categorisation.
On 26 November 2025 I was provided with an independent case review from the International Academies of Emergency Dispatch ("IAED"). They had reviewed the calls triaged via the MPDS system and confirmed that these calls had been properly assigned a category 1 response time. They were unable to comment on the calls triaged by NHS Pathways as it has no association with that algorithm.
On 4 September 2025 I was provided with further information from NHS England about the Triage systems in place. They confirmed that:
"MPDS is a long-established triage system launched in 1979, published by the Priority Dispatch Corporation (PDC), and its ongoing development is supported by the International Academies of Emergency Dispatch (IAED)… NHS England does not manage or oversee the MPDS and we are therefore unable to provide comment on their system.
NHS Pathways is a Clinical Decision Support System (CDSS) used for remote clinical assessment in urgent and emergency care. NHS Pathways was launched in 2005 and is developed and maintained by the Transformation Directorate at NHS England, and is overseen by the National Clinical Assurance Group (NCAG), an independent intercollegiate body hosted by the Academy of Medical Royal Colleges. It underpins all NHS 111 services and more than half of England’s 999 telephony services…
…Both triage systems are designed to assess the presenting symptoms/condition and acuity (severity and urgency of the symptoms/condition) of the patient based on the identification of priority symptoms (e.g. unconsciousness, difficulty breathing or chest pain). If, during the call, the patient’s condition changed (either improves or worsens), then there is an exception that the call handler will re-triage with the new information which may change the response being arranged."
The response from NHS England further confirmed that:
"Following a review of this case by NHS England’s Urgent & Emergency Care (UEC) Teams, it is clear that there is variation between the two triage systems with regards to respiratory distress in children under 5 , specifically in relation to the management of declared cyanosis (where the patient’s skin or lips have turned blue or grey). If a caller volunteers ‘cyanosis’, they will be recognised as having ineffective breathing through the MPDS triage. However, the presence of cyanosis is not interrogated within NHS Pathways and as such this symptom/sign is not a specific trigger for generating a Category 1 disposition for ineffective breathing within NHS Pathways, instead resulting in the generation of a Respiratory Distress disposition that is mapped to a Category 2 response."
I was advised within the letter that NHS England will work with the clinical coding groups and NHS Pathways to review this to ensure that the triage and categorisation of ineffective breathing and respiratory distress is consistent across the two triage systems and remains clinically appropriate, for which I am grateful. However, as this has not yet occurred and the two tiered triage system continues to exist, so does my duty to make a report to prevent future deaths in this matter.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 NHS Pathways to interrogate declared cyanosis as a trigger for Category 1 ineffective-breathing disposition
Wider context from the report “The difference in assessment and triage of calls under these two systems appears to create a two-tiered system of assessment and ambulance categorisation in the Devon area (and potentially nationally). It appears that similar breathing complaints requiring urgent medical attention will result in a different ambulance disposition depending on whether the call is triaged via MPDS (used by the 999 provider in Devon) or NHS Pathways (used by the 111 provider in Devon).
As a result of the evidence heard at the inquest I considered it likely that my duty to prevent future deaths was engaged in this case. However, I was conscious that I did not hear evidence directly from those responsible for the NHS Pathways or MPDS systems during the inquest.
I therefore requested further information from both of the organisations responsible for NHS Pathways and MPDS about why there appears to be a two tier system in Devon (and potentially nationally) which would result in a different ambulance categorisation (category 1 under MPDS and category 2 under NHS Pathways) when a caller describes breathing difficulties such as "fighting for breath", "turning blue", or "gasping".
Further I asked that if this two tier system does exist, either in Devon, nationally or both, for further information about what is being done to address those differences in call assessment, triage and ambulance categorisation.
On 26 November 2025 I was provided with an independent case review from the International Academies of Emergency Dispatch ("IAED"). They had reviewed the calls triaged via the MPDS system and confirmed that these calls had been properly assigned a category 1 response time. They were unable to comment on the calls triaged by NHS Pathways as it has no association with that algorithm.
On 4 September 2025 I was provided with further information from NHS England about the Triage systems in place. They confirmed that:
"MPDS is a long-established triage system launched in 1979, published by the Priority Dispatch Corporation (PDC), and its ongoing development is supported by the International Academies of Emergency Dispatch (IAED)… NHS England does not manage or oversee the MPDS and we are therefore unable to provide comment on their system.
NHS Pathways is a Clinical Decision Support System (CDSS) used for remote clinical assessment in urgent and emergency care. NHS Pathways was launched in 2005 and is developed and maintained by the Transformation Directorate at NHS England, and is overseen by the National Clinical Assurance Group (NCAG), an independent intercollegiate body hosted by the Academy of Medical Royal Colleges. It underpins all NHS 111 services and more than half of England’s 999 telephony services…
…Both triage systems are designed to assess the presenting symptoms/condition and acuity (severity and urgency of the symptoms/condition) of the patient based on the identification of priority symptoms (e.g. unconsciousness, difficulty breathing or chest pain). If, during the call, the patient’s condition changed (either improves or worsens), then there is an exception that the call handler will re-triage with the new information which may change the response being arranged."
The response from NHS England further confirmed that:
"Following a review of this case by NHS England’s Urgent & Emergency Care (UEC) Teams, it is clear that there is variation between the two triage systems with regards to respiratory distress in children under 5, specifically in relation to the management of declared cyanosis (where the patient’s skin or lips have turned blue or grey). If a caller volunteers ‘cyanosis’, they will be recognised as having ineffective breathing through the MPDS triage. However, the presence of cyanosis is not interrogated within NHS Pathways and as such this symptom/sign is not a specific trigger for generating a Category 1 disposition for ineffective breathing within NHS Pathways , instead resulting in the generation of a Respiratory Distress disposition that is mapped to a Category 2 response. "
I was advised within the letter that NHS England will work with the clinical coding groups and NHS Pathways to review this to ensure that the triage and categorisation of ineffective breathing and respiratory distress is consistent across the two triage systems and remains clinically appropriate, for which I am grateful. However, as this has not yet occurred and the two tiered triage system continues to exist, so does my duty to make a report to prevent future deaths in this matter.
” 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 Increase clinical support and oversight in 999 Emergency Operations Centres to enable reassessment and potential re-categorisation of high-risk patients.
Verbatim wording from the response “Although the MPDS and NHS Pathways use different triage methodologies, following our review, NHS England is assured that no system changes are required to maintain patient safety and consistency. Both triage systems consistently generate a Category 1 ambulance response for patients presenting with the same high-acuity clinical symptoms. In addition, strengthened clinical oversight within 999 Emergency Operations Centres provides significant further mitigation for patient safety.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the MPDS and NHS Pathways triage systems with clinical groups, ambulance services and providers to assess respiratory-distress consistency and clinical appropriateness.
Verbatim wording from the response “Your Report raises the concern that the triage and categorisation of ineffective breathing and respiratory distress is still not consistent across the two triage systems; NHS Pathways and the Medical Priority Dispatch System (MPDS). NHS England had informed you that a review would be undertaken of this, to ensure that the two triage systems are consistent and remain clinically appropriate. As you have not been informed that the review has occurred, this remains a concern.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue monitoring triage categorisation and strengthening clinical oversight.
Verbatim wording from the response “There has been a significant increase in clinical support within 999 Emergency Operations Centres, providing enhanced oversight for patients who may not initially receive a Category 1 triage outcome, but who may benefit from clinical reassessment and potential ambulance re-categorisation. This includes patients at the extremes of age and those presenting with symptoms such as severe breathing difficulty.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue refining and aligning the MPDS and NHS Pathways triage systems.
Verbatim wording from the response “NHS England welcomes the feedback from HM Coroner and will continue to refine and align both systems, monitor categorisation, and strengthen clinical oversight. I hope that this further response sufficiently addresses the outstanding concern raised within your Report.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Both MPDS and NHS Pathways would produce a category 1 response for another child presenting as Theo did, if triaged appropriately.
Verbatim wording from the response “The information above confirms that another child presenting as Theo did would result in a category 1 response being reached, when triaged appropriately using either MPDS or NHS Pathways.” Source location Response from NHS England (2)
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 two triage systems use different methodologies but consistently produce the same highest categorisation for patients with the relevant high-acuity symptoms.
Verbatim wording from the response “Although the MPDS and NHS Pathways use different triage methodologies, following our review, NHS England is assured that no system changes are required to maintain patient safety and consistency. Both triage systems consistently generate a Category 1 ambulance response for patients presenting with the same high-acuity clinical symptoms. In addition, strengthened clinical oversight within 999 Emergency Operations Centres provides significant further mitigation for patient safety.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No triage system changes are required because existing clinical oversight and alignment between the systems are considered sufficient to maintain patient safety.
Verbatim wording from the response “Although the MPDS and NHS Pathways use different triage methodologies, following our review, NHS England is assured that no system changes are required to maintain patient safety and consistency. Both triage systems consistently generate a Category 1 ambulance response for patients presenting with the same high-acuity clinical symptoms. In addition, strengthened clinical oversight within 999 Emergency Operations Centres provides significant further mitigation for patient safety.” Source location Response from NHS England
Open published response
6 Jan 2026 Adam Ali Hussain · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Failure of the urgent care pathway to adequately serve patients with serious, non-immediately-life-threatening systemic illness requiring a Category 3 ambulance response View source Insufficient skills among non-clinicians to safely transfer Category 3 calls to NEMS View source Lack of agreed and unambiguous criteria for transferring Category 3 calls to NEMS View source Failure to inform waiting families when an ambulance will not be sent View source Failure of EMAS staff to reliably read and consider transferred Computer Aided Dispatch information View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Adam Ali Hussain · 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
Adam Ali Hussain died on 16 May 2025 at Queens Medical Centre, Nottingham, from complicated appendicitis with perforation, peritonitis, severe intra-abdominal sepsis and multiple organ failure. The report identifies missed opportunities to recognise worsening illness and sepsis and to arrange face-to-face assessment, particularly on 14 May 2025. Concerns include unreliable handling and transfer of clinical information, unclear Category 3 ambulance-call criteria, and inadequate communication with families.
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 urgent care pathway to adequately serve patients with serious, non-immediately-life-threatening systemic illness requiring a Category 3 ambulance response
Wider context from the report “1. The urgent care pathway across Nottinghamshire, whilst working well for most patients, poorly serves patients with systemic illness that is serious, but not immediately life threatening, (such as is seen in sepsis), and where clinical assessment disposition reached is for a Category 3 ambulance response
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 skills among non-clinicians to safely transfer Category 3 calls to NEMS
Wider context from the report “4. Category 3 calls are viewed by non- clinicians at the EMAS Emergency Operations Centre, who do not have sufficient skills to safely transfer calls to NEMS , as the inclusion/exclusion criteria are open to interpretation
5. There is no agreement between EMAS and NEMS as to the criteria for transfer of a category 3 call, including whether or not a previous clinical validation would preclude transfer to NEMS
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 agreed and unambiguous criteria for transferring Category 3 calls to NEMS
Wider context from the report “4. Category 3 calls are viewed by non- clinicians at the EMAS Emergency Operations Centre, who do not have sufficient skills to safely transfer calls to NEMS, as the inclusion/exclusion criteria are open to interpretation
5. There is no agreement between EMAS and NEMS as to the criteria for transfer of a category 3 call, including whether or not a previous clinical validation would preclude transfer to NEMS
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 waiting families when an ambulance will not be sent
Wider context from the report “3. Families, waiting for an ambulance response, following a clinical assessment by a 111 clinical adviser are not told by EMAS that an ambulance will not be sent
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 EMAS staff to reliably read and consider transferred Computer Aided Dispatch information
Wider context from the report “2. There remains detailed information in the EMAS Computer Aided Dispatch (CAD) transferred from the 111 service that is not reliably read or considered by EMAS staff , when cancelling a requested ambulance response and referring a case on to the Clinical Assessment Service provided by NEMS.
” 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 Concerns other than concern three are better addressed by EMAS, NEMS and Nottingham and Nottinghamshire Integrated Care Board.
Verbatim wording from the response “We consider that the third concern listed above falls within NHS England’s remit and we have endeavoured to address this concern below. The remaining concerns would be better addressed by EMAS, NEMS and Nottingham and Nottinghamshire Integrated Care Board (ICB), who have also been sent your Report.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Integrated Care Board is best placed to address concerns about the exit scripts informing families whether an ambulance will be sent.
Verbatim wording from the response “We are unable to comment on the concern that families are not informed that an ambulance is not being sent as it was NHS 111 and the Nottingham Emergency Medical Service (commissioned by NHS Nottingham and Nottinghamshire ICB) who spoke to the patient, rather than the ambulance service. The ICB will therefore be best placed to address any concerns on their exit scripts.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England cannot comment on whether families were told an ambulance would not be sent because other services spoke to the patient.
Verbatim wording from the response “We are unable to comment on the concern that families are not informed that an ambulance is not being sent as it was NHS 111 and the Nottingham Emergency Medical Service (commissioned by NHS Nottingham and Nottinghamshire ICB) who spoke to the patient, rather than the ambulance service. The ICB will therefore be best placed to address any concerns on their exit scripts.” Source location Response from NHS England
Open published response
5 Jan 2026 Jake Kieran Hartwright · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 6 Insufficient skills among non-clinicians to safely transfer Category 3 calls to NEMS View source Inclusion and exclusion criteria for transferring Category 3 calls open to interpretation View source Lack of agreed criteria between EMAS and NEMS for transfer of Category 3 calls View source Failure of the urgent care pathway to safely serve patients with serious, non-immediately-life-threatening systemic illness requiring a Category 3 ambulance response View source Failure to inform waiting families that an ambulance will be sent View source Failure of EMAS staff to reliably read and consider transferred CAD information when cancelling ambulance responses and referring cases to the Clinical Assessment Service 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
Jake Kieran Hartwright · 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
Jake Kieran Hartwright developed severe illness associated with bowel ischaemia and had a cardiac arrest at home on 16 January 2025. He died at Queens Medical Centre in the early hours of 17 January 2025 from multiple organ failure secondary to extensive bowel ischaemia. The report identified serious issues in the urgent care pathway, including missed opportunities to arrange a Category 2 ambulance and problems with clinical information transfer and management of Category 3 calls.
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 skills among non-clinicians to safely transfer Category 3 calls to NEMS
Wider context from the report “4. Category 3 calls are viewed by non- clinicians at the EMAS Emergency Operations Centre, who do not have sufficient skills to safely transfer calls to NEMS , as the inclusion/exclusion criteria are open to interpretation
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inclusion and exclusion criteria for transferring Category 3 calls open to interpretation
Wider context from the report “4. Category 3 calls are viewed by non- clinicians at the EMAS Emergency Operations Centre, who do not have sufficient skills to safely transfer calls to NEMS, as the inclusion/exclusion criteria are open to interpretation
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 agreed criteria between EMAS and NEMS for transfer of Category 3 calls
Wider context from the report “5. There is no agreement between EMAS and NEMS as to the criteria for transfer of a category 3 call , including whether or not a previous clinical validation would preclude transfer to NEMS
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 urgent care pathway to safely serve patients with serious, non-immediately-life-threatening systemic illness requiring a Category 3 ambulance response
Wider context from the report “1. The urgent care pathway across Nottinghamshire, whilst working well for most patients, poorly serves patients with systemic illness that is serious, but not immediately life threatening, (such as is seen in sepsis), and where clinical assessment disposition is reached is for a Category 3 ambulance response
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 waiting families that an ambulance will be sent
Wider context from the report “3. Families, waiting for an ambulance response , following a clinical assessment by a 111 clinical adviser are not told by EMAS that an ambulance will be sent
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 EMAS staff to reliably read and consider transferred CAD information when cancelling ambulance responses and referring cases to the Clinical Assessment Service
Wider context from the report “2. There remains detailed information in the EMAS CAD transferred from the 111 service that is not reliably read or considered by EMAS staff , when cancelling a requested ambulance response and referring a case on to the Clinical Assessment Service provided by NEMS .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The ICB is best placed to address concerns about the wording of exit scripts informing families whether an ambulance will be sent.
Verbatim wording from the response “We are unable to comment on the concern that families are not informed that an ambulance is not being sent as it was NHS 111 and the Nottingham Emergency Medical Service (commissioned by NHS Nottingham and Nottinghamshire ICB) who spoke to the patient, rather than the ambulance service. The ICB will therefore be best placed to address any concerns on their exit scripts.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The response cannot comment on whether families were informed because NHS 111 and NEMS, rather than the ambulance service, spoke to the patient.
Verbatim wording from the response “We are unable to comment on the concern that families are not informed that an ambulance is not being sent as it was NHS 111 and the Nottingham Emergency Medical Service (commissioned by NHS Nottingham and Nottinghamshire ICB) who spoke to the patient, rather than the ambulance service. The ICB will therefore be best placed to address any concerns on their exit scripts.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Concerns about the urgent care pathway, CAD information, Category 3 call handling and transfer criteria should be addressed by EMAS, NEMS and the ICB.
Verbatim wording from the response “We consider that the third concern listed above falls within NHS England’s remit and we have endeavoured to address this concern below. The remaining concerns would be better addressed by EMAS, NEMS and Nottingham and Nottinghamshire Integrated Care Board (ICB), who have also been sent your Report.” Source location Response from NHS England
Open published response
11 Dec 2025 Mrs Ashana Charles · Prevention of Future Deaths report South London
View report summary
Concerns raised 8 Lack of assurance that PN and filter manufacturers issue consistent guidance and operationally consistent products View source Failure to establish adequate safety assurance from visual checks of PN products View source Failure of drug manufacturer guidance to specify the need, desirability or context of filter use for Omega Special View source Failure to submit 1.2 micron filter use for governance oversight View source Failure to retain infusion equipment and supplies for forensic investigation View source Inconsistency between regional guidance on use of filters in parenteral feeding View source Inadequate investigation of deaths potentially associated with IV feeding View source Failure to use 1.2 micron filters as standard practice in parenteral feeding View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mrs Ashana Charles · 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 Ashana Charles died suddenly in hospital on 20 November 2018 after an unexpected cardiac arrest during intravenous feeding. The inquest concluded that cellulose fibres from inadvertently contaminated intravenous infusions caused acute obstruction of small pulmonary arteries, and that the death would have been prevented by using a 1.2-micron filter, which was not standard practice at the time. Concerns included the failure to retain infusion equipment for forensic investigation, inconsistent guidance and practice on filters, and uncertainty about the adequacy of batch-based visual checks of parenteral nutrition products.
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 assurance that PN and filter manufacturers issue consistent guidance and operationally consistent products
Wider context from the report “1. That no source of contamination could be identified due to the infusion set, filter, feeding bag and lines not being retained for forensic investigation. The pathologist Professor ████████ gave an opinion that deaths that might be associated with IV feeding were probably underreported due to inadequate investigation.
2. ████████, expert pharmacist and pharmaceutical regulator drew attention to
a) The inconsistency at the time between US and European and UK guidance about use of filters in parenteral feeding (PN).
b) Reference to filters for Omega Special by the drug manufacturer at the time indicating an appropriate filter “if one was used”, but not its need or desirability or context of use, and the value of manufacturers and health providers integrating their approach to risk management.
c) The use of the 1.2 micron filter at the time was not standard practice, perhaps because of cost or operational reasons as the filter often led to blockages and delays in IV feeding. Now both that BNPG guidance and B Braun recommend the use of 1.2 micron filters on Omega Special label, but that does not give assurance that all PN and filter manufacturers issue the same guidance nor that their products are operationally consistent with guidance .
d) Lewisham & Greenwich NHS Trust have begun to re-evaluate the use of 1.2 micron filters in PN feeding but the matter had not yet gone to its governance department but should do so next year. There was a need for those responsible for decision implementation in hospitals nationally to cross work with manufacturers and specialist bodies.
e) Uncertainty whether the reported visual checks of PN products by batch rather than individually provided adequate safety assurance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to establish adequate safety assurance from visual checks of PN products
Wider context from the report “1. That no source of contamination could be identified due to the infusion set, filter, feeding bag and lines not being retained for forensic investigation. The pathologist Professor ████████ gave an opinion that deaths that might be associated with IV feeding were probably underreported due to inadequate investigation.
2. ████████, expert pharmacist and pharmaceutical regulator drew attention to
a) The inconsistency at the time between US and European and UK guidance about use of filters in parenteral feeding (PN).
b) Reference to filters for Omega Special by the drug manufacturer at the time indicating an appropriate filter “if one was used”, but not its need or desirability or context of use, and the value of manufacturers and health providers integrating their approach to risk management.
c) The use of the 1.2 micron filter at the time was not standard practice, perhaps because of cost or operational reasons as the filter often led to blockages and delays in IV feeding. Now both that BNPG guidance and B Braun recommend the use of 1.2 micron filters on Omega Special label, but that does not give assurance that all PN and filter manufacturers issue the same guidance nor that their products are operationally consistent with guidance.
d) Lewisham & Greenwich NHS Trust have begun to re-evaluate the use of 1.2 micron filters in PN feeding but the matter had not yet gone to its governance department but should do so next year. There was a need for those responsible for decision implementation in hospitals nationally to cross work with manufacturers and specialist bodies.
e) Uncertainty whether the reported visual checks of PN products by batch rather than individually provided adequate safety assurance .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 drug manufacturer guidance to specify the need, desirability or context of filter use for Omega Special
Wider context from the report “1. That no source of contamination could be identified due to the infusion set, filter, feeding bag and lines not being retained for forensic investigation. The pathologist Professor ████████ gave an opinion that deaths that might be associated with IV feeding were probably underreported due to inadequate investigation.
2. ████████, expert pharmacist and pharmaceutical regulator drew attention to
a) The inconsistency at the time between US and European and UK guidance about use of filters in parenteral feeding (PN).
b) Reference to filters for Omega Special by the drug manufacturer at the time indicating an appropriate filter “if one was used”, but not its need or desirability or context of use , and the value of manufacturers and health providers integrating their approach to risk management.
c) The use of the 1.2 micron filter at the time was not standard practice, perhaps because of cost or operational reasons as the filter often led to blockages and delays in IV feeding. Now both that BNPG guidance and B Braun recommend the use of 1.2 micron filters on Omega Special label, but that does not give assurance that all PN and filter manufacturers issue the same guidance nor that their products are operationally consistent with guidance.
d) Lewisham & Greenwich NHS Trust have begun to re-evaluate the use of 1.2 micron filters in PN feeding but the matter had not yet gone to its governance department but should do so next year. There was a need for those responsible for decision implementation in hospitals nationally to cross work with manufacturers and specialist bodies.
e) Uncertainty whether the reported visual checks of PN products by batch rather than individually provided adequate safety assurance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 submit 1.2 micron filter use for governance oversight
Wider context from the report “1. That no source of contamination could be identified due to the infusion set, filter, feeding bag and lines not being retained for forensic investigation. The pathologist Professor ████████ gave an opinion that deaths that might be associated with IV feeding were probably underreported due to inadequate investigation.
2. ████████, expert pharmacist and pharmaceutical regulator drew attention to
a) The inconsistency at the time between US and European and UK guidance about use of filters in parenteral feeding (PN).
b) Reference to filters for Omega Special by the drug manufacturer at the time indicating an appropriate filter “if one was used”, but not its need or desirability or context of use, and the value of manufacturers and health providers integrating their approach to risk management.
c) The use of the 1.2 micron filter at the time was not standard practice, perhaps because of cost or operational reasons as the filter often led to blockages and delays in IV feeding. Now both that BNPG guidance and B Braun recommend the use of 1.2 micron filters on Omega Special label, but that does not give assurance that all PN and filter manufacturers issue the same guidance nor that their products are operationally consistent with guidance.
d) Lewisham & Greenwich NHS Trust have begun to re-evaluate the use of 1.2 micron filters in PN feeding but the matter had not yet gone to its governance department but should do so next year. There was a need for those responsible for decision implementation in hospitals nationally to cross work with manufacturers and specialist bodies.
e) Uncertainty whether the reported visual checks of PN products by batch rather than individually provided adequate safety assurance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 retain infusion equipment and supplies for forensic investigation
Wider context from the report “1. That no source of contamination could be identified due to the infusion set, filter, feeding bag and lines not being retained for forensic investigation . The pathologist Professor ████████ gave an opinion that deaths that might be associated with IV feeding were probably underreported due to inadequate investigation.
2. ████████, expert pharmacist and pharmaceutical regulator drew attention to
a) The inconsistency at the time between US and European and UK guidance about use of filters in parenteral feeding (PN).
b) Reference to filters for Omega Special by the drug manufacturer at the time indicating an appropriate filter “if one was used”, but not its need or desirability or context of use, and the value of manufacturers and health providers integrating their approach to risk management.
c) The use of the 1.2 micron filter at the time was not standard practice, perhaps because of cost or operational reasons as the filter often led to blockages and delays in IV feeding. Now both that BNPG guidance and B Braun recommend the use of 1.2 micron filters on Omega Special label, but that does not give assurance that all PN and filter manufacturers issue the same guidance nor that their products are operationally consistent with guidance.
d) Lewisham & Greenwich NHS Trust have begun to re-evaluate the use of 1.2 micron filters in PN feeding but the matter had not yet gone to its governance department but should do so next year. There was a need for those responsible for decision implementation in hospitals nationally to cross work with manufacturers and specialist bodies.
e) Uncertainty whether the reported visual checks of PN products by batch rather than individually provided adequate safety assurance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inconsistency between regional guidance on use of filters in parenteral feeding
Wider context from the report “1. That no source of contamination could be identified due to the infusion set, filter, feeding bag and lines not being retained for forensic investigation. The pathologist Professor ████████ gave an opinion that deaths that might be associated with IV feeding were probably underreported due to inadequate investigation.
2. ████████, expert pharmacist and pharmaceutical regulator drew attention to
a) The inconsistency at the time between US and European and UK guidance about use of filters in parenteral feeding (PN) .
b) Reference to filters for Omega Special by the drug manufacturer at the time indicating an appropriate filter “if one was used”, but not its need or desirability or context of use, and the value of manufacturers and health providers integrating their approach to risk management.
c) The use of the 1.2 micron filter at the time was not standard practice, perhaps because of cost or operational reasons as the filter often led to blockages and delays in IV feeding. Now both that BNPG guidance and B Braun recommend the use of 1.2 micron filters on Omega Special label, but that does not give assurance that all PN and filter manufacturers issue the same guidance nor that their products are operationally consistent with guidance.
d) Lewisham & Greenwich NHS Trust have begun to re-evaluate the use of 1.2 micron filters in PN feeding but the matter had not yet gone to its governance department but should do so next year. There was a need for those responsible for decision implementation in hospitals nationally to cross work with manufacturers and specialist bodies.
e) Uncertainty whether the reported visual checks of PN products by batch rather than individually provided adequate safety assurance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 investigation of deaths potentially associated with IV feeding
Wider context from the report “1. That no source of contamination could be identified due to the infusion set, filter, feeding bag and lines not being retained for forensic investigation. The pathologist Professor ████████ gave an opinion that deaths that might be associated with IV feeding were probably underreported due to inadequate investigation .
2. ████████, expert pharmacist and pharmaceutical regulator drew attention to
a) The inconsistency at the time between US and European and UK guidance about use of filters in parenteral feeding (PN).
b) Reference to filters for Omega Special by the drug manufacturer at the time indicating an appropriate filter “if one was used”, but not its need or desirability or context of use, and the value of manufacturers and health providers integrating their approach to risk management.
c) The use of the 1.2 micron filter at the time was not standard practice, perhaps because of cost or operational reasons as the filter often led to blockages and delays in IV feeding. Now both that BNPG guidance and B Braun recommend the use of 1.2 micron filters on Omega Special label, but that does not give assurance that all PN and filter manufacturers issue the same guidance nor that their products are operationally consistent with guidance.
d) Lewisham & Greenwich NHS Trust have begun to re-evaluate the use of 1.2 micron filters in PN feeding but the matter had not yet gone to its governance department but should do so next year. There was a need for those responsible for decision implementation in hospitals nationally to cross work with manufacturers and specialist bodies.
e) Uncertainty whether the reported visual checks of PN products by batch rather than individually provided adequate safety assurance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 1.2 micron filters as standard practice in parenteral feeding
Wider context from the report “1. That no source of contamination could be identified due to the infusion set, filter, feeding bag and lines not being retained for forensic investigation. The pathologist Professor ████████ gave an opinion that deaths that might be associated with IV feeding were probably underreported due to inadequate investigation.
2. ████████, expert pharmacist and pharmaceutical regulator drew attention to
a) The inconsistency at the time between US and European and UK guidance about use of filters in parenteral feeding (PN).
b) Reference to filters for Omega Special by the drug manufacturer at the time indicating an appropriate filter “if one was used”, but not its need or desirability or context of use, and the value of manufacturers and health providers integrating their approach to risk management.
c) The use of the 1.2 micron filter at the time was not standard practice , perhaps because of cost or operational reasons as the filter often led to blockages and delays in IV feeding. Now both that BNPG guidance and B Braun recommend the use of 1.2 micron filters on Omega Special label, but that does not give assurance that all PN and filter manufacturers issue the same guidance nor that their products are operationally consistent with guidance.
d) Lewisham & Greenwich NHS Trust have begun to re-evaluate the use of 1.2 micron filters in PN feeding but the matter had not yet gone to its governance department but should do so next year. There was a need for those responsible for decision implementation in hospitals nationally to cross work with manufacturers and specialist bodies.
e) Uncertainty whether the reported visual checks of PN products by batch rather than individually provided adequate safety assurance.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The MHRA is the appropriate authority to regulate medical devices and medicines and coordinate relevant filtering guidance with other bodies.
Verbatim wording from the response “We note that your Report is also addressed to the Medicines and Healthcare Products Regulatory Agency (MHRA) and are of the opinion that, given the recommendations within the BPNG position statement and your concerns, the MHRA, as the regulator of medical devices and medication, is the appropriate responsible authority to respond to the question of regulation. It is within their remit to ensure that relevant information is included in the designated SmPCs. The MHRA is also expertly placed to liaise with NICE, the British Association for Parenteral and Enteral Nutrition (BAPEN) and the RCN for incorporation of the recommendations they consider necessary into relevant guidance around administration of parenteral nutrition.” Source location Response from NHS England
Open published response
9 Dec 2025 Hannah Louise Booth · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 4 Failure to record or cross-reference information relevant to both mother and baby in both records View source Lack of a single electronic patient record accessible to all services View source Lack of shared policies, guidance and understanding about information relevant for sharing between services View source Failure to escalate and share increasing contact with health visitors with perinatal 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.
×
AI-generated summary
Hannah Louise Booth · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Hannah Louise Booth, who had been diagnosed with post-natal depression after giving birth in July 2024, drowned in the Goyt River on 6 January 2025 after sending a message evidencing her intention to take her own life. The report identified concerns about information sharing between services, including different record systems, incomplete records, and relevant information about Hannah being recorded only in her baby’s records. Increasing contact about her baby’s development was not shared with perinatal mental health services or recognised as potentially indicating that Hannah was struggling.
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 record or cross-reference information relevant to both mother and baby in both records
Wider context from the report “This inquest has exposed important issues with information sharing between services and also within services. Those issues are:
• Difficulties encountered because different IT systems were being used for record keeping in different services. Essentially a lack of a single patient record.
• A lack of a shared understanding of what is relevant information and needs to be made available to other services.
• Relevant notes being made in records of baby and not repeated in notes of the mum.
Further detail:
1. Sett Valley, the health visitors and perinatal mental health services all had information about Hannah that was potentially relevant to her mental health, but none had the whole picture. It was evident that had those within the perinatal mental health services known about Hannah’s increasing frequency of contact with services about her baby’s development, it would have prompted further contact by them with Hannah and prompted a review of risk and support offered. They did not know and there was no further contact.
2. There was no single electronic patient record accessible to all services. Whilst the perinatal mental health and health visitors used SystmOne, Sett Valley did not. The health visitor had not informed Sett Valley about the contact Hannah had had with them on 27th December so that the GP seeing Hannah on 31st did not know that Hannah was beginning to make increased contact with services about her concerns and did not share any information about that consultation with other services.
3. There was increasing contact with health visitors that was not escalated to or shared with perinatal mental health. The significance of the increased contact, to Hannah’s mental health, did not appear to have been understood. The concerns raised at each contact around her baby’s development were dealt with at face value with exploration and examination of her baby’s development and reassurances given to Hannah regarding the particular concerns raised. The evidence revealed that it was not the individual concerns raised that were relevant to Hannah’s mental health but the fact that she was making more frequent contact which suggested she was struggling. There are no policies, guidance or any shared understanding between services of what might be relevant information to be shared and when.
4. Within both Sett Valley and health visitor records there was potentially important information relevant to Hannah’s mental health recorded only within her baby’s records. At any future appointments concerning Hannah the relevant medical history available on her record would have been incomplete. It also meant that whilst the perinatal mental health services had access to the health visitor notes in relation to Hannah (because they both used SystmOne), even had they had cause to look at Hannah’s notes they would still not have had all relevant information. There are no policies or guidance regarding when information potentially relevant to both mother and baby should be placed in both records or cross referenced. This appears to be particularly important in the perinatal period.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a single electronic patient record accessible to all services
Wider context from the report “This inquest has exposed important issues with information sharing between services and also within services. Those issues are:
• Difficulties encountered because different IT systems were being used for record keeping in different services. Essentially a lack of a single patient record.
• A lack of a shared understanding of what is relevant information and needs to be made available to other services.
• Relevant notes being made in records of baby and not repeated in notes of the mum.
Further detail:
1. Sett Valley, the health visitors and perinatal mental health services all had information about Hannah that was potentially relevant to her mental health, but none had the whole picture. It was evident that had those within the perinatal mental health services known about Hannah’s increasing frequency of contact with services about her baby’s development, it would have prompted further contact by them with Hannah and prompted a review of risk and support offered. They did not know and there was no further contact.
2. There was no single electronic patient record accessible to all services. Whilst the perinatal mental health and health visitors used SystmOne, Sett Valley did not. The health visitor had not informed Sett Valley about the contact Hannah had had with them on 27th December so that the GP seeing Hannah on 31st did not know that Hannah was beginning to make increased contact with services about her concerns and did not share any information about that consultation with other services.
3. There was increasing contact with health visitors that was not escalated to or shared with perinatal mental health. The significance of the increased contact, to Hannah’s mental health, did not appear to have been understood. The concerns raised at each contact around her baby’s development were dealt with at face value with exploration and examination of her baby’s development and reassurances given to Hannah regarding the particular concerns raised. The evidence revealed that it was not the individual concerns raised that were relevant to Hannah’s mental health but the fact that she was making more frequent contact which suggested she was struggling. There are no policies, guidance or any shared understanding between services of what might be relevant information to be shared and when.
4. Within both Sett Valley and health visitor records there was potentially important information relevant to Hannah’s mental health recorded only within her baby’s records. At any future appointments concerning Hannah the relevant medical history available on her record would have been incomplete. It also meant that whilst the perinatal mental health services had access to the health visitor notes in relation to Hannah (because they both used SystmOne), even had they had cause to look at Hannah’s notes they would still not have had all relevant information. There are no policies or guidance regarding when information potentially relevant to both mother and baby should be placed in both records or cross referenced. This appears to be particularly important in the perinatal period.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of shared policies, guidance and understanding about information relevant for sharing between services
Wider context from the report “This inquest has exposed important issues with information sharing between services and also within services. Those issues are:
• Difficulties encountered because different IT systems were being used for record keeping in different services. Essentially a lack of a single patient record.
• A lack of a shared understanding of what is relevant information and needs to be made available to other services.
• Relevant notes being made in records of baby and not repeated in notes of the mum.
Further detail:
1. Sett Valley, the health visitors and perinatal mental health services all had information about Hannah that was potentially relevant to her mental health, but none had the whole picture. It was evident that had those within the perinatal mental health services known about Hannah’s increasing frequency of contact with services about her baby’s development, it would have prompted further contact by them with Hannah and prompted a review of risk and support offered. They did not know and there was no further contact.
2. There was no single electronic patient record accessible to all services. Whilst the perinatal mental health and health visitors used SystmOne, Sett Valley did not. The health visitor had not informed Sett Valley about the contact Hannah had had with them on 27th December so that the GP seeing Hannah on 31st did not know that Hannah was beginning to make increased contact with services about her concerns and did not share any information about that consultation with other services.
3. There was increasing contact with health visitors that was not escalated to or shared with perinatal mental health. The significance of the increased contact, to Hannah’s mental health, did not appear to have been understood. The concerns raised at each contact around her baby’s development were dealt with at face value with exploration and examination of her baby’s development and reassurances given to Hannah regarding the particular concerns raised. The evidence revealed that it was not the individual concerns raised that were relevant to Hannah’s mental health but the fact that she was making more frequent contact which suggested she was struggling. There are no policies, guidance or any shared understanding between services of what might be relevant information to be shared and when.
4. Within both Sett Valley and health visitor records there was potentially important information relevant to Hannah’s mental health recorded only within her baby’s records. At any future appointments concerning Hannah the relevant medical history available on her record would have been incomplete. It also meant that whilst the perinatal mental health services had access to the health visitor notes in relation to Hannah (because they both used SystmOne), even had they had cause to look at Hannah’s notes they would still not have had all relevant information. There are no policies or guidance regarding when information potentially relevant to both mother and baby should be placed in both records or cross referenced. This appears to be particularly important in the perinatal period.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate and share increasing contact with health visitors with perinatal mental health services
Wider context from the report “This inquest has exposed important issues with information sharing between services and also within services. Those issues are:
• Difficulties encountered because different IT systems were being used for record keeping in different services. Essentially a lack of a single patient record.
• A lack of a shared understanding of what is relevant information and needs to be made available to other services.
• Relevant notes being made in records of baby and not repeated in notes of the mum.
Further detail:
1. Sett Valley, the health visitors and perinatal mental health services all had information about Hannah that was potentially relevant to her mental health, but none had the whole picture. It was evident that had those within the perinatal mental health services known about Hannah’s increasing frequency of contact with services about her baby’s development, it would have prompted further contact by them with Hannah and prompted a review of risk and support offered. They did not know and there was no further contact.
2. There was no single electronic patient record accessible to all services. Whilst the perinatal mental health and health visitors used SystmOne, Sett Valley did not. The health visitor had not informed Sett Valley about the contact Hannah had had with them on 27th December so that the GP seeing Hannah on 31st did not know that Hannah was beginning to make increased contact with services about her concerns and did not share any information about that consultation with other services.
3. There was increasing contact with health visitors that was not escalated to or shared with perinatal mental health. The significance of the increased contact, to Hannah’s mental health, did not appear to have been understood. The concerns raised at each contact around her baby’s development were dealt with at face value with exploration and examination of her baby’s development and reassurances given to Hannah regarding the particular concerns raised. The evidence revealed that it was not the individual concerns raised that were relevant to Hannah’s mental health but the fact that she was making more frequent contact which suggested she was struggling. There are no policies, guidance or any shared understanding between services of what might be relevant information to be shared and when.
4. Within both Sett Valley and health visitor records there was potentially important information relevant to Hannah’s mental health recorded only within her baby’s records. At any future appointments concerning Hannah the relevant medical history available on her record would have been incomplete. It also meant that whilst the perinatal mental health services had access to the health visitor notes in relation to Hannah (because they both used SystmOne), even had they had cause to look at Hannah’s notes they would still not have had all relevant information. There are no policies or guidance regarding when information potentially relevant to both mother and baby should be placed in both records or cross referenced. This appears to be particularly important in the perinatal period.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop the Single Patient Record to provide unified access to patient information across care settings.
Verbatim wording from the response “Work is also progressing to develop a Single Patient Record (SPR). The SPR aims to provide a clear, unified view of a patient’s health and care history, regardless of where” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the Summary Care Record Programme to support wider access to relevant patient information.
Verbatim wording from the response “NHS England is aware of the challenges in sharing medical records between providers and the variability between areas using different technologies. We are also aware that use of the SCR is variable across different care settings.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish perinatal mental health care pathway guidance and provide supporting e-learning resources for healthcare staff.
Verbatim wording from the response “The NHS has expanded specialist perinatal mental health support and access has more than doubled (113%) from 31,163 patients in March 2020 to 66,468 in October 2025. NHS England previously published guidance on perinatal mental health care pathways in May 2018, to support all healthcare professionals working across the wider perinatal mental health pathway in identifying cases requiring specialist input. This is supported by e-learning resources for all staff, including modules for health visitors and a broader perinatal mental health resource covering risks to parents.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Encourage specialist perinatal mental health teams to include record keeping in training for the wider perinatal pathway.
Verbatim wording from the response “Following this case, NHS England via the regional Perinatal Mental Health networks will encourage specialist perinatal mental health teams to include record keeping as a component of their training to the wider pathway, to help support staff to understand their experiences for documenting assessments, risks, red flags, information sharing and consent.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £20 million investment to connect care records across England by March 2026.
Verbatim wording from the response “NHS England recognises the challenge of separate systems being used by different health and social care organisations. New initiatives and systems are being designed to integrate records. NHS England has invested £20 million to connect care records across England by March 2026. This will facilitate the safe and secure exchange of electronic health data across different systems, devices and applications. It is also expected that this will improve the information available to health and social care staff.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England does not mandate IT infrastructure, so it cannot require a single electronic patient record across providers.
Verbatim wording from the response “Historically, different care settings have adopted different clinical systems to maintain a clinical record; some areas have adopted the same electronic patient record (such as SystmOne), whereas other areas have adopted shared care records which can provide access to records from different care settings. The GP record is available via GP Connect, the Summary Care Record and the Medical Interoperability Gateway (MIG), but the availability and content does vary across England. NHS England does not mandate IT infrastructure.” Source location Response from NHS England
Open published response
Concerns raised 3 Reactive determination of the funding ICB when additional care or changes are required View source Delays in accessing increased funding, support, services or suitable placements View source Failure to identify and communicate the commissioning service responsible for a resident 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
John Graham ALSTON · 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 Alston, a 70-year-old man with dementia living in a specialist care home, was punched by another resident on 2 November 2022, suffered an unsurvivable brain bleed, and died in a hospice on 8 November 2022. The concerns relate to confusion over which commissioning body was responsible for the other resident, delays in finding a safer placement, and difficulties sharing discharge information; the report warns that similar delays could contribute to 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 Reactive determination of the funding ICB when additional care or changes are required
Wider context from the report “1. ████████ had been moved to the Lancashire ICB commissioning area by a Bolton (Greater Manchester) commissioning service due to the existence of care home with a place for him (care home one). His placement at that care home broke down and he was taken to the local accident and emergency department. ████████ remained in hospital for some time and was then discharged to care home two where the circumstances resulted in Mr Alston's death occurred.
It was quickly apparent that care home two could not meet ████████ needs and this was escalated to the Lancashire ICB. However the care home had first been directed to the Bolton (Greater Manchester) authorities by the local hospital. There was confusion as to which ICB was the commissioning body. This resulted in work being carried out by Lancashire ICB which ought to have been completed by the Bolton (Greater Manchester) ICB and a delay in commencing a search for an alternative and safe placement for ████████.
There were also difficulties in sharing information for discharge processes because it was unclear which area or from where ████████ had come.
This inquest concluded that due to the complexity of ████████ presentation, the delays due to confusion about ICB identification did not contribute to Mr Alston's death occurring at the time at which it did. However, I am concerned that there may be other cases where inaccurate or unknown information about which commissioning service is responsible for a resident can result in delays to accessing increased funding for support, services or more suitable placements.
I am concerned that these delays may result in future deaths and that a clearer system is necessary to identify at an early stage and appropriately communicate that to a home who accepts a resident.
I am concerned that determination of funding ICB arises on a reactive basis when additional care or changes are required and thus the time taken to resolve the issue causes necessary care or changes when proactive determination of the issue before problems arise ought to be possible .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in accessing increased funding, support, services or suitable placements
Wider context from the report “1. ████████ had been moved to the Lancashire ICB commissioning area by a Bolton (Greater Manchester) commissioning service due to the existence of care home with a place for him (care home one). His placement at that care home broke down and he was taken to the local accident and emergency department. ████████ remained in hospital for some time and was then discharged to care home two where the circumstances resulted in Mr Alston's death occurred.
It was quickly apparent that care home two could not meet ████████ needs and this was escalated to the Lancashire ICB. However the care home had first been directed to the Bolton (Greater Manchester) authorities by the local hospital. There was confusion as to which ICB was the commissioning body. This resulted in work being carried out by Lancashire ICB which ought to have been completed by the Bolton (Greater Manchester) ICB and a delay in commencing a search for an alternative and safe placement for ████████.
There were also difficulties in sharing information for discharge processes because it was unclear which area or from where ████████ had come.
This inquest concluded that due to the complexity of ████████ presentation, the delays due to confusion about ICB identification did not contribute to Mr Alston's death occurring at the time at which it did. However, I am concerned that there may be other cases where inaccurate or unknown information about which commissioning service is responsible for a resident can result in delays to accessing increased funding for support, services or more suitable placements.
I am concerned that these delays may result in future deaths and that a clearer system is necessary to identify at an early stage and appropriately communicate that to a home who accepts a resident.
I am concerned that determination of funding ICB arises on a reactive basis when additional care or changes are required and thus the time taken to resolve the issue causes necessary care or changes when proactive determination of the issue before problems arise ought to be possible.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and communicate the commissioning service responsible for a resident
Wider context from the report “1. ████████ had been moved to the Lancashire ICB commissioning area by a Bolton (Greater Manchester) commissioning service due to the existence of care home with a place for him (care home one). His placement at that care home broke down and he was taken to the local accident and emergency department. ████████ remained in hospital for some time and was then discharged to care home two where the circumstances resulted in Mr Alston's death occurred.
It was quickly apparent that care home two could not meet ████████ needs and this was escalated to the Lancashire ICB. However the care home had first been directed to the Bolton (Greater Manchester) authorities by the local hospital. There was confusion as to which ICB was the commissioning body. This resulted in work being carried out by Lancashire ICB which ought to have been completed by the Bolton (Greater Manchester) ICB and a delay in commencing a search for an alternative and safe placement for ████████.
There were also difficulties in sharing information for discharge processes because it was unclear which area or from where ████████ had come.
This inquest concluded that due to the complexity of ████████ presentation, the delays due to confusion about ICB identification did not contribute to Mr Alston's death occurring at the time at which it did. However, I am concerned that there may be other cases where inaccurate or unknown information about which commissioning service is responsible for a resident can result in delays to accessing increased funding for support, services or more suitable placements.
I am concerned that these delays may result in future deaths and that a clearer system is necessary to identify at an early stage and appropriately communicate that to a home who accepts a resident.
I am concerned that determination of funding ICB arises on a reactive basis when additional care or changes are required and thus the time taken to resolve the issue causes necessary care or changes when proactive determination of the issue before problems arise ought to be possible.
” 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 Information-sharing difficulties and clearer communication of commissioning responsibility should be addressed and implemented by the involved ICBs, rather than NHS England.
Verbatim wording from the response “The concerns raised in your Report around the difficulties in information sharing and the delays in identifying the responsible ICB would be best addressed by the ICBs involved, rather than NHS England. In particular, it would be for the ICBs to comment upon how they could implement a clearer system to appropriately communicate the position around commissioning responsibility to care homes, where a new resident has moved areas.” Source location Response from NHS England
Open published response
4 Dec 2025 Lina Piroli · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 9 Failure to provide coordinated care in A&E View source Failure to provide regular clinical reviews in A&E View source Insufficient A&E nursing capacity for patient numbers View source Lack of ward-bed capacity causing delayed transfer of elderly and complex medical patients from A&E View source Delays in access to specialist nurses for patients in A&E View source Failure to provide robust symptom control in A&E View source Failure of A&E environments to provide appropriate care for elderly and complex medical patients View source Failure to provide staff with the expertise required for patients treated in A&E View source Unavailability of geriatric team assessment in A&E View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lina Piroli · 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
Lina Piroli, aged 93, was admitted with an E. coli infection and later suffered an unstable C2 fracture and a stable L1 fracture after a fall down stairs. She remained in A&E for a prolonged period because no elderly care ward bed was available, while experiencing pain, confusion and delirium. The report raises concerns about delayed transfer to a ward and the resulting lack of access to specialist, coordinated care and appropriate symptom management for an elderly, complex patient.
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 coordinated care in A&E
Wider context from the report “When Lina presented to the Whittington Hospital on the evening of 2 February 2025 it was identified that due to her fractured spine, she would need a bed on an elderly care ward. She was accepted by the medical team but there were no beds available. This meant that she remained in A&E at a time when she was experiencing pain, confusion and delirium due to her injury, infection, pain, pain medication and dementia. I heard that there is guidance on how to treat people with dementia during a hospital admission but that this is simply not achievable in a busy and overcrowded emergency department. Lina was a complex presentation and 93 years old.
Whilst Lina received the immediately necessary tests and treatment, she was not seen by the geriatric team (who do not work in A&E) and had delayed access to specialist nurses, robust symptom control measures, regular reviews and coordinated care . She remained in a busy, noisy and frightening environment. It was not until she was moved to a ward that advice was sought on the best management of her spinal fracture. The delay in transferring her to a ward was detrimental to optimising her chances of recovery.
I heard evidence that this is not uncommon at the Whittington and is a problem across all London hospitals (and hospitals throughout the UK). When there are no ward beds to transfer patients to, they stay in A&E and A&E is not set up to deliver the care that, particularly elderly and complex medical, patients require. Nursing staff are having to treat double the number of patients that the department is designed to accommodate and patients who require care and treatment outside of their expertise. This means that patients are not receiving the appropriate level of care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide regular clinical reviews in A&E
Wider context from the report “When Lina presented to the Whittington Hospital on the evening of 2 February 2025 it was identified that due to her fractured spine, she would need a bed on an elderly care ward. She was accepted by the medical team but there were no beds available. This meant that she remained in A&E at a time when she was experiencing pain, confusion and delirium due to her injury, infection, pain, pain medication and dementia. I heard that there is guidance on how to treat people with dementia during a hospital admission but that this is simply not achievable in a busy and overcrowded emergency department. Lina was a complex presentation and 93 years old.
Whilst Lina received the immediately necessary tests and treatment, she was not seen by the geriatric team (who do not work in A&E) and had delayed access to specialist nurses, robust symptom control measures, regular reviews and coordinated care. She remained in a busy, noisy and frightening environment. It was not until she was moved to a ward that advice was sought on the best management of her spinal fracture. The delay in transferring her to a ward was detrimental to optimising her chances of recovery.
I heard evidence that this is not uncommon at the Whittington and is a problem across all London hospitals (and hospitals throughout the UK). When there are no ward beds to transfer patients to, they stay in A&E and A&E is not set up to deliver the care that, particularly elderly and complex medical, patients require. Nursing staff are having to treat double the number of patients that the department is designed to accommodate and patients who require care and treatment outside of their expertise. This means that patients are not receiving the appropriate level of care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient A&E nursing capacity for patient numbers
Wider context from the report “When Lina presented to the Whittington Hospital on the evening of 2 February 2025 it was identified that due to her fractured spine, she would need a bed on an elderly care ward. She was accepted by the medical team but there were no beds available. This meant that she remained in A&E at a time when she was experiencing pain, confusion and delirium due to her injury, infection, pain, pain medication and dementia. I heard that there is guidance on how to treat people with dementia during a hospital admission but that this is simply not achievable in a busy and overcrowded emergency department. Lina was a complex presentation and 93 years old.
Whilst Lina received the immediately necessary tests and treatment, she was not seen by the geriatric team (who do not work in A&E) and had delayed access to specialist nurses, robust symptom control measures, regular reviews and coordinated care. She remained in a busy, noisy and frightening environment. It was not until she was moved to a ward that advice was sought on the best management of her spinal fracture. The delay in transferring her to a ward was detrimental to optimising her chances of recovery.
I heard evidence that this is not uncommon at the Whittington and is a problem across all London hospitals (and hospitals throughout the UK). When there are no ward beds to transfer patients to, they stay in A&E and A&E is not set up to deliver the care that, particularly elderly and complex medical, patients require. Nursing staff are having to treat double the number of patients that the department is designed to accommodate and patients who require care and treatment outside of their expertise. This means that patients are not receiving the appropriate level of care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of ward-bed capacity causing delayed transfer of elderly and complex medical patients from A&E
Wider context from the report “When Lina presented to the Whittington Hospital on the evening of 2 February 2025 it was identified that due to her fractured spine, she would need a bed on an elderly care ward. She was accepted by the medical team but there were no beds available . This meant that she remained in A&E at a time when she was experiencing pain, confusion and delirium due to her injury, infection, pain, pain medication and dementia. I heard that there is guidance on how to treat people with dementia during a hospital admission but that this is simply not achievable in a busy and overcrowded emergency department. Lina was a complex presentation and 93 years old.
Whilst Lina received the immediately necessary tests and treatment, she was not seen by the geriatric team (who do not work in A&E) and had delayed access to specialist nurses, robust symptom control measures, regular reviews and coordinated care. She remained in a busy, noisy and frightening environment. It was not until she was moved to a ward that advice was sought on the best management of her spinal fracture. The delay in transferring her to a ward was detrimental to optimising her chances of recovery.
I heard evidence that this is not uncommon at the Whittington and is a problem across all London hospitals (and hospitals throughout the UK). When there are no ward beds to transfer patients to, they stay in A&E and A&E is not set up to deliver the care that, particularly elderly and complex medical, patients require. Nursing staff are having to treat double the number of patients that the department is designed to accommodate and patients who require care and treatment outside of their expertise. This means that patients are not receiving the appropriate level of care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in access to specialist nurses for patients in A&E
Wider context from the report “When Lina presented to the Whittington Hospital on the evening of 2 February 2025 it was identified that due to her fractured spine, she would need a bed on an elderly care ward. She was accepted by the medical team but there were no beds available. This meant that she remained in A&E at a time when she was experiencing pain, confusion and delirium due to her injury, infection, pain, pain medication and dementia. I heard that there is guidance on how to treat people with dementia during a hospital admission but that this is simply not achievable in a busy and overcrowded emergency department. Lina was a complex presentation and 93 years old.
Whilst Lina received the immediately necessary tests and treatment, she was not seen by the geriatric team (who do not work in A&E) and had delayed access to specialist nurses , robust symptom control measures, regular reviews and coordinated care. She remained in a busy, noisy and frightening environment. It was not until she was moved to a ward that advice was sought on the best management of her spinal fracture. The delay in transferring her to a ward was detrimental to optimising her chances of recovery.
I heard evidence that this is not uncommon at the Whittington and is a problem across all London hospitals (and hospitals throughout the UK). When there are no ward beds to transfer patients to, they stay in A&E and A&E is not set up to deliver the care that, particularly elderly and complex medical, patients require. Nursing staff are having to treat double the number of patients that the department is designed to accommodate and patients who require care and treatment outside of their expertise. This means that patients are not receiving the appropriate level of care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide robust symptom control in A&E
Wider context from the report “When Lina presented to the Whittington Hospital on the evening of 2 February 2025 it was identified that due to her fractured spine, she would need a bed on an elderly care ward. She was accepted by the medical team but there were no beds available. This meant that she remained in A&E at a time when she was experiencing pain, confusion and delirium due to her injury, infection, pain, pain medication and dementia. I heard that there is guidance on how to treat people with dementia during a hospital admission but that this is simply not achievable in a busy and overcrowded emergency department. Lina was a complex presentation and 93 years old.
Whilst Lina received the immediately necessary tests and treatment, she was not seen by the geriatric team (who do not work in A&E) and had delayed access to specialist nurses, robust symptom control measures , regular reviews and coordinated care. She remained in a busy, noisy and frightening environment. It was not until she was moved to a ward that advice was sought on the best management of her spinal fracture. The delay in transferring her to a ward was detrimental to optimising her chances of recovery.
I heard evidence that this is not uncommon at the Whittington and is a problem across all London hospitals (and hospitals throughout the UK). When there are no ward beds to transfer patients to, they stay in A&E and A&E is not set up to deliver the care that, particularly elderly and complex medical, patients require. Nursing staff are having to treat double the number of patients that the department is designed to accommodate and patients who require care and treatment outside of their expertise. This means that patients are not receiving the appropriate level of care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of A&E environments to provide appropriate care for elderly and complex medical patients
Wider context from the report “When Lina presented to the Whittington Hospital on the evening of 2 February 2025 it was identified that due to her fractured spine, she would need a bed on an elderly care ward. She was accepted by the medical team but there were no beds available. This meant that she remained in A&E at a time when she was experiencing pain, confusion and delirium due to her injury, infection, pain, pain medication and dementia. I heard that there is guidance on how to treat people with dementia during a hospital admission but that this is simply not achievable in a busy and overcrowded emergency department. Lina was a complex presentation and 93 years old.
Whilst Lina received the immediately necessary tests and treatment, she was not seen by the geriatric team (who do not work in A&E) and had delayed access to specialist nurses, robust symptom control measures, regular reviews and coordinated care. She remained in a busy, noisy and frightening environment . It was not until she was moved to a ward that advice was sought on the best management of her spinal fracture. The delay in transferring her to a ward was detrimental to optimising her chances of recovery.
I heard evidence that this is not uncommon at the Whittington and is a problem across all London hospitals (and hospitals throughout the UK). When there are no ward beds to transfer patients to, they stay in A&E and A&E is not set up to deliver the care that, particularly elderly and complex medical, patients require . Nursing staff are having to treat double the number of patients that the department is designed to accommodate and patients who require care and treatment outside of their expertise. This means that patients are not receiving the appropriate level of care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide staff with the expertise required for patients treated in A&E
Wider context from the report “When Lina presented to the Whittington Hospital on the evening of 2 February 2025 it was identified that due to her fractured spine, she would need a bed on an elderly care ward. She was accepted by the medical team but there were no beds available. This meant that she remained in A&E at a time when she was experiencing pain, confusion and delirium due to her injury, infection, pain, pain medication and dementia. I heard that there is guidance on how to treat people with dementia during a hospital admission but that this is simply not achievable in a busy and overcrowded emergency department. Lina was a complex presentation and 93 years old.
Whilst Lina received the immediately necessary tests and treatment, she was not seen by the geriatric team (who do not work in A&E) and had delayed access to specialist nurses, robust symptom control measures, regular reviews and coordinated care. She remained in a busy, noisy and frightening environment. It was not until she was moved to a ward that advice was sought on the best management of her spinal fracture. The delay in transferring her to a ward was detrimental to optimising her chances of recovery.
I heard evidence that this is not uncommon at the Whittington and is a problem across all London hospitals (and hospitals throughout the UK). When there are no ward beds to transfer patients to, they stay in A&E and A&E is not set up to deliver the care that, particularly elderly and complex medical, patients require. Nursing staff are having to treat double the number of patients that the department is designed to accommodate and patients who require care and treatment outside of their expertise . This means that patients are not receiving the appropriate level of care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unavailability of geriatric team assessment in A&E
Wider context from the report “When Lina presented to the Whittington Hospital on the evening of 2 February 2025 it was identified that due to her fractured spine, she would need a bed on an elderly care ward. She was accepted by the medical team but there were no beds available. This meant that she remained in A&E at a time when she was experiencing pain, confusion and delirium due to her injury, infection, pain, pain medication and dementia. I heard that there is guidance on how to treat people with dementia during a hospital admission but that this is simply not achievable in a busy and overcrowded emergency department. Lina was a complex presentation and 93 years old.
Whilst Lina received the immediately necessary tests and treatment, she was not seen by the geriatric team (who do not work in A&E) and had delayed access to specialist nurses, robust symptom control measures, regular reviews and coordinated care. She remained in a busy, noisy and frightening environment. It was not until she was moved to a ward that advice was sought on the best management of her spinal fracture. The delay in transferring her to a ward was detrimental to optimising her chances of recovery.
I heard evidence that this is not uncommon at the Whittington and is a problem across all London hospitals (and hospitals throughout the UK). When there are no ward beds to transfer patients to, they stay in A&E and A&E is not set up to deliver the care that, particularly elderly and complex medical, patients require. Nursing staff are having to treat double the number of patients that the department is designed to accommodate and patients who require care and treatment outside of their expertise. This means that patients are not receiving the appropriate level of care.
” 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 developing services that shift unplanned urgent care outside acute hospitals, support alternatives to admission and improve discharge.
Verbatim wording from the response “working with the regions to support Acute Trusts to eliminate crowding in EDs in the longer term. Improvements are being progressed through NHS England’s operational planning guidance, where Integrated Care Boards (ICBs) were asked to focus on delivering improved patient flow. This has included increasing the productivity of acute and non-acute healthcare services, improving flow and length of stay, as well as clinical outcomes. In addition to this, we are continuing to develop services that shift activity from acute hospital settings to settings outside of an acute hospital for patients with unplanned urgent needs, supporting proactive care, alternatives to admission and improving hospital discharge.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish and implement the two-year Urgent and Emergency Care Recovery Plan to improve urgent and emergency care performance.
Verbatim wording from the response “NHS England recognises the significant pressures on all NHS services and, in January 2023, published a two-year Urgent & Emergency Care (UEC) Recovery Plan. The plan prioritised improvements to the 4-hour standard – a constitutional standard aiming for 95% of patients to be admitted, transferred, or discharged within four hours of arrival. The plan outlined key actions to recover and improve urgent and emergency care services. Despite significant challenges, including high demand for services, there was an improvement in the headline ambition between 2023 and 2025.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with regions to support acute trusts in eliminating emergency-department crowding through improved patient flow and length of stay.
Verbatim wording from the response “working with the regions to support Acute Trusts to eliminate crowding in EDs in the longer term. Improvements are being progressed through NHS England’s operational planning guidance, where Integrated Care Boards (ICBs) were asked to focus on delivering improved patient flow. This has included increasing the productivity of acute and non-acute healthcare services, improving flow and length of stay, as well as clinical outcomes. In addition to this, we are continuing to develop services that shift activity from acute hospital settings to settings outside of an acute hospital for patients with unplanned urgent needs, supporting proactive care, alternatives to admission and improving hospital discharge.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the 2025/26 Urgent and Emergency Care Plan to improve hospital flow, reduce prolonged waits and eliminate corridor care.
Verbatim wording from the response “Recognising that there is further work to be done, in June 2025, NHS England published the Urgent and Emergency Care Plan for 2025/26 which included an ambition to ‘improve flow through hospitals with a particular focus on patients waiting over 12 hours and making progress on eliminating corridor care’. NHS England is” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a national bed-occupancy reduction sprint to reduce occupancy and improve timely movement of patients to ward beds.
Verbatim wording from the response “NHS England also undertook a bed occupancy reduction sprint to manage demand nationally, which commenced in October 2025 and concluded on 24th December 2025. This has enabled a reduced bed occupancy and enabled providers to respond to surges in demand that the NHS traditionally experiences during winter, enabling patients to move in a more timely manner to ward beds.” Source location Response from NHS England
Open published response
26 Nov 2025 Evie Rae Le Masurier-O'Sullivan · Prevention of Future Deaths report South London
View report summary
Concerns raised 2 Failure to elicit and provide an opportunity for sharing parental concerns about a baby’s wellbeing during postnatal contacts View source Lack of training for temporary staff in eliciting parental concerns about a baby’s wellbeing during postnatal contacts 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
Evie Rae Le Masurier-O'Sullivan · 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
Evie became unwell with respiratory distress on the post-natal ward less than a day after birth and died after deteriorating with sepsis-related complications. The report identified concerns that staff did not elicit or provide an opportunity for her parents to share concerns about her crying and breathing, contributing to a lack of neonatal assessment and escalation, and that antibiotics were delayed. It also identified a training gap for temporary staff in eliciting parental concerns, creating a risk of future deaths unless action is taken.
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 elicit and provide an opportunity for sharing parental concerns about a baby’s wellbeing during postnatal contacts
Wider context from the report “4. On attending the mother’s bedside, the midwife or midwife assistant (also known as maternity assistants or midwifery assistants) should ensure that there are no parental concerns about the baby. Although there are different ways in which this important objective can be achieved, the midwife or midwife assistant should ensure that they ask questions in a way that ensures that the family had an “open space” to share their concerns . In other words, it is important that: (i) the questions asked by the midwife or midwife assistant are asked in a way that can elicit any such concerns ; (ii) they afford the parents an adequate opportunity for those concerns to be shared ; and (iii) their attitude to, and interactions with, the parents creates an environment in which parents feel able to share concerns.
In Evie’s case, I concluded that: although Evie's mother was seen by a member of the midwifery team at postnatal contacts at around 00:30 and by a midwife at around 02:30, they did not elicit concerns Evie's parents had about Evie's crying and breathing, and nor did they afford an opportunity for these concerns to be shared ; and this led to an absence of neonatal assessments being carried out and absence of escalation to the hospital's neonatal team, which contributed to the death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of training for temporary staff in eliciting parental concerns about a baby’s wellbeing during postnatal contacts
Wider context from the report “However, I also received evidence that: (i) all temporary staffing supplied at Croydon University Hospital including midwives is provided by “On-Framework” suppliers under framework RM6281 (RM6281 is a framework agreement managed under the NHS Workforce Alliance for the procurement of clinical and healthcare staffing across the UK); and (ii) most NHS Trusts, including Croydon Health Services NHS Trust, do not provide in-house training to their agency staff as they are not provided with funding for them to be trained . This means that there is a training gap, in that temporary staff provided by “On-Framework” suppliers under framework RM6281, including those working at Croydon University Hospital, will not receive the additional training identified above in relation to eliciting parental concerns about a baby’s wellbeing at postnatal contacts . In my opinion, this training gap gives rise to a risk that future deaths could occur unless action is taken .
” 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 Eliciting parental concerns about neonatal wellbeing falls under midwifery fitness to practise and NMC regulation.
Verbatim wording from the response “The specifics of eliciting parental concerns about a baby’s wellbeing at postnatal contacts falls under fitness to practise and regulation, as all midwives should have these skills. A number of standards within the Standards of Proficiency for Midwives guidance, published by the Nursing & Midwifery Council (NMC), relate to eliciting parental concerns regarding neonatal wellbeing during postnatal contacts. Specifically, the following two standards reflect what a midwife should be competent” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National NHS England does not mandate agency staff training because this is a local NHS Trust-level issue.
Verbatim wording from the response “The training of agency staff is a local Trust level issue and not something that NHS England mandates nationally. The Maternity Incentive Scheme (MIS) safety action 8 states ‘It is the responsibility of the employing agency to provide training to staff, it is the responsibility of the Trust to ensure that all agency staff have met minimum training requirements before working in the Trust. The Safe, Sustainable and Productive Staffing resource highlights that “All temporary staff should receive local training and induction, so they are familiar with how the organisation works.”” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Employing agencies must train agency staff, while Trusts must ensure temporary staff meet minimum training requirements before working.
Verbatim wording from the response “The training of agency staff is a local Trust level issue and not something that NHS England mandates nationally. The Maternity Incentive Scheme (MIS) safety action 8 states ‘It is the responsibility of the employing agency to provide training to staff, it is the responsibility of the Trust to ensure that all agency staff have met minimum training requirements before working in the Trust. The Safe, Sustainable and Productive Staffing resource highlights that “All temporary staff should receive local training and induction, so they are familiar with how the organisation works.”” Source location Response from NHS England
Open published response
24 Nov 2025 Diana Ocean Grant · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Lack of work or review addressing secure mental health unit capacity and associated risk View source Inability of prison healthcare provision to fully meet mental health patients’ needs View source Inability to provide compulsory medication and treatment in prison View source Requirement for pre-planning before secure mental health unit admission View source Insufficient capacity in the secure mental health unit estate View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Diana Ocean Grant · 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
Diana Ocean Grant, who was experiencing a relapse of paranoid schizophrenia and symptoms of psychosis, died in her prison cell after a foreign object became lodged in her upper airway. The report identified concerns about failures and delays in mental health assessment, treatment, information-sharing, observation and prison placement, as well as the limited availability of secure mental health beds for people requiring admission.
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 work or review addressing secure mental health unit capacity and associated risk
Wider context from the report “The concern arises in relation to persons who are judged to need immediate admission to a mental health unit for assessment and/or treatment, but who are also judged to need admission to a secure unit because they are dangerous to others, whether by reason of being under arrest for, or charged with, a serious criminal offence or otherwise.
The evidence I received established that, despite changes made since the Deceased’s death, including the recent introduction of NHS England’s “Mental Health Crisis Care for Londoners: London’s Section 136 Pathway and Health Based Place of Safety Specification”, it remains extremely unlikely that such a person will be granted immediate admission to a secure mental health unit. This is principally because of the restricted capacity of the secure mental health unit estate, but also because of an expectation that some element of pre-planning will take place before such an admission occurs.
Consequently, for many persons in the circumstances described above, detention in prison prior to transfer to a secure mental health unit continues to be unavoidable. The evidence I heard at the inquest suggested that although the expectation, in those circumstances, is that transfer from prison to hospital should take place within 28 days, the low availability of beds actually results in transfers taking, on average, as long as 80 to 90 days.
Detention in prison of persons requiring mental health unit admission raises a concern for risk of death. The evidence I heard established that this is because a mental health patient’s needs cannot be fully met in prison, even in a prison’s health care wing. This is by reason of the fact that there is a material difference in the physical environment, the nursing and therapeutic regimes, and the access to psychological and other therapeutic treatments. Further, whilst medication and treatment can be given compulsorily in hospital, that is not the case in prison.
The witness from whom I heard, stated that he was not aware of any work or review currently being undertaken to address the lack of capacity within the secure mental health unit estate or to address how the above risk may be resolved or managed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inability of prison healthcare provision to fully meet mental health patients’ needs
Wider context from the report “The concern arises in relation to persons who are judged to need immediate admission to a mental health unit for assessment and/or treatment, but who are also judged to need admission to a secure unit because they are dangerous to others, whether by reason of being under arrest for, or charged with, a serious criminal offence or otherwise.
The evidence I received established that, despite changes made since the Deceased’s death, including the recent introduction of NHS England’s “Mental Health Crisis Care for Londoners: London’s Section 136 Pathway and Health Based Place of Safety Specification”, it remains extremely unlikely that such a person will be granted immediate admission to a secure mental health unit. This is principally because of the restricted capacity of the secure mental health unit estate, but also because of an expectation that some element of pre-planning will take place before such an admission occurs.
Consequently, for many persons in the circumstances described above, detention in prison prior to transfer to a secure mental health unit continues to be unavoidable. The evidence I heard at the inquest suggested that although the expectation, in those circumstances, is that transfer from prison to hospital should take place within 28 days, the low availability of beds actually results in transfers taking, on average, as long as 80 to 90 days.
Detention in prison of persons requiring mental health unit admission raises a concern for risk of death. The evidence I heard established that this is because a mental health patient’s needs cannot be fully met in prison, even in a prison’s health care wing . This is by reason of the fact that there is a material difference in the physical environment, the nursing and therapeutic regimes, and the access to psychological and other therapeutic treatments . Further, whilst medication and treatment can be given compulsorily in hospital, that is not the case in prison.
The witness from whom I heard, stated that he was not aware of any work or review currently being undertaken to address the lack of capacity within the secure mental health unit estate or to address how the above risk may be resolved or managed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inability to provide compulsory medication and treatment in prison
Wider context from the report “The concern arises in relation to persons who are judged to need immediate admission to a mental health unit for assessment and/or treatment, but who are also judged to need admission to a secure unit because they are dangerous to others, whether by reason of being under arrest for, or charged with, a serious criminal offence or otherwise.
The evidence I received established that, despite changes made since the Deceased’s death, including the recent introduction of NHS England’s “Mental Health Crisis Care for Londoners: London’s Section 136 Pathway and Health Based Place of Safety Specification”, it remains extremely unlikely that such a person will be granted immediate admission to a secure mental health unit. This is principally because of the restricted capacity of the secure mental health unit estate, but also because of an expectation that some element of pre-planning will take place before such an admission occurs.
Consequently, for many persons in the circumstances described above, detention in prison prior to transfer to a secure mental health unit continues to be unavoidable. The evidence I heard at the inquest suggested that although the expectation, in those circumstances, is that transfer from prison to hospital should take place within 28 days, the low availability of beds actually results in transfers taking, on average, as long as 80 to 90 days.
Detention in prison of persons requiring mental health unit admission raises a concern for risk of death. The evidence I heard established that this is because a mental health patient’s needs cannot be fully met in prison, even in a prison’s health care wing. This is by reason of the fact that there is a material difference in the physical environment, the nursing and therapeutic regimes, and the access to psychological and other therapeutic treatments. Further, whilst medication and treatment can be given compulsorily in hospital, that is not the case in prison .
The witness from whom I heard, stated that he was not aware of any work or review currently being undertaken to address the lack of capacity within the secure mental health unit estate or to address how the above risk may be resolved or managed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Requirement for pre-planning before secure mental health unit admission
Wider context from the report “The concern arises in relation to persons who are judged to need immediate admission to a mental health unit for assessment and/or treatment, but who are also judged to need admission to a secure unit because they are dangerous to others, whether by reason of being under arrest for, or charged with, a serious criminal offence or otherwise.
The evidence I received established that, despite changes made since the Deceased’s death, including the recent introduction of NHS England’s “Mental Health Crisis Care for Londoners: London’s Section 136 Pathway and Health Based Place of Safety Specification”, it remains extremely unlikely that such a person will be granted immediate admission to a secure mental health unit. This is principally because of the restricted capacity of the secure mental health unit estate, but also because of an expectation that some element of pre-planning will take place before such an admission occurs .
Consequently, for many persons in the circumstances described above, detention in prison prior to transfer to a secure mental health unit continues to be unavoidable. The evidence I heard at the inquest suggested that although the expectation, in those circumstances, is that transfer from prison to hospital should take place within 28 days, the low availability of beds actually results in transfers taking, on average, as long as 80 to 90 days.
Detention in prison of persons requiring mental health unit admission raises a concern for risk of death. The evidence I heard established that this is because a mental health patient’s needs cannot be fully met in prison, even in a prison’s health care wing. This is by reason of the fact that there is a material difference in the physical environment, the nursing and therapeutic regimes, and the access to psychological and other therapeutic treatments. Further, whilst medication and treatment can be given compulsorily in hospital, that is not the case in prison.
The witness from whom I heard, stated that he was not aware of any work or review currently being undertaken to address the lack of capacity within the secure mental health unit estate or to address how the above risk may be resolved or managed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 capacity in the secure mental health unit estate
Wider context from the report “The concern arises in relation to persons who are judged to need immediate admission to a mental health unit for assessment and/or treatment, but who are also judged to need admission to a secure unit because they are dangerous to others, whether by reason of being under arrest for, or charged with, a serious criminal offence or otherwise.
The evidence I received established that, despite changes made since the Deceased’s death, including the recent introduction of NHS England’s “Mental Health Crisis Care for Londoners: London’s Section 136 Pathway and Health Based Place of Safety Specification”, it remains extremely unlikely that such a person will be granted immediate admission to a secure mental health unit . This is principally because of the restricted capacity of the secure mental health unit estate , but also because of an expectation that some element of pre-planning will take place before such an admission occurs.
Consequently, for many persons in the circumstances described above, detention in prison prior to transfer to a secure mental health unit continues to be unavoidable. The evidence I heard at the inquest suggested that although the expectation, in those circumstances, is that transfer from prison to hospital should take place within 28 days, the low availability of beds actually results in transfers taking, on average, as long as 80 to 90 days .
Detention in prison of persons requiring mental health unit admission raises a concern for risk of death. The evidence I heard established that this is because a mental health patient’s needs cannot be fully met in prison, even in a prison’s health care wing. This is by reason of the fact that there is a material difference in the physical environment, the nursing and therapeutic regimes, and the access to psychological and other therapeutic treatments. Further, whilst medication and treatment can be given compulsorily in hospital, that is not the case in prison.
The witness from whom I heard, stated that he was not aware of any work or review currently being undertaken to address the lack of capacity within the secure mental health unit estate or to address how the above risk may be resolved or managed.
” 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 Complete an independent review of HMP Bronzefield healthcare provision and submit its findings to the Prisons and Probation Ombudsman.
Verbatim wording from the response “An independent review of the healthcare provision at HMP Bronzefield was commissioned and submitted to the Prisons and Probation Ombudsman (PPO) in February 2023. The PPO’s final report was published in January 2025. Alongside Sodexo, the Clinical Lead for Central and North West London NHS Foundation Trust was involved with developing an action plan in May 2023 and this was submitted to the PPO.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a national adult forensic Access Assessment Services specification requiring emergency adult forensic bed admission arrangements, including out-of-hours access.
Verbatim wording from the response “Using this information, and in collaboration with relevant stakeholders, we are developing a new national service specification for Access Assessment Services (for adult forensic services), that will include a requirement that arrangements are in place for emergency admissions to an adult forensic bed, including out of hours.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and submit an action plan addressing findings from the HMP Bronzefield healthcare review.
Verbatim wording from the response “An independent review of the healthcare provision at HMP Bronzefield was commissioned and submitted to the Prisons and Probation Ombudsman (PPO) in February 2023. The PPO’s final report was published in January 2025. Alongside Sodexo, the Clinical Lead for Central and North West London NHS Foundation Trust was involved with developing an action plan in May 2023 and this was submitted to the PPO.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review local causes of delays against the 28-day prison-to-hospital transfer target with providers, including guidance, escalation pathways, referral forms and contact lists.
Verbatim wording from the response “Locally, NHS England’s South East Health and Justice Commissioning team and Direct and Specialised Commissioning Quality team have engaged with the national programme of mental health improvements, along with working with local providers, to review areas that can cause delays to achieve the 28 day transfer target referred to within your Report, including looking at the Who Pays guidance, escalation pathways, referral forms and contact lists. There are also working groups with a focus on alternatives to custody.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Map emergency admission arrangements across adult forensic provider collaboratives, including out-of-hours access.
Verbatim wording from the response “NHS England’s Adult Forensic Services Team are currently mapping arrangements across all 15 Adult Secure Provider Collaboratives for emergency admissions to an adult forensic bed, including out of hours, to understand variation across England.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue the national programme addressing delays in transfers from prison to mental health hospitals.
Verbatim wording from the response “There is also an ongoing significant national programme of work to address delays in transfers from prison to mental health hospitals.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch and maintain a national database of adult forensic Access Assessment Services with referral and out-of-hours contact information.
Verbatim wording from the response “We have also created a database of Access Assessment Services (for adult forensic services) across England, that includes the direct contact information for referrals and urgent referrals, and out of hours contact information. This has now been launched and is accessible via the NHS Futures Collaboration Platform.” Source location Response from NHS England
Open published response
Concerns raised 2 Lack of guidance defining the component elements and required depth of s.117 plans View source Absence of formal documented s.117 discharge plans agreed by all responsible care and treatment providers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Timothy Thomas Reading · 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 Thomas Reading died on 9 January 2025. He had a history of mental illness and had been discharged from inpatient care into the community under a community treatment order. The report identified the absence of a formal documented section 117 support plan, slow and disjointed transition arrangements, and no handover between responsible clinicians; the inquest concluded that he died by suicide, with hanging recorded as the medical cause of death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance defining the component elements and required depth of s.117 plans
Wider context from the report “(2) I was informed by the Representative of BSMHFT that there is no national guidance from the NHS or other source that explains what a s.117 plan should address . If so, this represents a lacuna which gives rise to concern that mental health providers are unclear as to the component elements for a s.117 plan and the degree or depth of planning required for individual 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 Absence of formal documented s.117 discharge plans agreed by all responsible care and treatment providers
Wider context from the report “(1) The absence of a formal documented s.117 plan agreed by all those responsible for a patient’s care and treatment upon discharge into the Community from a lengthy inpatient stay creates a risk of disjointed, disorganized and inadequate support for vulnerable people suffering serious mental health conditions . This, in turn, may cause them to feel unsupported and helpless. BSMHFT did not provide a Plan despite requests to do so. S.117 is intended to ensure that patients receive planned and structured support tailored to their requirements. Such planning was absent in this case.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust is better placed to respond to concerns about the absence of a requested Section 117 plan.
Verbatim wording from the response “We note that your report has also been addressed to the Trust who will be better placed to respond to the concerns raised around the absence of Section 117 plan provided by the Trust despite it being requested.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing national guidance sufficiently addresses the required content and planning of Section 117 aftercare plans.
Verbatim wording from the response “NHS England Mental Health colleagues have advised that there is clear guidance set out in the Mental Health Act Code of Practice on Section 117 aftercare which includes planning based on the person’s individual needs. It includes examples such as ensuring the person’s wider social, cultural and spiritual needs are met and specifies that after care should aim to support people in regaining or enhancing their skills, or learning new skills, in order to cope with life outside of hospital. Before deciding to discharge or grant more than a very short-term leave of absence to a patient, or to place a patient onto a Community Treatment Order (CTO), the responsible clinician should ensure that the patient’s needs for after-care have been fully assessed, discussed with the patient (and their carers, where appropriate) and addressed in their care plan.” Source location Response from NHS England
Open published response
Concerns raised 4 Failure to complete standard community needs and treatment assessments View source Failure to provide appointments from allocated Community Psychiatric Nurses and key workers View source Lack of policy, guidance or framework governing standard community needs and treatment assessments View source Lack of policy or procedure governing the timing and conduct of appointments 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
Lynsey Ellen Dearden · 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 Lynsey Ellen Dearden was found deceased at her home on 11 March 2025. The inquest concluded with a short-form conclusion of suicide; the stated cause of death was asphyxiation, with anxiety and depression recorded in Part II. Concerns included failures to provide allocated Community Psychiatric Nurse appointments and to complete a standard assessment framework, alongside the absence of policies or guidance governing these 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 Failure to complete standard community needs and treatment assessments
Wider context from the report “2. Evidence emerged during the inquest that Mrs Dearden was allocated a Community Psychiatric Nurse, on the 31st December 2024, to facilitate a standard assessment framework, to assess what help and treatment Mrs Dearden may need in the community. This did not take place , and there was no answer as to when this should have taken place, or how this should have been carried out as there is no policy, guidance or framework in place to govern this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appointments from allocated Community Psychiatric Nurses and key workers
Wider context from the report “1. Evidence emerged during the inquest that Mrs Dearden was allocated a Community Psychiatric Nurse, and key worker in November 2024 but had not received any appointments to the date of her death on the 11 March 2025 . There was no real explanation as to why, or any policy or procedure to give a framework as to how or when appointments should take place;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of policy, guidance or framework governing standard community needs and treatment assessments
Wider context from the report “2. Evidence emerged during the inquest that Mrs Dearden was allocated a Community Psychiatric Nurse, on the 31st December 2024, to facilitate a standard assessment framework, to assess what help and treatment Mrs Dearden may need in the community. This did not take place, and there was no answer as to when this should have taken place, or how this should have been carried out as there is no policy, guidance or framework in place to govern this .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of policy or procedure governing the timing and conduct of appointments
Wider context from the report “1. Evidence emerged during the inquest that Mrs Dearden was allocated a Community Psychiatric Nurse, and key worker in November 2024 but had not received any appointments to the date of her death on the 11 March 2025. There was no real explanation as to why, or any policy or procedure to give a framework as to how or when appointments should take place;
” Open source report
17 Nov 2025 Paolino AMICO · Prevention of Future Deaths report Essex
View report summary
Concerns raised 19 Failure to provide clear oxygen-therapy discharge planning and referral information View source Failure to review the patient before prescribing a controlled drug View source Failure to consider or plan alternative pain management during opioid overdose treatment View source Failure to accurately record medication administration View source Non-mandatory medicines-administration refresher training for nurses View source Failure to escalate medication concerns to appropriately senior clinicians View source Failure to make an emergency call for an unresponsive patient View source Failure of medicines-administration training to support recognition of inappropriate MST prescribing View source Failure to administer MST at the prescribed frequency View source Failure to provide opioid reversal in accordance with applicable guidance View source Failure to administer prescribed medication View source Failure to identify prescription errors and prior doses during controlled-drug checks View source Failure to implement the local recommendation to include mandatory medicines-administration refresher training View source Failure to scrutinise prescribed medication and medication-system information View source Failure to communicate overnight deterioration and family medication concerns to the on-call doctor View source Failure to provide oxygen flow meeting patient requirements at discharge View source Delay and inappropriate escalation of a high NEWS score View source Failure to make an emergency call after escalation of concerns View source Out-of-date PAT testing for oxygen equipment View source See 16 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paolino AMICO · 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
Paolino Amico, who had metastatic bladder cancer and advanced clinical frailty, was admitted with severe bilateral pneumonia and died in hospital on 12 June 2024. He received multiple overdoses of slow-release morphine following a prescription error, with concerns also raised about medication administration, delayed emergency escalation, oxygen provision after discharge, and the management of morphine reversal and pain relief.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear oxygen-therapy discharge planning and referral information
Wider context from the report “(1) The consultant required a discharge plan for oxygen therapy to be in place before Mr Amico could go home. The hospital discharge plan and medications were confusing and the referral for oxygen therapy requirement was unclear , and the PAT testing for the machine was out of date. Paramedics advised the family that the oxygen provided on Mr Amico’s discharge was low flow and was not meeting his oxygen requirements with his oxygen saturations at 68% and this immediately improved on ambulance crew equipment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 the patient before prescribing a controlled drug
Wider context from the report “(2) Mr Amico did not receive his prescribed medications during his second admissions when he was readmitted to hospital on 9 June.
a. On 9 June a doctor in Accident & Emergency had reviewed Mr Amico’s prescribed medications and increased liquid oral morphine sulphate 10 mg in 5mL Solution 4 hourly as required with 2.5 -5 mg max 6 doses at 22:57 hours with slow released morphine sulphate (MST) continued 2 times daily. Trust staff did not administer any morphine to Mr Amico although he and his family were raising concerns about his high level of pain.
b. The family was informed incorrectly that medications had not been prescribed. On the morning of 10 June, the family were given permission by a nurse to dispense from Mr Amico’s own supply of medications that he had brought to the hospital due to his level of pain. This was not accurately recorded in Mr Amico’s record. Mr Amico took his prescribed morning dose of MST.
c. On 10 June the nurse in Accident & Emergency did not escalate to the nurse in charge or a senior doctor that she could not locate the doctor allocated to Mr Amico and instead approached a foundation year 1 doctor to prescribe pain relief for Mr Amico. The nurse informed the doctor who was junior and very busy that the frequency of the morphine needed to be increased for Mr Amico. The doctor did not escalate the matter and did not review Mr Amico before prescribing a controlled drug .
d. Neither the nurse nor the doctor sufficiently scrutinised the medication prescribed on 9 June or on the Trust system that would have shown the correct medications. This led to a prescription error being made with MST being increased from 2 times daily to 4 times daily. Mr Amico was not referred for pain management.
e. Mr Amico then moved to a ward. Multiple nurses were involved in checking and administering a controlled drug morphine sulphate slow release (MST) on 5 separate occasions between 10 and 11 June 2024 and did not raise concerns about the potential for a prescription error or note that Mr Amico had already received 1 dose of MST that morning.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to consider or plan alternative pain management during opioid overdose treatment
Wider context from the report “(6) Mr Amico morphine overdose was partially treated:
a. There was an immediate response to Naloxone but the opioid reversal for overdose was not in accordance with British National Formulary guidelines or with an NHS England alert previously issued.
b. There was no consideration or plan for alternative pain management in a patient who had been receiving morphine pain relief as part of his treatment plan for cancer.
c. Mr Amico suffered acute withdrawal syndrome and family complained about his suffering to hospital staff that they stated was not ameliorated. An emergency call would have triggered the attendance of an Anaesthetist who could have given advice on opioid reversal in a palliative patient.
Princess Alexandra Hospital & NHS England
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record medication administration
Wider context from the report “(2) Mr Amico did not receive his prescribed medications during his second admissions when he was readmitted to hospital on 9 June.
a. On 9 June a doctor in Accident & Emergency had reviewed Mr Amico’s prescribed medications and increased liquid oral morphine sulphate 10 mg in 5mL Solution 4 hourly as required with 2.5 -5 mg max 6 doses at 22:57 hours with slow released morphine sulphate (MST) continued 2 times daily. Trust staff did not administer any morphine to Mr Amico although he and his family were raising concerns about his high level of pain.
b. The family was informed incorrectly that medications had not been prescribed. On the morning of 10 June, the family were given permission by a nurse to dispense from Mr Amico’s own supply of medications that he had brought to the hospital due to his level of pain. This was not accurately recorded in Mr Amico’s record . Mr Amico took his prescribed morning dose of MST.
c. On 10 June the nurse in Accident & Emergency did not escalate to the nurse in charge or a senior doctor that she could not locate the doctor allocated to Mr Amico and instead approached a foundation year 1 doctor to prescribe pain relief for Mr Amico. The nurse informed the doctor who was junior and very busy that the frequency of the morphine needed to be increased for Mr Amico. The doctor did not escalate the matter and did not review Mr Amico before prescribing a controlled drug.
d. Neither the nurse nor the doctor sufficiently scrutinised the medication prescribed on 9 June or on the Trust system that would have shown the correct medications. This led to a prescription error being made with MST being increased from 2 times daily to 4 times daily. Mr Amico was not referred for pain management.
e. Mr Amico then moved to a ward. Multiple nurses were involved in checking and administering a controlled drug morphine sulphate slow release (MST) on 5 separate occasions between 10 and 11 June 2024 and did not raise concerns about the potential for a prescription error or note that Mr Amico had already received 1 dose of MST that morning.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Non-mandatory medicines-administration refresher training for nurses
Wider context from the report “(8) Medicines administration refresher training for nurses is not mandatory and the Trust in reviewing this case has not followed a local recommendation from senior nurses for this to be included.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 medication concerns to appropriately senior clinicians
Wider context from the report “(2) Mr Amico did not receive his prescribed medications during his second admissions when he was readmitted to hospital on 9 June.
a. On 9 June a doctor in Accident & Emergency had reviewed Mr Amico’s prescribed medications and increased liquid oral morphine sulphate 10 mg in 5mL Solution 4 hourly as required with 2.5 -5 mg max 6 doses at 22:57 hours with slow released morphine sulphate (MST) continued 2 times daily. Trust staff did not administer any morphine to Mr Amico although he and his family were raising concerns about his high level of pain.
b. The family was informed incorrectly that medications had not been prescribed. On the morning of 10 June, the family were given permission by a nurse to dispense from Mr Amico’s own supply of medications that he had brought to the hospital due to his level of pain. This was not accurately recorded in Mr Amico’s record. Mr Amico took his prescribed morning dose of MST.
c. On 10 June the nurse in Accident & Emergency did not escalate to the nurse in charge or a senior doctor that she could not locate the doctor allocated to Mr Amico and instead approached a foundation year 1 doctor to prescribe pain relief for Mr Amico. The nurse informed the doctor who was junior and very busy that the frequency of the morphine needed to be increased for Mr Amico. The doctor did not escalate the matter and did not review Mr Amico before prescribing a controlled drug.
d. Neither the nurse nor the doctor sufficiently scrutinised the medication prescribed on 9 June or on the Trust system that would have shown the correct medications. This led to a prescription error being made with MST being increased from 2 times daily to 4 times daily. Mr Amico was not referred for pain management.
e. Mr Amico then moved to a ward. Multiple nurses were involved in checking and administering a controlled drug morphine sulphate slow release (MST) on 5 separate occasions between 10 and 11 June 2024 and did not raise concerns about the potential for a prescription error or note that Mr Amico had already received 1 dose of MST that morning.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to make an emergency call for an unresponsive patient
Wider context from the report “(3) Mr Amico’s NEWS score increased, and an emergency call was not put out on 11 June when it was established that Mr Amico was unresponsive even to pain from 03:00 hours .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of medicines-administration training to support recognition of inappropriate MST prescribing
Wider context from the report “(7) Multiple nurses were involved in morphine administration and all had completed their original training outside of the UK and had undertaken a Trust medicines administration training that should have recognised that the prescription of MST 4 times a day was not appropriate . Mr Amico received 6 doses of MST in less than 24 hours instead of 2.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 administer MST at the prescribed frequency
Wider context from the report “(7) Multiple nurses were involved in morphine administration and all had completed their original training outside of the UK and had undertaken a Trust medicines administration training that should have recognised that the prescription of MST 4 times a day was not appropriate. Mr Amico received 6 doses of MST in less than 24 hours instead of 2 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 opioid reversal in accordance with applicable guidance
Wider context from the report “(6) Mr Amico morphine overdose was partially treated:
a. There was an immediate response to Naloxone but the opioid reversal for overdose was not in accordance with British National Formulary guidelines or with an NHS England alert previously issued .
b. There was no consideration or plan for alternative pain management in a patient who had been receiving morphine pain relief as part of his treatment plan for cancer.
c. Mr Amico suffered acute withdrawal syndrome and family complained about his suffering to hospital staff that they stated was not ameliorated. An emergency call would have triggered the attendance of an Anaesthetist who could have given advice on opioid reversal in a palliative patient.
Princess Alexandra Hospital & NHS England
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 administer prescribed medication
Wider context from the report “(2) Mr Amico did not receive his prescribed medications during his second admissions when he was readmitted to hospital on 9 June.
a. On 9 June a doctor in Accident & Emergency had reviewed Mr Amico’s prescribed medications and increased liquid oral morphine sulphate 10 mg in 5mL Solution 4 hourly as required with 2.5 -5 mg max 6 doses at 22:57 hours with slow released morphine sulphate (MST) continued 2 times daily. Trust staff did not administer any morphine to Mr Amico although he and his family were raising concerns about his high level of pain.
b. The family was informed incorrectly that medications had not been prescribed. On the morning of 10 June, the family were given permission by a nurse to dispense from Mr Amico’s own supply of medications that he had brought to the hospital due to his level of pain. This was not accurately recorded in Mr Amico’s record. Mr Amico took his prescribed morning dose of MST.
c. On 10 June the nurse in Accident & Emergency did not escalate to the nurse in charge or a senior doctor that she could not locate the doctor allocated to Mr Amico and instead approached a foundation year 1 doctor to prescribe pain relief for Mr Amico. The nurse informed the doctor who was junior and very busy that the frequency of the morphine needed to be increased for Mr Amico. The doctor did not escalate the matter and did not review Mr Amico before prescribing a controlled drug.
d. Neither the nurse nor the doctor sufficiently scrutinised the medication prescribed on 9 June or on the Trust system that would have shown the correct medications. This led to a prescription error being made with MST being increased from 2 times daily to 4 times daily. Mr Amico was not referred for pain management.
e. Mr Amico then moved to a ward. Multiple nurses were involved in checking and administering a controlled drug morphine sulphate slow release (MST) on 5 separate occasions between 10 and 11 June 2024 and did not raise concerns about the potential for a prescription error or note that Mr Amico had already received 1 dose of MST that morning.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to identify prescription errors and prior doses during controlled-drug checks
Wider context from the report “(2) Mr Amico did not receive his prescribed medications during his second admissions when he was readmitted to hospital on 9 June.
a. On 9 June a doctor in Accident & Emergency had reviewed Mr Amico’s prescribed medications and increased liquid oral morphine sulphate 10 mg in 5mL Solution 4 hourly as required with 2.5 -5 mg max 6 doses at 22:57 hours with slow released morphine sulphate (MST) continued 2 times daily. Trust staff did not administer any morphine to Mr Amico although he and his family were raising concerns about his high level of pain.
b. The family was informed incorrectly that medications had not been prescribed. On the morning of 10 June, the family were given permission by a nurse to dispense from Mr Amico’s own supply of medications that he had brought to the hospital due to his level of pain. This was not accurately recorded in Mr Amico’s record. Mr Amico took his prescribed morning dose of MST.
c. On 10 June the nurse in Accident & Emergency did not escalate to the nurse in charge or a senior doctor that she could not locate the doctor allocated to Mr Amico and instead approached a foundation year 1 doctor to prescribe pain relief for Mr Amico. The nurse informed the doctor who was junior and very busy that the frequency of the morphine needed to be increased for Mr Amico. The doctor did not escalate the matter and did not review Mr Amico before prescribing a controlled drug.
d. Neither the nurse nor the doctor sufficiently scrutinised the medication prescribed on 9 June or on the Trust system that would have shown the correct medications. This led to a prescription error being made with MST being increased from 2 times daily to 4 times daily. Mr Amico was not referred for pain management.
e. Mr Amico then moved to a ward. Multiple nurses were involved in checking and administering a controlled drug morphine sulphate slow release (MST) on 5 separate occasions between 10 and 11 June 2024 and did not raise concerns about the potential for a prescription error or note that Mr Amico had already received 1 dose of MST that morning .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to implement the local recommendation to include mandatory medicines-administration refresher training
Wider context from the report “(8) Medicines administration refresher training for nurses is not mandatory and the Trust in reviewing this case has not followed a local recommendation from senior nurses for this to be included .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 scrutinise prescribed medication and medication-system information
Wider context from the report “(2) Mr Amico did not receive his prescribed medications during his second admissions when he was readmitted to hospital on 9 June.
a. On 9 June a doctor in Accident & Emergency had reviewed Mr Amico’s prescribed medications and increased liquid oral morphine sulphate 10 mg in 5mL Solution 4 hourly as required with 2.5 -5 mg max 6 doses at 22:57 hours with slow released morphine sulphate (MST) continued 2 times daily. Trust staff did not administer any morphine to Mr Amico although he and his family were raising concerns about his high level of pain.
b. The family was informed incorrectly that medications had not been prescribed. On the morning of 10 June, the family were given permission by a nurse to dispense from Mr Amico’s own supply of medications that he had brought to the hospital due to his level of pain. This was not accurately recorded in Mr Amico’s record. Mr Amico took his prescribed morning dose of MST.
c. On 10 June the nurse in Accident & Emergency did not escalate to the nurse in charge or a senior doctor that she could not locate the doctor allocated to Mr Amico and instead approached a foundation year 1 doctor to prescribe pain relief for Mr Amico. The nurse informed the doctor who was junior and very busy that the frequency of the morphine needed to be increased for Mr Amico. The doctor did not escalate the matter and did not review Mr Amico before prescribing a controlled drug.
d. Neither the nurse nor the doctor sufficiently scrutinised the medication prescribed on 9 June or on the Trust system that would have shown the correct medications. This led to a prescription error being made with MST being increased from 2 times daily to 4 times daily . Mr Amico was not referred for pain management.
e. Mr Amico then moved to a ward. Multiple nurses were involved in checking and administering a controlled drug morphine sulphate slow release (MST) on 5 separate occasions between 10 and 11 June 2024 and did not raise concerns about the potential for a prescription error or note that Mr Amico had already received 1 dose of MST that morning.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate overnight deterioration and family medication concerns to the on-call doctor
Wider context from the report “(4) The on-call doctor was called approximately one hour after Mr Amico’s NEWS score was found to be 10 and arrived at 07:50, this was not an emergency call. The on-call doctor had not been informed of:
a. the deterioration in Mr Amico’s presentation during the night
b. that the family had informed nursing staff of their concerns Mr Amico had been given the wrong medication when he was noted to be unresponsive at approximately 03:00 hours, that should have immediately raised concerns about an overdose of MST.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 oxygen flow meeting patient requirements at discharge
Wider context from the report “(1) The consultant required a discharge plan for oxygen therapy to be in place before Mr Amico could go home. The hospital discharge plan and medications were confusing and the referral for oxygen therapy requirement was unclear, and the PAT testing for the machine was out of date. Paramedics advised the family that the oxygen provided on Mr Amico’s discharge was low flow and was not meeting his oxygen requirements with his oxygen saturations at 68% and this immediately improved on ambulance crew equipment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delay and inappropriate escalation of a high NEWS score
Wider context from the report “(4) The on-call doctor was called approximately one hour after Mr Amico’s NEWS score was found to be 10 and arrived at 07:50, this was not an emergency call . The on-call doctor had not been informed of:
a. the deterioration in Mr Amico’s presentation during the night
b. that the family had informed nursing staff of their concerns Mr Amico had been given the wrong medication when he was noted to be unresponsive at approximately 03:00 hours, that should have immediately raised concerns about an overdose of MST.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to make an emergency call after escalation of concerns
Wider context from the report “(5) The on-call doctor escalated concerns immediately but not emergency call was put out .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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-date PAT testing for oxygen equipment
Wider context from the report “(1) The consultant required a discharge plan for oxygen therapy to be in place before Mr Amico could go home. The hospital discharge plan and medications were confusing and the referral for oxygen therapy requirement was unclear, and the PAT testing for the machine was out of date . Paramedics advised the family that the oxygen provided on Mr Amico’s discharge was low flow and was not meeting his oxygen requirements with his oxygen saturations at 68% and this immediately improved on ambulance crew equipment.
” 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 Operate networks for Controlled Drugs Accountable Officers and Medication Safety Officers to receive and spread learning from medication errors.
Verbatim wording from the response “NHS England offers support to providers to improve the safe use of controlled drugs. NHS Trusts must appoint a Controlled Drugs Accountable Officer and a Medication Safety Officer. Their remits differ however both have a duty to ensure the safe use of opioids in their organisations. NHS England operates networks for both groups to receive and spread the learning from errors. We also offer guidance and tools to enable NHS Trusts to effectively learn from patient safety incidents through the Patient Safety Incident Response Framework. We note that the Patient Safety Incident Response Plan for the Princess Alexandra Hospital includes workstreams to improve safety in ED, in Medicines management, controlled drugs and medicines reconciliation.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide guidance and tools to NHS Trusts for learning from patient safety incidents and improving controlled-drug safety.
Verbatim wording from the response “NHS England offers support to providers to improve the safe use of controlled drugs. NHS Trusts must appoint a Controlled Drugs Accountable Officer and a Medication Safety Officer. Their remits differ however both have a duty to ensure the safe use of opioids in their organisations. NHS England operates networks for both groups to receive and spread the learning from errors. We also offer guidance and tools to enable NHS Trusts to effectively learn from patient safety incidents through the Patient Safety Incident Response Framework. We note that the Patient Safety Incident Response Plan for the Princess Alexandra Hospital includes workstreams to improve safety in ED, in Medicines management, controlled drugs and medicines reconciliation.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.
Verbatim wording from the response “The Princess Alexandra Hospital NHS Trust will be providing their own response to this Report, however, the Hertfordshire & West Essex ICB have advised NHS England of the Trust’s governance arrangements and actions being taken to address the concerns raised. It is understood that the Trust’s Patient Safety Group (PSG) has active oversight of several of the areas highlighted in the Report, particularly medicines safety, recognition of deterioration, and incident learning.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Education and training alone would not sufficiently mitigate recurrence; systems improvements and mechanisms are also required.
Verbatim wording from the response “The NICE medicines optimisation guidance NG 5 (2015) referenced above recommends that organisations support healthcare professionals through training and education to ensure safe prescribing, dispensing and administration. In this specific case, education and training alone would not prevent these types of safety system issues and would not be sufficient to mitigate the risk of reoccurrence. Systems improvements and mechanisms will need to be implemented to ensure lessons are learnt and that the current organisational and systems factors and processes highlighted in this case are addressed, to ensure the safe and effective checking and administration of medications. This has been substantiated by safety research and incident analysis.” Source location Response from NHS England
Open published response
Concerns raised 3 Lack of universal guidance for timely primary care follow-up of vulnerable mental health patients transferred from secondary services View source Lack of safety-netting arrangements for timely primary care follow-up of vulnerable mental health patients transferred from secondary services View source Failure of secondary mental health services to ensure primary care follow-up has been undertaken after transfer View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Suzanne Julia ELLERBY · 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
Suzanne Ellerby was found deceased at her father’s home in Addlestone, Surrey, on 4 January 2025, after a period of mental health deterioration and no contact with mental health or medical practitioners since 13 December 2024. The principal concern was the transfer of vulnerable patients from secondary mental health services to primary care without universal guidance, safety-netting, or arrangements to ensure timely follow-up, leaving patients responsible for arranging care themselves.
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 universal guidance for timely primary care follow-up of vulnerable mental health patients transferred from secondary services
Wider context from the report “Surrey and Borders and Madeira Medical Practice have both recognised the risk of the transfer period from secondary to primary mental health care in vulnerable patients, and have put in hand changes within their organisations to address this. However, as highlighted by Madeira Medical Practice: “there is no expectation from NHS England or mental health services to following up these patients urgently ”, and therefore no universal guidance for all mental health trusts and GP practices .
There are no safety netting guidelines or policies in place to ensure vulnerable mental health patients are followed up within a timely period by primary care services on transfer from secondary services, nor expectations on secondary services to ensure this has been undertaken by primary care services. Patients are therefore being relied upon to ensure this takes place, at a time when they are particularly vulnerable.
- Vulnerable patients are often transferred back to primary care by mental health services for their onward care, which is effected by way of a Discharge Letter;
- NHS England has not provided any guidance in respect of expectation for follow up by primary care services when this transfer takes place ;
- In the absence of such guidance, the onus is on vulnerable patients to ensure they follow up their care with their GP, without any safety netting in place should they fail to do so.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of safety-netting arrangements for timely primary care follow-up of vulnerable mental health patients transferred from secondary services
Wider context from the report “Surrey and Borders and Madeira Medical Practice have both recognised the risk of the transfer period from secondary to primary mental health care in vulnerable patients, and have put in hand changes within their organisations to address this. However, as highlighted by Madeira Medical Practice: “there is no expectation from NHS England or mental health services to following up these patients urgently”, and therefore no universal guidance for all mental health trusts and GP practices.
There are no safety netting guidelines or policies in place to ensure vulnerable mental health patients are followed up within a timely period by primary care services on transfer from secondary services , nor expectations on secondary services to ensure this has been undertaken by primary care services. Patients are therefore being relied upon to ensure this takes place, at a time when they are particularly vulnerable.
- Vulnerable patients are often transferred back to primary care by mental health services for their onward care, which is effected by way of a Discharge Letter;
- NHS England has not provided any guidance in respect of expectation for follow up by primary care services when this transfer takes place;
- In the absence of such guidance, the onus is on vulnerable patients to ensure they follow up their care with their GP, without any safety netting in place should they fail to do so .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of secondary mental health services to ensure primary care follow-up has been undertaken after transfer
Wider context from the report “Surrey and Borders and Madeira Medical Practice have both recognised the risk of the transfer period from secondary to primary mental health care in vulnerable patients, and have put in hand changes within their organisations to address this. However, as highlighted by Madeira Medical Practice: “there is no expectation from NHS England or mental health services to following up these patients urgently”, and therefore no universal guidance for all mental health trusts and GP practices.
There are no safety netting guidelines or policies in place to ensure vulnerable mental health patients are followed up within a timely period by primary care services on transfer from secondary services, nor expectations on secondary services to ensure this has been undertaken by primary care services . Patients are therefore being relied upon to ensure this takes place, at a time when they are particularly vulnerable.
- Vulnerable patients are often transferred back to primary care by mental health services for their onward care, which is effected by way of a Discharge Letter;
- NHS England has not provided any guidance in respect of expectation for follow up by primary care services when this transfer takes place;
- In the absence of such guidance, the onus is on vulnerable patients to ensure they follow up their care with their GP, without any safety netting in place should they fail to do so.
” 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 Draft and share the Personalised Care Framework with systems to support early adoption of safer mental-health care transitions.
Verbatim wording from the response “NHS England continues to support systems to improve care for people with mental health problems needing help from secondary mental health services. NHS England has drafted guidance called the Personalised Care Framework (PCF), that sets out the core aspects of care for people who require help from secondary or integrated primary health services, the Voluntary Community and Social Enterprise (VCSE) and secondary care mental health services. It has been shared as a draft with systems to facilitate early adoption.” Source location Response from NHS England
Open published response
Concerns raised 2 Lack of clear guidance and protocols for clinicians to seek and include family or other relevant views in care and safety planning View source Lack of safe and supportive spaces for mental health patients needing more support than home treatment teams can provide 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
Joanna Chamberlain · 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
Joanna Chamberlain took her own life at home on 23 January 2025 after a recent overdose, other self-harm incidents and an assessment that she was at moderate risk. The report raises concerns about the lack of safe, supportive spaces for people needing more support than home treatment teams can provide, and about clinicians seeking and including family or other relevant input when care plans depend on protective factors.
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 clear guidance and protocols for clinicians to seek and include family or other relevant views in care and safety planning
Wider context from the report “Equally, whilst I recognise the importance and value in clinicians rapidly assessing a patient’s risk of self-harm, using their individual professional judgement, and forming an immediate care and safety plan, there is a potential need for clearer national guidance on, direction to and protocols for clinicians to appropriately seek and include the views and input of family members, or others (e.g. GP) , reinforcing the triangle of care, and especially where the delivery or assurance of a care and safety plan depends on them . This appears even more necessary where such individuals themselves are a key protective factor .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 safe and supportive spaces for mental health patients needing more support than home treatment teams can provide
Wider context from the report “Whilst I am keenly aware that it is not for Coroners to investigate matters of national public policy or resource, there appears to be a local and national gap in the provision of safe and supportive spaces , where clinical help and care can be given to mental health patients who may not be in immediate crisis yet who would benefit from more support than can be given by home treatment teams . Or whose risk assessment suggests may benefit when protective factors change or are temporarily unavailable at certain times of the day or night .
” 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 Launch nationally available e-learning training complementing the suicide-safety guidance for mental health practitioners.
Verbatim wording from the response “NHS England has also launched an e-learning session, which is designed to complement our Staying Safe from Suicide Guidance. The Staying Safe from Suicide: Best practice guidance e-learning session is now available for all mental health practitioners across the country. The guidance and the training both cover sections on confidentiality and the law, and refer to the Consensus statement for information sharing and suicide prevention.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement 24/7 neighbourhood mental health centres providing community support for people with serious mental illness.
Verbatim wording from the response “24/7 Neighbourhood Mental Health Centres” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide formal implementation support to associate neighbourhood mental health centre sites.
Verbatim wording from the response “There are also sixteen associate sites who are in receipt of the formal implementation support offer from NHS England however not additional funding. These sites include:” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish national best-practice guidance promoting proactive involvement of trusted others in safety assessment and management.
Verbatim wording from the response “NHS England published the Staying Safe from Suicide: Best Practice Guidance for Safety Assessment, Formulation and Management on 4 April 2025. It promotes a shift towards a more holistic, person-centred approach rather than relying on risk prediction, which is unreliable because suicidal thoughts can change quickly. Instead, it recommends using a method based on understanding each person’s situation and managing their safety. One of its 10 overarching principles of approach is that of 'involving others: encourage the involvement of trusted others, where possible and as appropriate'. The guidance applies to all mental health practitioners and promotes the proactive engagement of trusted others within legal limits, highlighting that "in the case of immediate risk to life, the duty to share information overrides confidentiality". This guidance therefore clarifies previous national guidance.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share draft personalised-care guidance with Integrated Care Boards on involving families, carers and support networks in care and safety planning.
Verbatim wording from the response “Personalised Care Framework” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Published suicide safety guidance clarifies national expectations for proactively involving trusted others in safety planning.
Verbatim wording from the response “NHS England published the Staying Safe from Suicide: Best Practice Guidance for Safety Assessment, Formulation and Management on 4 April 2025. It promotes a shift towards a more holistic, person-centred approach rather than relying on risk prediction, which is unreliable because suicidal thoughts can change quickly. Instead, it recommends using a method based on understanding each person’s situation and managing their safety. One of its 10 overarching principles of approach is that of 'involving others: encourage the involvement of trusted others, where possible and as appropriate'. The guidance applies to all mental health practitioners and promotes the proactive engagement of trusted others within legal limits, highlighting that "in the case of immediate risk to life, the duty to share information overrides confidentiality". This guidance therefore clarifies previous national guidance.” Source location Response from NHS England
Open published response
Concerns raised 15 Lack of specialist commissioning of home birth services View source Failure to personalise and individualise pregnancy and birth risk assessment View source Failure to routinely provide women with community midwives’ delivery experience View source Unavailability or significant delay of required interventions during high-risk home births View source Lack of national data collection on home birth transfers, outcomes and out-of-guidance care View source Omission of maternal death risk from intrapartum guidance View source Inconsistent models of home birth care View source Failure to discuss maternal and neonatal death risk with women considering home birth View source Lack of national guidance on home birth care View source Lack of a national framework for safe home birth eligibility and midwifery practice View source Lack of mandated delivery experience requirements for midwives maintaining registration View source Lack of national guidance on staffing, training and experience for home birth midwives View source Use of pregnancy terminology that obscures stage-specific risk View source Lack of bespoke training needs analysis for home birth team midwives View source Lack of national guidance on the ethical responsibility and proportionality of offering home birth under the NHS View source See 12 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
Jennifer Cahill and Agnes Cahill · 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 Cahill died in hospital on 4 June 2024 after post-partum haemorrhage, a fourth-degree perineal tear and cardiac arrest following a home birth. Her daughter, Agnes Cahill, was born on 2 June 2024, required resuscitation after complications during birth, and died in neonatal intensive care on 7 June 2024. The report identified concerns including failures in antenatal planning, fetal monitoring, resuscitation and post-birth care, as well as the absence of national guidance and a robust framework for supporting higher-risk home births.
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 specialist commissioning of home birth services
Wider context from the report “3. The lack of national guidance means there are differing models of care and unlike other specialities home births are not a specialist commissioned service . There is no national guidance considering the ethical responsibility and proportionality of offering a home birth model under the NHS framework.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 personalise and individualise pregnancy and birth risk assessment
Wider context from the report “6. Terminology around pregnancies describes them as ‘high’ or ‘low risk pregnancy’ and leads women to consider that pregnancy encompasses all stages through to delivery of a child. Practice does not personalise or individualise risk so women can fully understand what the level of risk is for them in actually being pregnant, or what the level of risk is for them in giving birth .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely provide women with community midwives’ delivery experience
Wider context from the report “7. In order to maintain their skills, there is no set number of deliveries a community midwife must conduct following qualification. There is no mandated number of deliveries that any midwife (irrespective of the settings in which they are working) must complete once they have qualified as a midwife in order to maintain their registration. The level of experience of community midwives in conducting deliveries is not information routinely provided to women to inform their decision whether to have a homebirth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 or significant delay of required interventions during high-risk home births
Wider context from the report “2. There is an increase in the number of women with ‘high risk pregnancies’ requesting home births where required interventions cannot take place or would be significantly delayed and there is no robust framework for midwives supporting home birth care. There is no national guidance to support consistent practice across the country including, for example, details of clinical scenarios where women, following robust assessment, have been considered too high risk to safely receive care in a home-setting.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of national data collection on home birth transfers, outcomes and out-of-guidance care
Wider context from the report “9. The lack of national data collection means there is no data to evidence the number of women who are transferred in during labour or after birth, maternal or neonatal outcomes, number of women who are considered out of guidance .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Omission of maternal death risk from intrapartum guidance
Wider context from the report “5. NICE guidance on intrapartum care (2023 updated June 2025) Section 1.3.3 only refers to the potential risk of death to a baby . There is no mention in the guidance of risk to the mother .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inconsistent models of home birth care
Wider context from the report “3. The lack of national guidance means there are differing models of care and unlike other specialities home births are not a specialist commissioned service. There is no national guidance considering the ethical responsibility and proportionality of offering a home birth model under the NHS framework.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 discuss maternal and neonatal death risk with women considering home birth
Wider context from the report “4. Even though there is a very small risk of death, this is not something which is discussed with women particularly in relation to maternal death , even if the woman has a recognised risk such as a post-partum haemorrhage. There is no guidance to ensure the risk of death to both mother and baby is discussed with any woman considering a home birth irrespective of being considered high or low 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 Lack of national guidance on home birth care
Wider context from the report “1. There is no national guidance in respect of home births . Specifically, robust evidenced based guidance on home birth care , similar to that which is in place for intrapartum care in a hospital setting.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a national framework for safe home birth eligibility and midwifery practice
Wider context from the report “2. There is an increase in the number of women with ‘high risk pregnancies’ requesting home births where required interventions cannot take place or would be significantly delayed and there is no robust framework for midwives supporting home birth care . There is no national guidance to support consistent practice across the country including, for example, details of clinical scenarios where women, following robust assessment, have been considered too high risk to safely receive care in a home-setting .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of mandated delivery experience requirements for midwives maintaining registration
Wider context from the report “7. In order to maintain their skills, there is no set number of deliveries a community midwife must conduct following qualification . There is no mandated number of deliveries that any midwife (irrespective of the settings in which they are working) must complete once they have qualified as a midwife in order to maintain their registration. The level of experience of community midwives in conducting deliveries is not information routinely provided to women to inform their decision whether to have a homebirth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 staffing, training and experience for home birth midwives
Wider context from the report “10. The no national guidance on the model of staffing, training and experience for midwives providing home birth care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Use of pregnancy terminology that obscures stage-specific risk
Wider context from the report “6. Terminology around pregnancies describes them as ‘high’ or ‘low risk pregnancy’ and leads women to consider that pregnancy encompasses all stages through to delivery of a child . Practice does not personalise or individualise risk so women can fully understand what the level of risk is for them in actually being pregnant, or what the level of risk is for them in giving birth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 bespoke training needs analysis for home birth team midwives
Wider context from the report “8. No bespoke training needs analysis has been conducted focusing on midwives practicing in home birth teams .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 the ethical responsibility and proportionality of offering home birth under the NHS
Wider context from the report “3. The lack of national guidance means there are differing models of care and unlike other specialities home births are not a specialist commissioned service. There is no national guidance considering the ethical responsibility and proportionality of offering a home birth model under the NHS framework .
” 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 the UK Midwifery Study System to develop national data on transfers from home to hospital and maternal and neonatal outcomes.
Verbatim wording from the response “With regard to national data, some is already available. Data drawn from the MBRACE 2009 to 2024 reports, by Professor Marian Knight, Director of the National Perinatal Epidemiology Unit, highlights that over 15 years, there have been 19 women who died who planned to give birth at home, amongst 11.5 million women giving birth and that, of those 19 women, 6 actually gave birth at home. We acknowledge that this does not provide evidence of the number of women who have been transferred from home to hospital during labour or after birth, or of their and their baby’s outcomes. We will work with the UK Midwifery Study System (UKMIDSS) to develop a solution to this.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require trusts to implement risk assessment at each pregnancy contact, including ongoing review of intended place of birth.
Verbatim wording from the response “For all women, communication around risk should be personalised. Donna Ockenden, in her review of the maternity services at Shrewsbury and Telford Hospital NHS Trust, made it clear that staff must ensure that women undergo a risk assessment at each contact throughout the pregnancy pathway and that “risk assessment must include ongoing review of the intended place of birth.” NHS England asked Trusts to implement this at the time. All pregnant women should also be offered a personalised care and support plan where such information is recorded, alongside the decisions they make about their care.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ask all NHS maternity providers to urgently review the safety and quality of their homebirth services.
Verbatim wording from the response “On 26 November 2025, NHS England wrote to all NHS maternity providers in England asking them to urgently review the safety and quality of their homebirth services. In particular, we have urged them to consider the following issues which were highlighted in your Report:” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind maternity providers of expectations for homebirth operating procedures and high-risk homebirth pathways, with escalation through the Perinatal Quality Oversight Model.
Verbatim wording from the response “We already expect maternity provider Trusts to have operating procedures for planning births at home and pathways for women with high-risk pregnancies requesting home births. We have written to all maternity providers reminding them of those expectations and action to be taken. As a way to escalate where Trusts may not have appropriate operating procedures for planning births at home and managing high-risk pregnancies, the Perinatal Quality Oversight Model (2025) provides a structured approach for identifying and responding to safety concerns across Trusts, Integrated Care Boards (ICBs), and neonatal operational delivery networks.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the Nursing and Midwifery Council to consider post-registration standards specifically focused on homebirths.
Verbatim wording from the response “The NMC also maintains standards of proficiency for all midwives, which represent the skills, knowledge and attributes they must demonstrate. While the number of births attended is not alone a reliable indicator of a midwife’s fitness to practise, we will work with the NMC to consider the requirements for post-registration standards, that have a specific focus on homebirths, as part of the development of resources mentioned above.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure multidisciplinary training for obstetric emergencies includes a scenario beginning in a community or homebirth setting.
Verbatim wording from the response “Midwives practicing in homebirth settings require the same level of skills, knowledge and proficiencies and provide the same clinical care as midwives in other settings. However, midwives providing care at home must be able to respond to developing emergencies in these specific settings, sometimes without the support of multi-disciplinary teams and immediate access to hospital facilities and are expected to undergo regular training in this. We will work with other organisations to ensure that multi-disciplinary team training for obstetric emergencies includes at least one scenario starting in a community/homebirth setting.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop national resources with partner organisations to clarify safe homebirth support, including responses to high-risk requests and variation in service models.
Verbatim wording from the response “We acknowledge that the current intrapartum care guidance does not provide sufficient clarity to women, staff and services as to how to safely support requests for and the provision of homebirth services. NHS England will work with partners including NICE, the Royal College of Midwives, the Royal College of Obstetrics and Gynaecology, the Nursing & Midwifery Council, Maternity & Newborn Safety Investigations, the Care Quality Commission, and the General Medical Council to develop further resources that enable services to consistently support commissioners, providers and women and families.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide the out-of-hospital Neonatal Life Support course, including homebirth scenarios, to NHS trusts.
Verbatim wording from the response “NHS England has also commissioned the Resuscitation Council UK (RSUK) to design an updated Neonatal Life Support (NLS) course, specific to roles and responsibilities for clinicians, including the out-of-hospital course. Training is available for multi-disciplinary teams, including ambulance crews. Funding is being provided for 6,000 practitioners to have NLS training over a 2-year period. The course build remains to be completed. However, the out-of-hospital course is now available to Trusts and includes homebirth scenarios.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clarify with partners whether maternity professionals may withdraw services when homebirth or requested care is considered highly unsafe or unreasonable.
Verbatim wording from the response “addition, some women who cannot be supported to birth at home due to the level of risk may choose to give birth unassisted, which carries a higher risk. We will build on work already started, looking to clarify whether NHS health professionals providing maternity services may withdraw midwifery services from women birthing at home against professional advice and/or from women making requests with regards to care/treatment that are considered highly unsafe or unreasonable.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Some national homebirth data already exists, although it does not capture transfers or maternal and neonatal outcomes.
Verbatim wording from the response “With regard to national data, some is already available. Data drawn from the MBRACE 2009 to 2024 reports, by Professor Marian Knight, Director of the National Perinatal Epidemiology Unit, highlights that over 15 years, there have been 19 women who died who planned to give birth at home, amongst 11.5 million women giving birth and that, of those 19 women, 6 actually gave birth at home. We acknowledge that this does not provide evidence of the number of women who have been transferred from home to hospital during labour or after birth, or of their and their baby’s outcomes. We will work with the UK Midwifery Study System (UKMIDSS) to develop a solution to this.” Source location Response from NHS England
Open published response
Concerns raised 7 Excessive and prolonged holding of people in mental health crisis in A&E View source Failure to answer a sufficient proportion of 111 and Blue Light Line calls View source Lack of a safe lawful detention pathway for people who cannot be held under s.3 at the hospital View source Failure of A&E environments to provide adequate security for people in mental health crisis View source Inadequate 24/7 crisis response and formal gatekeeping of inpatient admissions View source Insufficient availability of independent-sector mental health beds View source Failure to divert people in mental health crisis to suitable alternatives to A&E where available View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Patricia Genders · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Patricia Genders died on 22 February 2024 after absconding from the Enhanced Observation Unit at the Royal Sussex County Hospital while detained under the Mental Health Act. She was found on the coastal side of a safety fence, taken to A&E, and pronounced dead shortly afterwards. The concerns included the use of A&E for people in mental health crisis, the absence of an agreed home-care package, the decision not to transport Patricia to a more therapeutic setting, and shortcomings in hospital security, communication and responses to absconding.
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 and prolonged holding of people in mental health crisis in A&E
Wider context from the report “My concern is that despite significant ongoing efforts by the various partner agencies (particularly the hospital trust (University Hospitals Sussex NHS Foundation Trust (“UHS”)), the trust making most of the mental health provision in this area (Sussex Partnership NHS Foundation Trust (“SPFT”)), the local authorities (West Sussex and Brighton and Hove) and the police, there is still far too much use of A&E space for those in mental health crisis, pending finding a dedicated mental health placement . My concern is that without specific investment (particularised below), from the commissioner of services, too many people will continue to be held in A&E for too long .
This case shows, in quite dramatic form, some of the consequences of the use of A&E. See again the jury's conclusions, but a noisy and busy department, lit 24 hours, with limited space, may well make someone worse, and probably did here. Moreover, A&E departments cannot be made fully secure. People are coming and going; doors cannot always be monitored; and it is harder to restrain someone in a relatively public space and with fewer mental health practitioners around.
Tricia was able, quite easily, to abscond. The detail of what happened next, and its impact on all, will be obvious. That impact was not just on the family but most obviously also the nurse who tried to stall her, and the member of the public and the police and fireman at the cliffs.
All of these people are victims of a system which cannot do what is being asked of it. Significant steps have been made to try to improve, again, the partnership working between the relevant trusts and the police, and in trying to improve the security of the hospital. It is now not possible to hold someone under s.3 at the hospital (although that produces a new set of onwards risks. It arguably focuses minds on the need to move someone on faster, but also creates a risk that someone will simply be left with no basis for detention at all). All this, however, is just patching a fundamentally unsatisfactory situation.
I took a lot of evidence about the remaining risks and the need for action. It is clear that joint working between health and social care is required (which is why I am sending this report to the Secretary of State for Health and Social Care as well as to NHS England). It is also clear that there is a limit to what the local trusts and other agencies can do on their own. The problem may be particularly pronounced in Brighton where the numbers of mentally ill people are well above the national average, but I am told it is of wider concern.
The evidence I heard is that three things are required of those responsible for commissioning these services:
1. Strengthening the 111 and Blue Light Line services so that calls are answered and people are diverted to better places where such places are available. At the moment, I was told, only about half of those calls are answered. That requires recruitment, which requires investment.
2. An improved 24/7 crisis response, to deal with those who present at A&E out of hours. Solving that requires the establishment of teams who can formally gatekeep inpatient admissions.
3. For a while, there will need to be an increase in the number of mental health beds available in the independent sector. This would be to provide beds and alleviate flow pressures whilst longer term, systemic change, embeds.
Absent something along these lines, it seems to me there is a real risk that the events seen in this case will recur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 a sufficient proportion of 111 and Blue Light Line calls
Wider context from the report “My concern is that despite significant ongoing efforts by the various partner agencies (particularly the hospital trust (University Hospitals Sussex NHS Foundation Trust (“UHS”)), the trust making most of the mental health provision in this area (Sussex Partnership NHS Foundation Trust (“SPFT”)), the local authorities (West Sussex and Brighton and Hove) and the police, there is still far too much use of A&E space for those in mental health crisis, pending finding a dedicated mental health placement. My concern is that without specific investment (particularised below), from the commissioner of services, too many people will continue to be held in A&E for too long.
This case shows, in quite dramatic form, some of the consequences of the use of A&E. See again the jury's conclusions, but a noisy and busy department, lit 24 hours, with limited space, may well make someone worse, and probably did here. Moreover, A&E departments cannot be made fully secure. People are coming and going; doors cannot always be monitored; and it is harder to restrain someone in a relatively public space and with fewer mental health practitioners around.
Tricia was able, quite easily, to abscond. The detail of what happened next, and its impact on all, will be obvious. That impact was not just on the family but most obviously also the nurse who tried to stall her, and the member of the public and the police and fireman at the cliffs.
All of these people are victims of a system which cannot do what is being asked of it. Significant steps have been made to try to improve, again, the partnership working between the relevant trusts and the police, and in trying to improve the security of the hospital. It is now not possible to hold someone under s.3 at the hospital (although that produces a new set of onwards risks. It arguably focuses minds on the need to move someone on faster, but also creates a risk that someone will simply be left with no basis for detention at all). All this, however, is just patching a fundamentally unsatisfactory situation.
I took a lot of evidence about the remaining risks and the need for action. It is clear that joint working between health and social care is required (which is why I am sending this report to the Secretary of State for Health and Social Care as well as to NHS England). It is also clear that there is a limit to what the local trusts and other agencies can do on their own. The problem may be particularly pronounced in Brighton where the numbers of mentally ill people are well above the national average, but I am told it is of wider concern.
The evidence I heard is that three things are required of those responsible for commissioning these services:
1. Strengthening the 111 and Blue Light Line services so that calls are answered and people are diverted to better places where such places are available. At the moment, I was told, only about half of those calls are answered . That requires recruitment, which requires investment.
2. An improved 24/7 crisis response, to deal with those who present at A&E out of hours. Solving that requires the establishment of teams who can formally gatekeep inpatient admissions.
3. For a while, there will need to be an increase in the number of mental health beds available in the independent sector. This would be to provide beds and alleviate flow pressures whilst longer term, systemic change, embeds.
Absent something along these lines, it seems to me there is a real risk that the events seen in this case will recur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 safe lawful detention pathway for people who cannot be held under s.3 at the hospital
Wider context from the report “My concern is that despite significant ongoing efforts by the various partner agencies (particularly the hospital trust (University Hospitals Sussex NHS Foundation Trust (“UHS”)), the trust making most of the mental health provision in this area (Sussex Partnership NHS Foundation Trust (“SPFT”)), the local authorities (West Sussex and Brighton and Hove) and the police, there is still far too much use of A&E space for those in mental health crisis, pending finding a dedicated mental health placement. My concern is that without specific investment (particularised below), from the commissioner of services, too many people will continue to be held in A&E for too long.
This case shows, in quite dramatic form, some of the consequences of the use of A&E. See again the jury's conclusions, but a noisy and busy department, lit 24 hours, with limited space, may well make someone worse, and probably did here. Moreover, A&E departments cannot be made fully secure. People are coming and going; doors cannot always be monitored; and it is harder to restrain someone in a relatively public space and with fewer mental health practitioners around.
Tricia was able, quite easily, to abscond. The detail of what happened next, and its impact on all, will be obvious. That impact was not just on the family but most obviously also the nurse who tried to stall her, and the member of the public and the police and fireman at the cliffs.
All of these people are victims of a system which cannot do what is being asked of it. Significant steps have been made to try to improve, again, the partnership working between the relevant trusts and the police, and in trying to improve the security of the hospital. It is now not possible to hold someone under s.3 at the hospital (although that produces a new set of onwards risks. It arguably focuses minds on the need to move someone on faster, but also creates a risk that someone will simply be left with no basis for detention at all ). All this, however, is just patching a fundamentally unsatisfactory situation.
I took a lot of evidence about the remaining risks and the need for action. It is clear that joint working between health and social care is required (which is why I am sending this report to the Secretary of State for Health and Social Care as well as to NHS England). It is also clear that there is a limit to what the local trusts and other agencies can do on their own. The problem may be particularly pronounced in Brighton where the numbers of mentally ill people are well above the national average, but I am told it is of wider concern.
The evidence I heard is that three things are required of those responsible for commissioning these services:
1. Strengthening the 111 and Blue Light Line services so that calls are answered and people are diverted to better places where such places are available. At the moment, I was told, only about half of those calls are answered. That requires recruitment, which requires investment.
2. An improved 24/7 crisis response, to deal with those who present at A&E out of hours. Solving that requires the establishment of teams who can formally gatekeep inpatient admissions.
3. For a while, there will need to be an increase in the number of mental health beds available in the independent sector. This would be to provide beds and alleviate flow pressures whilst longer term, systemic change, embeds.
Absent something along these lines, it seems to me there is a real risk that the events seen in this case will recur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 A&E environments to provide adequate security for people in mental health crisis
Wider context from the report “My concern is that despite significant ongoing efforts by the various partner agencies (particularly the hospital trust (University Hospitals Sussex NHS Foundation Trust (“UHS”)), the trust making most of the mental health provision in this area (Sussex Partnership NHS Foundation Trust (“SPFT”)), the local authorities (West Sussex and Brighton and Hove) and the police, there is still far too much use of A&E space for those in mental health crisis, pending finding a dedicated mental health placement. My concern is that without specific investment (particularised below), from the commissioner of services, too many people will continue to be held in A&E for too long.
This case shows, in quite dramatic form, some of the consequences of the use of A&E. See again the jury's conclusions, but a noisy and busy department, lit 24 hours, with limited space, may well make someone worse, and probably did here. Moreover, A&E departments cannot be made fully secure . People are coming and going; doors cannot always be monitored ; and it is harder to restrain someone in a relatively public space and with fewer mental health practitioners around .
Tricia was able, quite easily, to abscond . The detail of what happened next, and its impact on all, will be obvious. That impact was not just on the family but most obviously also the nurse who tried to stall her, and the member of the public and the police and fireman at the cliffs.
All of these people are victims of a system which cannot do what is being asked of it. Significant steps have been made to try to improve, again, the partnership working between the relevant trusts and the police, and in trying to improve the security of the hospital. It is now not possible to hold someone under s.3 at the hospital (although that produces a new set of onwards risks. It arguably focuses minds on the need to move someone on faster, but also creates a risk that someone will simply be left with no basis for detention at all). All this, however, is just patching a fundamentally unsatisfactory situation.
I took a lot of evidence about the remaining risks and the need for action. It is clear that joint working between health and social care is required (which is why I am sending this report to the Secretary of State for Health and Social Care as well as to NHS England). It is also clear that there is a limit to what the local trusts and other agencies can do on their own. The problem may be particularly pronounced in Brighton where the numbers of mentally ill people are well above the national average, but I am told it is of wider concern.
The evidence I heard is that three things are required of those responsible for commissioning these services:
1. Strengthening the 111 and Blue Light Line services so that calls are answered and people are diverted to better places where such places are available. At the moment, I was told, only about half of those calls are answered. That requires recruitment, which requires investment.
2. An improved 24/7 crisis response, to deal with those who present at A&E out of hours. Solving that requires the establishment of teams who can formally gatekeep inpatient admissions.
3. For a while, there will need to be an increase in the number of mental health beds available in the independent sector. This would be to provide beds and alleviate flow pressures whilst longer term, systemic change, embeds.
Absent something along these lines, it seems to me there is a real risk that the events seen in this case will recur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 24/7 crisis response and formal gatekeeping of inpatient admissions
Wider context from the report “My concern is that despite significant ongoing efforts by the various partner agencies (particularly the hospital trust (University Hospitals Sussex NHS Foundation Trust (“UHS”)), the trust making most of the mental health provision in this area (Sussex Partnership NHS Foundation Trust (“SPFT”)), the local authorities (West Sussex and Brighton and Hove) and the police, there is still far too much use of A&E space for those in mental health crisis, pending finding a dedicated mental health placement. My concern is that without specific investment (particularised below), from the commissioner of services, too many people will continue to be held in A&E for too long.
This case shows, in quite dramatic form, some of the consequences of the use of A&E. See again the jury's conclusions, but a noisy and busy department, lit 24 hours, with limited space, may well make someone worse, and probably did here. Moreover, A&E departments cannot be made fully secure. People are coming and going; doors cannot always be monitored; and it is harder to restrain someone in a relatively public space and with fewer mental health practitioners around.
Tricia was able, quite easily, to abscond. The detail of what happened next, and its impact on all, will be obvious. That impact was not just on the family but most obviously also the nurse who tried to stall her, and the member of the public and the police and fireman at the cliffs.
All of these people are victims of a system which cannot do what is being asked of it. Significant steps have been made to try to improve, again, the partnership working between the relevant trusts and the police, and in trying to improve the security of the hospital. It is now not possible to hold someone under s.3 at the hospital (although that produces a new set of onwards risks. It arguably focuses minds on the need to move someone on faster, but also creates a risk that someone will simply be left with no basis for detention at all). All this, however, is just patching a fundamentally unsatisfactory situation.
I took a lot of evidence about the remaining risks and the need for action. It is clear that joint working between health and social care is required (which is why I am sending this report to the Secretary of State for Health and Social Care as well as to NHS England). It is also clear that there is a limit to what the local trusts and other agencies can do on their own. The problem may be particularly pronounced in Brighton where the numbers of mentally ill people are well above the national average, but I am told it is of wider concern.
The evidence I heard is that three things are required of those responsible for commissioning these services:
1. Strengthening the 111 and Blue Light Line services so that calls are answered and people are diverted to better places where such places are available. At the moment, I was told, only about half of those calls are answered. That requires recruitment, which requires investment.
2. An improved 24/7 crisis response, to deal with those who present at A&E out of hours . Solving that requires the establishment of teams who can formally gatekeep inpatient admissions .
3. For a while, there will need to be an increase in the number of mental health beds available in the independent sector. This would be to provide beds and alleviate flow pressures whilst longer term, systemic change, embeds.
Absent something along these lines, it seems to me there is a real risk that the events seen in this case will recur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of independent-sector mental health beds
Wider context from the report “My concern is that despite significant ongoing efforts by the various partner agencies (particularly the hospital trust (University Hospitals Sussex NHS Foundation Trust (“UHS”)), the trust making most of the mental health provision in this area (Sussex Partnership NHS Foundation Trust (“SPFT”)), the local authorities (West Sussex and Brighton and Hove) and the police, there is still far too much use of A&E space for those in mental health crisis, pending finding a dedicated mental health placement. My concern is that without specific investment (particularised below), from the commissioner of services, too many people will continue to be held in A&E for too long.
This case shows, in quite dramatic form, some of the consequences of the use of A&E. See again the jury's conclusions, but a noisy and busy department, lit 24 hours, with limited space, may well make someone worse, and probably did here. Moreover, A&E departments cannot be made fully secure. People are coming and going; doors cannot always be monitored; and it is harder to restrain someone in a relatively public space and with fewer mental health practitioners around.
Tricia was able, quite easily, to abscond. The detail of what happened next, and its impact on all, will be obvious. That impact was not just on the family but most obviously also the nurse who tried to stall her, and the member of the public and the police and fireman at the cliffs.
All of these people are victims of a system which cannot do what is being asked of it. Significant steps have been made to try to improve, again, the partnership working between the relevant trusts and the police, and in trying to improve the security of the hospital. It is now not possible to hold someone under s.3 at the hospital (although that produces a new set of onwards risks. It arguably focuses minds on the need to move someone on faster, but also creates a risk that someone will simply be left with no basis for detention at all). All this, however, is just patching a fundamentally unsatisfactory situation.
I took a lot of evidence about the remaining risks and the need for action. It is clear that joint working between health and social care is required (which is why I am sending this report to the Secretary of State for Health and Social Care as well as to NHS England). It is also clear that there is a limit to what the local trusts and other agencies can do on their own. The problem may be particularly pronounced in Brighton where the numbers of mentally ill people are well above the national average, but I am told it is of wider concern.
The evidence I heard is that three things are required of those responsible for commissioning these services:
1. Strengthening the 111 and Blue Light Line services so that calls are answered and people are diverted to better places where such places are available. At the moment, I was told, only about half of those calls are answered. That requires recruitment, which requires investment.
2. An improved 24/7 crisis response, to deal with those who present at A&E out of hours. Solving that requires the establishment of teams who can formally gatekeep inpatient admissions.
3. For a while, there will need to be an increase in the number of mental health beds available in the independent sector . This would be to provide beds and alleviate flow pressures whilst longer term, systemic change, embeds.
Absent something along these lines, it seems to me there is a real risk that the events seen in this case will recur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 divert people in mental health crisis to suitable alternatives to A&E where available
Wider context from the report “My concern is that despite significant ongoing efforts by the various partner agencies (particularly the hospital trust (University Hospitals Sussex NHS Foundation Trust (“UHS”)), the trust making most of the mental health provision in this area (Sussex Partnership NHS Foundation Trust (“SPFT”)), the local authorities (West Sussex and Brighton and Hove) and the police, there is still far too much use of A&E space for those in mental health crisis, pending finding a dedicated mental health placement. My concern is that without specific investment (particularised below), from the commissioner of services, too many people will continue to be held in A&E for too long.
This case shows, in quite dramatic form, some of the consequences of the use of A&E. See again the jury's conclusions, but a noisy and busy department, lit 24 hours, with limited space, may well make someone worse, and probably did here. Moreover, A&E departments cannot be made fully secure. People are coming and going; doors cannot always be monitored; and it is harder to restrain someone in a relatively public space and with fewer mental health practitioners around.
Tricia was able, quite easily, to abscond. The detail of what happened next, and its impact on all, will be obvious. That impact was not just on the family but most obviously also the nurse who tried to stall her, and the member of the public and the police and fireman at the cliffs.
All of these people are victims of a system which cannot do what is being asked of it. Significant steps have been made to try to improve, again, the partnership working between the relevant trusts and the police, and in trying to improve the security of the hospital. It is now not possible to hold someone under s.3 at the hospital (although that produces a new set of onwards risks. It arguably focuses minds on the need to move someone on faster, but also creates a risk that someone will simply be left with no basis for detention at all). All this, however, is just patching a fundamentally unsatisfactory situation.
I took a lot of evidence about the remaining risks and the need for action. It is clear that joint working between health and social care is required (which is why I am sending this report to the Secretary of State for Health and Social Care as well as to NHS England). It is also clear that there is a limit to what the local trusts and other agencies can do on their own. The problem may be particularly pronounced in Brighton where the numbers of mentally ill people are well above the national average, but I am told it is of wider concern.
The evidence I heard is that three things are required of those responsible for commissioning these services:
1. Strengthening the 111 and Blue Light Line services so that calls are answered and people are diverted to better places where such places are available . At the moment, I was told, only about half of those calls are answered. That requires recruitment, which requires investment.
2. An improved 24/7 crisis response, to deal with those who present at A&E out of hours. Solving that requires the establishment of teams who can formally gatekeep inpatient admissions.
3. For a while, there will need to be an increase in the number of mental health beds available in the independent sector. This would be to provide beds and alleviate flow pressures whilst longer term, systemic change, embeds.
Absent something along these lines, it seems to me there is a real risk that the events seen in this case will recur.
” 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 Invest £2.3 billion in mental health services under the Long Term Plan, including funding for adult community, crisis and acute services.
Verbatim wording from the response “However, given increasing lengths of stay and the increased number of patients clinically ready for discharge, providing more beds will be considered as part of a whole system transformation approach. This was supported by the NHS Long Term Plan (LTP), which saw an additional £2.3 billion funding invested in mental health services from 2019/20 – 2023/24, around £1.3 billion of which was for adult community, crisis and acute mental health services to help people get quicker access to the care they need and prevent avoidable deterioration and hospital admission.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Open more specialist Mental Health Emergency Departments alongside general Emergency Departments.
Verbatim wording from the response “NHS England is rolling out dedicated 24/7 neighbourhood mental health centres to better support the community, opening more specialist Mental Health Emergency Departments alongside general Emergency Departments and having a 24/7 psychiatric liaison team available. A pilot programme for these centres started in October 2025 which will run until July 2026. This will be followed by an Implementation Support Programme which will roll out to sites from March 2026.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out dedicated 24/7 neighbourhood mental health centres through the pilot and subsequent implementation support programme.
Verbatim wording from the response “NHS England is rolling out dedicated 24/7 neighbourhood mental health centres to better support the community, opening more specialist Mental Health Emergency Departments alongside general Emergency Departments and having a 24/7 psychiatric liaison team available. A pilot programme for these centres started in October 2025 which will run until July 2026. This will be followed by an Implementation Support Programme which will roll out to sites from March 2026.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review local system plans for suitable 111-service investment and provide feedback on required improvements.
Verbatim wording from the response “Alongside this, local system plans will be reviewed by NHS England’s regional leads to determine whether there is suitable investment in 111 services, where capacity constraints exist. This review will run from December 2025 – March 2026. Regional leads will provide feedback to organisations on the plans and discuss areas of improvement required within the plans.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor delivery of Sussex mental health-crisis improvement plans through joint ICB and provider oversight meetings.
Verbatim wording from the response “Sussex Partnership NHS Foundation Trust (SPFT) and Sussex ICB have set out a series of actions to deliver improvements in the care provided to people in mental health crisis. NHS England is monitoring the delivery of these plans through joint ICB and provider oversight meetings. These plans do include reference to increased capacity in 'blue light' and 111 services, alongside the delivery of 24/7 crisis response services. Should the Coroner require further information regarding this, SPFT and Sussex ICB would be best placed to provide this.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide 24/7 psychiatric liaison teams alongside Emergency Departments.
Verbatim wording from the response “NHS England is rolling out dedicated 24/7 neighbourhood mental health centres to better support the community, opening more specialist Mental Health Emergency Departments alongside general Emergency Departments and having a 24/7 psychiatric liaison team available. A pilot programme for these centres started in October 2025 which will run until July 2026. This will be followed by an Implementation Support Programme which will roll out to sites from March 2026.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Task local health systems through operational planning guidance to improve mental health crisis-pathway flow and reduce Emergency Department waits exceeding 12 hours.
Verbatim wording from the response “NHS England is also taking steps to address the current operational pressures driving these issues. The 2025/26 priorities and operational planning guidance tasks local health systems to improve patient flow through mental health crisis pathways and to reduce waits of more than 12 hours in Emergency Departments.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain the national NHS 111 mental health call option to support reductions in Emergency Department attendance.
Verbatim wording from the response “Since August 2024, the NHS 111 mental health call option has been established around the country to support reductions in Emergency Department attendance and Mental Health Response Vehicles have also been established to see and treat patients away from an A&E setting. New integrated operational pressures escalation levels (OPEL) scoring systems have also been established for mental health, enabling greater transparency and escalation of risks across mental health pathways.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish Mental Health Emergency Departments co-located with Type 1 Emergency Departments.
Verbatim wording from the response “Colleagues in NHS England’s South East Region have confirmed that, to improve their ability to respond to patients in mental health crisis and ensure the needs of mental health patients are met in an appropriate environment, the NHS has committed to establish Mental Health Emergency Departments (MHEDs), also described as Crisis Assessment Centres (CACs), which will be co-located with Type 1 Emergency Departments. They aim to offer calm, therapeutic settings and ensure timely onward connection into mental health inpatient provision or into broader community services.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make £75 million of additional capital available to improve local mental health bed capacity and reduce Out of Area Placements.
Verbatim wording from the response “NHS England is aware of the issues in some systems around high bed occupancy and limited local bed availability. This is related to long lengths of stay and high numbers of patients clinically ready for discharge but unable to be discharged, leading to flow pressures across systems. To improve this, in 2025/26, NHS England made £75 million of additional capital available for local systems to invest in improving local bed capacity and reduce the use of Out of Area Placements.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish Mental Health Response Vehicles to assess and treat patients away from Emergency Departments.
Verbatim wording from the response “Since August 2024, the NHS 111 mental health call option has been established around the country to support reductions in Emergency Department attendance and Mental Health Response Vehicles have also been established to see and treat patients away from an A&E setting. New integrated operational pressures escalation levels (OPEL) scoring systems have also been established for mental health, enabling greater transparency and escalation of risks across mental health pathways.” Source location Response from NHS England
Open published response
Concerns raised 4 Failure of document exchange and communication between gastroenterology and cardiology teams View source Failure to obtain cardiology review of discharge appropriateness View source Failure to arrange cardiology follow-up after discharge View source Failure to investigate what went wrong and why between treating and administration teams 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
Lynn SILCOCK · 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
Lynn Silcock was admitted to hospital in September 2022 with symptoms including breathlessness and fatigue, and was diagnosed with aortic stenosis among other conditions. She was discharged without a cardiology referral, appointment or plan, and a gastroscopy report was not followed by a cardiology referral. She died at home on 10 July 2025; the postmortem identified aortic stenosis on a background of bicuspid aortic valve, with myocardial fibrosis. The report raised concerns about communication and document exchange between teams, the absence of an appropriate referral, and the lack of an investigation into what went wrong.
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 document exchange and communication between gastroenterology and cardiology teams
Wider context from the report “(3) There was no document exchange or communication between the gastroenterology team and the cardiology team meaning that Ms Silcock was then forgotten about.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 cardiology review of discharge appropriateness
Wider context from the report “(1) Discharged by the gastroenterology team without referral to the cardiology team as to whether the discharge was appropriate .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 arrange cardiology follow-up after discharge
Wider context from the report “(2) Discharged without a cardiology clinic appointment or plan to be later referred .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 investigate what went wrong and why between treating and administration teams
Wider context from the report “(4) No investigation by Shrewsbury and Telford NHS Trust as to what went wrong and why between the treating teams and their respective administration teams .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and roll out the national Frontline Digitisation Programme, including electronic-record deployment guidance and support for safe implementation.
Verbatim wording from the response “NHS England has long recognised that omissions in information-sharing within or between healthcare organisations can contribute to poor continuity of care and lead to poor health outcomes. In 2021, NHS England developed and rolled out a national ‘Frontline Digitisation’ (FD) Programme, which aimed to support NHS Trusts in England with the procurement and deployment of Electronic Patient Record (EPR) systems. The aim of this was to support increased digital maturity of organisations and improve information sharing within and between organisations. Beyond facilitating the procurement of EPR systems, the FD Programme also provided guidance and support to ensure safe and effective deployments.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The concerns fall outside NHS England’s role and remit as a commissioner of certain healthcare services.
Verbatim wording from the response “The concerns raised in your Report will be dealt with by SATH, to whom your Report has also been addressed, and there is no action for NHS England to take in regard to this matter as the issues fall outside of NHS England’s role and remit as a commissioner of certain healthcare services. However, the following information may be useful to the Coroner as background.” Source location Response from NHS England
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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 Shrewsbury and Telford Hospital NHS Trust is responsible for addressing the concerns raised in the report.
Verbatim wording from the response “The concerns raised in your Report will be dealt with by SATH, to whom your Report has also been addressed, and there is no action for NHS England to take in regard to this matter as the issues fall outside of NHS England’s role and remit as a commissioner of certain healthcare services. However, the following information may be useful to the Coroner as background.” Source location Response from NHS England
Open published response
22 Oct 2025 Ricky James MONAHAN · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Unprotected fire escapes providing easy access to roofs in rehabilitation settings View source Lack of environmental risk assessment of fire escape and roof accessibility View source Lack of guidelines specifying required fire escape protections in rehabilitation settings View source Reliance on individual patient risk assessments instead of environmental access controls View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ricky James MONAHAN · 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
Ricky James MONAHAN, a resident of a rehabilitation unit detained under section 37 of the Mental Health Act, died after falling from a height on 18 March 2025. The report identified an unprotected fire escape accessible from the garden and roof, no environmental risk assessment of this access, reliance on individual risk assessments, and a lack of guidelines for protecting fire escapes in rehabilitation settings.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unprotected fire escapes providing easy access to roofs in rehabilitation settings
Wider context from the report “1. Mr Monahan was in a 10 bedded rehabilitation unit and was detained under S37 of the Mental Health Act. There was an unprotected fire escape at the rear of the building which could be easily accessed from the garden which in turn gave easy access to the roof . No environmental risk assessment had been completed regarding how accessible the fire escape was and how it easily provided access to the roof due to inadequate railings at the top of the staircase . The trust relied on individual risk assessments when considering what controls were required for individual patients when accessing the garden.
2. The inquest heard how there are no current guidelines setting out what protections are required for fire escapes in rehabilitation settings. The lack of any guidelines presents a risk of future deaths and in my view, action should be taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of environmental risk assessment of fire escape and roof accessibility
Wider context from the report “1. Mr Monahan was in a 10 bedded rehabilitation unit and was detained under S37 of the Mental Health Act. There was an unprotected fire escape at the rear of the building which could be easily accessed from the garden which in turn gave easy access to the roof. No environmental risk assessment had been completed regarding how accessible the fire escape was and how it easily provided access to the roof due to inadequate railings at the top of the staircase. The trust relied on individual risk assessments when considering what controls were required for individual patients when accessing the garden.
2. The inquest heard how there are no current guidelines setting out what protections are required for fire escapes in rehabilitation settings. The lack of any guidelines presents a risk of future deaths and in my view, action should be taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidelines specifying required fire escape protections in rehabilitation settings
Wider context from the report “1. Mr Monahan was in a 10 bedded rehabilitation unit and was detained under S37 of the Mental Health Act. There was an unprotected fire escape at the rear of the building which could be easily accessed from the garden which in turn gave easy access to the roof. No environmental risk assessment had been completed regarding how accessible the fire escape was and how it easily provided access to the roof due to inadequate railings at the top of the staircase. The trust relied on individual risk assessments when considering what controls were required for individual patients when accessing the garden.
2. The inquest heard how there are no current guidelines setting out what protections are required for fire escapes in rehabilitation settings . The lack of any guidelines presents a risk of future deaths and in my view, action should be taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Reliance on individual patient risk assessments instead of environmental access controls
Wider context from the report “1. Mr Monahan was in a 10 bedded rehabilitation unit and was detained under S37 of the Mental Health Act. There was an unprotected fire escape at the rear of the building which could be easily accessed from the garden which in turn gave easy access to the roof. No environmental risk assessment had been completed regarding how accessible the fire escape was and how it easily provided access to the roof due to inadequate railings at the top of the staircase. The trust relied on individual risk assessments when considering what controls were required for individual patients when accessing the garden .
2. The inquest heard how there are no current guidelines setting out what protections are required for fire escapes in rehabilitation settings. The lack of any guidelines presents a risk of future deaths and in my view, action should be taken.
” 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 Scope revisions to HTM 05-02 fire-safety guidance for healthcare-premises design.
Verbatim wording from the response “NHS England’s Estates Team are currently scoping HTM 05-02, fire safety in the design of healthcare premises, which will be revised imminently.” Source location Response from NHS England
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish national best-practice guidance promoting person-centred safety assessment, formulation, management and environmental safety planning.
Verbatim wording from the response “NHS England also published the Staying Safe from Suicide: Best Practice Guidance for Safety Assessment, Formulation and Management on 4 April 2025. It promotes a shift towards a more holistic, person-centred approach rather than relying on risk prediction, which can be unreliable because suicidal thoughts can change quickly. Instead, it recommends using a method based on understanding each person’s situation and managing their safety. The purpose of this guidance is to enable mental health practitioners to adopt best practice principles in working with people of all ages to stay safe from suicide. The guidance highlights environmental safety as one of six steps of safety planning, which should include reducing access to or avoiding high risk locations.” Source location Response from NHS England
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Liaise with Birmingham and Solihull Mental Health Foundation Trust about environmental risk assessment and unauthorised roof access from the fire escape.
Verbatim wording from the response “NHS England’s regional mental health team has liaised with the Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) regarding your concerns, including the lack of environmental risk assessment of the fire escape, and particularly its ability to allow unauthorised access to the roof.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing guidance and provider risk-assessment arrangements are considered appropriate to manage fire-escape and roof-access risks.
Verbatim wording from the response “Whilst none of the documents mentioned above specifically refer to fire escapes, secure access to fire escapes should be embedded within the provider’s risk assessments. The clinical risk assessment should cover the patient’s current level of risk (absconding, self-harm etc) and the patient should be supervised according to the level of risk posed.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Further comment on the specific local risk assessment cannot be provided.
Verbatim wording from the response “Ultimately, there appears to be appropriate guidance in place to ensure that incidents such as this should not happen, however it appears that the local risk assessment did not take the specific risks of the fire escape and access to the roof into account. NHS England is not able to comment further on this and directs the Coroner to the Birmingham and Solihull Integrated Care Service in this regard.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Birmingham and Solihull Integrated Care Service is responsible for addressing the local fire-escape risk assessment in greater detail.
Verbatim wording from the response “I note that your Report is also addressed to the Birmingham and Solihull Integrated Care Service, who will be able to address the position locally in more detail.” Source location Response from NHS England
Open published response
20 Oct 2025 Declan Carr · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 1 Failure to ensure continuity of psycho-social drug misuse support during prisoner transfers 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
Declan Carr · 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
On 28 August 2023, Declan Carr was found deceased in his cell at HMP Humber and was declared deceased by paramedics. The report identified failures involving communication about his psychosocial substance-misuse support during transfer between prisons, healthcare reception screening, induction documentation and allocation of a keyworker. It raised concern that inadequate continuity of psychosocial support for drug misuse could pose a risk of future deaths.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure continuity of psycho-social drug misuse support during prisoner transfers
Wider context from the report “Mr Carr was receiving psycho-social support regarding his substance misuse from healthcare services whilst he was in HMP Hull. He was due to have a further appointment with them on 16th August 2023. However, on this date Mr Carr was transferred to HMP Humber.
HMP Humber were not made aware that Mr Carr was receiving psycho-social support and there was no handover to the support services in HMP Humber. There was then no support in place for Mr Carr.
During the inquest I heard evidence that if Mr Carr had been receiving clinical support for drug misuse there would have been a handover for that to continue.
I was also made aware that HMP Humber and HMP Hull now have a local policy in place to allow the prisons to share information about those that are receiving psycho-social support when transferring prisoners between these 2 prisons as they are the same agency that provide that service.
However, I was informed that this a purely local arrangement and this is not a process that happens nationally and would cease if one of the prisons changed providers.
If there is a lack of continuity of care for prisoners receiving psycho-social for drug misuse support then there is a risk of future deaths occurring.
” 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 Use nationally agreed clinical templates, including Court, Release and Transfer Out screening, to standardise information sharing and healthcare delivery.
Verbatim wording from the response “There are nationally agreed clinical templates embedded on SystemOne, which is an electronic patient medical record system. One of these templates is specific to Court, Release and Transfer Out screening. A copy of the template has been attached with this response. The purpose of national agreed templates is to ensure standardised healthcare delivery aligned with National Institute for Health and Care Excellence (NICE) guidance and key performance indicators.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit continuity of care for relevant transfers between HMP Hull and HMP Humber.
Verbatim wording from the response “For assurance, an audit on the continuity of care between HMP Hull to HMP Humber for those in service with CGL not prescribed opioid substitution therapy was conducted for transfers in June 2025. This audit confirmed that:” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a second audit against the same continuity-of-care parameters in January 2026.
Verbatim wording from the response “A second audit will be completed against the same parameters in January 2026. There was no action plan attached to the audit, as the findings showed that the pathway was being followed correctly and 100% of those transferred from HMP Hull were picked up and a referral opened in HMP Humber.” Source location Response from NHS England
Open published response
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing transfer pathway was considered sufficient because it was followed correctly and referrals were opened for all transferred service users.
Verbatim wording from the response “A second audit will be completed against the same parameters in January 2026. There was no action plan attached to the audit, as the findings showed that the pathway was being followed correctly and 100% of those transferred from HMP Hull were picked up and a referral opened in HMP Humber.” Source location Response from NHS England
Open published response
20 Oct 2025 Ms. Amy Jo Cross · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Lack of a system for passing important healthcare information between criminal justice healthcare providers during conveyance View source Lack of a standard medical records system accessible to each healthcare organisation 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
Ms. Amy Jo Cross · 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
Ms. Amy Jo Cross was arrested on 9 June 2023, experienced reported drug and alcohol withdrawal symptoms, and died in a prison cell on 10 June 2023 after being found unresponsive before prescribed medication was administered. The report identified concerns about the transfer of healthcare information, including recent medication administration and physical observations, between police, court and prison healthcare providers, and the absence of a shared medical records system.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for passing important healthcare information between criminal justice healthcare providers during conveyance
Wider context from the report “(1) There is no system to ensure that important healthcare information including recent administration of medicines and the results of physical observations is passed between separate providers of healthcare in the criminal justice system at the time a person is conveyed between the police, the court and the prison.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a standard medical records system accessible to each healthcare organisation
Wider context from the report “(2) There is no standard medical records system which can be accessed by each healthcare organisation to ensure the efficient and effective transfer of medical information.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue discussions with PECS to commence pilots enabling Liaison and Diversion services to access and update the Digital Person Escort Record.
Verbatim wording from the response “NHS England does commission Liaison & Diversion services, which also operate with police custody suites, addressing mental health and wider vulnerabilities. There is no indication that a referral was made in this case to Liaison & Diversion services at either Torquay or Exeter police custody suites. Liaison & Diversion services do not currently have access to enter information directly onto the DPER, but with an individual’s consent, they will share relevant health information with the police and the police will be responsible for updating the DPER. NHS England is in discussion with PECS to commence pilot schemes in London and West Yorkshire, whereby PECS will issue licences to Liaison & Diversion Services, to enable them to directly access the DPER and enter health information. The pilots are expected to commence in 2026 at the following sites:” Source location Response from NHS England
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations