12 Nov 2024 Lisa Gale · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Failure of urgent liver function test reporting thresholds to account for pregnancy-specific conditions View source Failure to communicate grossly abnormal liver function test results from laboratory staff to clinical staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Lisa Gale · 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
Lisa Gale developed Acute Fatty Liver of Pregnancy (AFLP) and later died despite hospital treatment and intensive care. The report raises concerns that markedly abnormal liver-function results were not urgently communicated because reporting thresholds did not account for pregnancy-specific conditions, resulting in a delay in diagnosing AFLP and starting appropriate treatment.
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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 of urgent liver function test reporting thresholds to account for pregnancy-specific conditions
Wider context from the report “(1) Blood was taken for liver function tests (LFTs) on admission before her condition was diagnosed;
(2) Lisa’s LFT’s were grossly elevated (normal range in brackets) – ALT 612 (10-50), bilirubin 122 (<21), creatine 168 (45-84);
(3) This was due to a potentially fatal condition – Acute Fatty Liver of Pregnancy – from which she subsequently died;
(3) Despite being grossly elevated, the results once obtained in the laboratory were not phoned through by the laboratory staff to the clinical staff;
(4) This was because the Royal College of Pathologists’ guidelines for urgent reporting only provides for the same with levels above 750 for ALT, 300 for bilirubin and 354 for creatinine – and does not provide for different reporting levels for those taken in pregnant women ;
(5) This is despite pregnancy specific conditions such as AFLP being potentially fatal at much lower levels of abnormal LFTs than those set currently by the Royal College of Pathologists ;
(4) As a result there was a delay in diagnosing her AFLP and starting appropriate treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate grossly abnormal liver function test results from laboratory staff to clinical staff
Wider context from the report “(1) Blood was taken for liver function tests (LFTs) on admission before her condition was diagnosed;
(2) Lisa’s LFT’s were grossly elevated (normal range in brackets) – ALT 612 (10-50), bilirubin 122 (<21), creatine 168 (45-84);
(3) This was due to a potentially fatal condition – Acute Fatty Liver of Pregnancy – from which she subsequently died;
(3) Despite being grossly elevated, the results once obtained in the laboratory were not phoned through by the laboratory staff to the clinical staff ;
(4) This was because the Royal College of Pathologists’ guidelines for urgent reporting only provides for the same with levels above 750 for ALT, 300 for bilirubin and 354 for creatinine – and does not provide for different reporting levels for those taken in pregnant women;
(5) This is despite pregnancy specific conditions such as AFLP being potentially fatal at much lower levels of abnormal LFTs than those set currently by the Royal College of Pathologists;
(4) As a result there was a delay in diagnosing her AFLP and starting appropriate treatment.
” Open source report
Concerns raised 2 Failure to robustly monitor bottles of sevoflurane View source Failure to confirm or refute the provenance of bottles of sevoflurane 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
Gemma Louise Helen RALPH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Gemma Louise Helen Ralph, a Theatre Support Assistant at Cannock Chase Hospital, died at home on 26 January 2024 after inhaling the anaesthetic sevoflurane without intent to end her life. Concerns remained about the monitoring of sevoflurane bottles and the inability to confirm or refute whether the bottle found at her home originated from Cannock Chase Hospital.
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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 robustly monitor bottles of sevoflurane
Wider context from the report “Notwithstanding an assurance that “the processes in place for safe supply, storage and use of Sevoflurane in the trust is in line with relevant sources of national guidance and best practice” the following remains a source of concern:
That bottles of sevoflurane, whether unopened or partially used after theatre, does not appear to be robustly monitored to the degree that it was possible for a bottle of sevoflurane to be removed from Cannock Chase Hospital without this being flagged by the auditing system .
That the trust was unable to confirm or refute that the bottle found at the deceased’s home address originated from Cannock Chase Hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 confirm or refute the provenance of bottles of sevoflurane
Wider context from the report “Notwithstanding an assurance that “the processes in place for safe supply, storage and use of Sevoflurane in the trust is in line with relevant sources of national guidance and best practice” the following remains a source of concern:
That bottles of sevoflurane, whether unopened or partially used after theatre, does not appear to be robustly monitored to the degree that it was possible for a bottle of sevoflurane to be removed from Cannock Chase Hospital without this being flagged by the auditing system.
That the trust was unable to confirm or refute that the bottle found at the deceased’s home address originated from Cannock Chase Hospital.
” 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 exploring and supporting improvements to controlled, authorised and auditable access to medicines.
Verbatim wording from the response “NHS England will continue to explore and support improvements in the controlled, authorised and auditable access to medicines.” 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 Consider the hospital’s response and any resulting actions concerning Sevoflurane storage and monitoring.
Verbatim wording from the response “With regard to your specific concerns about how Sevoflurane is stored and monitored at Cannock Chase Hospital, I note that you have also addressed your Report to the hospital and refer you to their response on these issues. NHS England will also consider the hospital’s response and any actions arising from this in due course.” 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 The hospital is responsible for Sevoflurane storage and monitoring, while NHS England will consider its response and any resulting actions.
Verbatim wording from the response “With regard to your specific concerns about how Sevoflurane is stored and monitored at Cannock Chase Hospital, I note that you have also addressed your Report to the hospital and refer you to their response on these issues. NHS England will also consider the hospital’s response and any actions arising from this in due course.” Source location Response from NHS England
Open published response
8 Nov 2024 Anne Taylor · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 4 Failure to assess capacity to decide to leave hospital View source Lack of clarity in the standard operating procedure for patients leaving hospital before clinical assessment View source Failure to consider secondary investigations during clinical waiting times View source Delays in clinical assessment resulting in patients leaving hospital before assessment 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
Anne Taylor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Anne Taylor sustained a head injury after banging her head on a bedside cabinet and falling from a bed during a holiday. After initially leaving hospital before assessment because of waiting times, she returned the next day and was diagnosed with a traumatic brain injury involving bilateral acute subdural bleeding and midline shift; she deteriorated and died on 31 July 2024. Concerns included the lack of consideration of investigations during the waiting period, the absence of evidence that her capacity to leave was assessed, and uncertainty about a new procedure for patients leaving before clinical assessment.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to assess capacity to decide to leave hospital
Wider context from the report “3. No evidence was provided that the deceased’s capacity to decide to leave the hospital was assessed given the history of suspected head injury .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in the standard operating procedure for patients leaving hospital before clinical assessment
Wider context from the report “4. Reference was made to a new standard operating procedure being developed relating to patients leaving the hospital before a clinical assessment occurs, but it was unclear what this will include .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 secondary investigations during clinical waiting times
Wider context from the report “2. There was no consideration of whether secondary investigations could be undertaken during the waiting time for example CT scan which would likely be required by a clinician in order to make a diagnosis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 clinical assessment resulting in patients leaving hospital before assessment
Wider context from the report “1. During evidence, it was heard that the deceased had elected to leave the Hospital on Friday 19 July because of waiting times, before being clinically assessed .
” 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 and implement the two-year delivery plan for recovering urgent and emergency care services.
Verbatim wording from the response “NHS England recognises the significant pressures on all NHS services and, in January 2023, published a two-year Delivery plan for recovering urgent and emergency care (UEC) services. The plan prioritised improvements to four hour performance in Emergency Departments and outlined key actions to recover and improve urgent and emergency care services. Despite significant challenges, including higher than anticipated demand, there has been a marked improvement in the headline ambition, with over 2.5 million more people completing their Accident & Emergency treatment within four hours in 2023/24 compared to 2022/23.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support regions and providers to eliminate longer-term crowding in emergency departments and improve patient flow.
Verbatim wording from the response “NHS England is working to support its regions to support providers to eliminate crowding in Emergency Departments in the longer term. Improvements are being demonstrated through NHS England’s operational planning guidance where health systems were asked to focus on areas to deliver improved patient flow and this has included increasing the productivity of acute and non-acute hospital services, improving flow as well as clinical outcomes.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use operational planning guidance to direct health systems toward improved patient flow and clinical outcomes.
Verbatim wording from the response “NHS England is working to support its regions to support providers to eliminate crowding in Emergency Departments in the longer term. Improvements are being demonstrated through NHS England’s operational planning guidance where health systems were asked to focus on areas to deliver improved patient flow and this has included increasing the productivity of acute and non-acute hospital services, improving flow as well as clinical outcomes.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Salford Royal Hospital Foundation Trust is the appropriate organisation to respond to the concerns raised.
Verbatim wording from the response “I note that your Report has also been sent to Salford Royal Hospital Foundation Trust, who are the appropriate organisation to respond to the concerns raised. NHS England has asked to be sighted on the Trust’s response to the Coroner and will review this once received.” Source location Response from NHS England
Open published response
Concerns raised 3 Failure to adhere to national ambulance response-time targets View source Use of NHS Pathways call-handler script wording that misleadingly implies ambulance dispatch View source Cancellation of ambulance responses without discussion with callers 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
Simon Boyd · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Simon Boyd, who had reported dizziness, lethargy, sweating and later breathlessness, was found unresponsive at home on 1 June 2024 after an ambulance response was cancelled and a routine same-day home visit was arranged. Attempts to revive him were unsuccessful, and the inquest recorded myocardial infarction, coronary artery disease and hypertension. Concerns included ambulance response times not meeting national targets, potentially misleading NHS Pathways wording about ambulance dispatch, and cancellation of an ambulance response without first discussing this with the caller.
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 adhere to national ambulance response-time targets
Wider context from the report “1. The court heard evidence to the effect that, notwithstanding the national target for Category 3 99% calls of 9 out of 10 responses within 120 minutes, the anticipated wait for a Category 3 ambulance on 1st June 2024 was around 3 hours and 15 minutes. This is a factor which contributed to decision-making in this case.
I am concerned that national targets for ambulance response times continue not to be adhered to .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 NHS Pathways call-handler script wording that misleadingly implies ambulance dispatch
Wider context from the report “1. I am concerned that the current wording of some of the script used by Call Handlers under NHS Pathways creates an impression that an ambulance has been dispatched to a caller at a point when this is, in fact, not the case .
Phrases such as ‘An emergency ambulance has been arranged’, ‘we will be with you as soon as possible, as soon as an ambulance is available’ and ‘if you can ask for someone to meet and direct the vehicle and shut any dogs away if there are any’ potentially give a misleading impression as to ambulance dispatch having occurred , which could conceivably deter a caller from taking steps which might realistically result in them obtaining faster help.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Cancellation of ambulance responses without discussion with callers
Wider context from the report “2. A further matter of concern arises from the potential under the NHS Pathways paradigm for an ambulance response to be cancelled without this first being discussed with the person who has felt it necessary to dial 999 and request an ambulance in the first place .
” 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 Issue a national directive requiring clinical validation of Category 3 and Category 4 ambulance responses in NHS 111 and 999 services.
Verbatim wording from the response “In order to support ambulance providers to manage their available resources, NHS England has issued a national directive, requiring providers to undertake clinical validation of Category 3 and Category 4 ambulance responses within both NHS 111 and 999 services. This involves validation of the disposition by a clinician (arranged locally), which can result in a different disposition being subsequently reached. The information captured in NHS Pathways may allow a clinician to re-categorise the call without direct contact with the patient. The Ambulance Trust’s Computer Aided Dispatch (CAD) system, rather than NHS Pathways, is used to manage the validation process. It is a requirement that the CAD must be able to provide appropriate exit scripts for Category 3 / Category 4 codes or dispositions. The wording of the exit scripts is for local determination.” 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 Greater Manchester Clinical Assessment Service is responsible for investigating the ambulance validation and cancellation.
Verbatim wording from the response “Simon was subsequently spoken to by a clinician within the Greater Manchester Clinical Assessment Service, who would have cancelled the ambulance. This validation and cancellation of an ambulance is not within the remit of the NHS Pathways system, and no data is provided back to NHS Pathways or the provider as to the changing of a disposition. Should the Coroner wish to investigate this further, he would be best placed contacting the Greater Manchester Clinical Assessment Service.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local ambulance providers determine Category 3 and 4 exit-script wording rather than NHS England determining it nationally.
Verbatim wording from the response “In order to support ambulance providers to manage their available resources, NHS England has issued a national directive, requiring providers to undertake clinical validation of Category 3 and Category 4 ambulance responses within both NHS 111 and 999 services. This involves validation of the disposition by a clinician (arranged locally), which can result in a different disposition being subsequently reached. The information captured in NHS Pathways may allow a clinician to re-categorise the call without direct contact with the patient. The Ambulance Trust’s Computer Aided Dispatch (CAD) system, rather than NHS Pathways, is used to manage the validation process. It is a requirement that the CAD must be able to provide appropriate exit scripts for Category 3 / Category 4 codes or dispositions. The wording of the exit scripts is for local determination.” 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 Ambulance validation and cancellation fall outside NHS Pathways’ remit.
Verbatim wording from the response “Simon was subsequently spoken to by a clinician within the Greater Manchester Clinical Assessment Service, who would have cancelled the ambulance. This validation and cancellation of an ambulance is not within the remit of the NHS Pathways system, and no data is provided back to NHS Pathways or the provider as to the changing of a disposition. Should the Coroner wish to investigate this further, he would be best placed contacting the Greater Manchester Clinical Assessment Service.” Source location Response from NHS England
Open published response
Concerns raised 1 Lack of sufficient mental health bed capacity 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
JAGJEET SINGH · 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
Jagjeet Singh, who had a history of intravenous substance misuse and mental and physical health problems, injected heroin after leaving hospital and was found deceased the following day with a syringe nearby. The inquest concluded that the death was drug related, with acute respiratory depression and fatal morphine and methadone toxicity identified as causes. The report raised concerns about the lack of an available mental health bed after medical-ward admissions, resulting in temporary accommodation, eviction and at least one night sleeping rough.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficient mental health bed capacity
Wider context from the report “Mr Singh was an inpatient on a mental health ward at the Homerton Hospital from 20 August 2023 until 6 March 2024, initially under s.2 of the Mental Health Act and then as an informal patient. On three occasions he spent time on medical wards for infected leg ulcers, arising from his IV drug use. During these periods his mental health bed was, understandably, allocated to other patients. However, on discharge from the medical ward, there was no mental health bed available for him and he either went home or, as his property was uninhabitable for a period of time, was accommodated in a Travel Lodge at the cost of the Trust, returning to the mental health ward for meals and medication. Mr Singh did not like the Travel Lodge and on one occasion was evicted. He therefore slept on a coach in the mental health ward and appears to have spent at least one night sleeping rough.
I heard that a bed on the mental health ward should have been available for Mr Singh when he was discharged from the medical wards but that there is a chronic shortage of mental health beds and not just in London but nationally . It was described to me as a crisis .
” 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 recurrent funding to Integrated Care Boards to recommission inpatient care under locally appropriate therapeutic models.
Verbatim wording from the response “This is being supplemented by a further £42 million recurrent investment from 2024/25 for all Integrated Care Boards (ICBs) in the country to recommission inpatient care, in line with local models that provide the best evidence of therapeutic support.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest in new mental health inpatient units to address local bed shortages.
Verbatim wording from the response “In some local areas there is a need for more beds, this is being addressed in part through investment in new units and additionally 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. NHS England’s 2024/25 priorities and operational planning guidance reinforces this focus on improving patient flow as a key priority – with systems directed to reduce the average length of stay in adult acute mental health wards in order to deliver more timely access to local beds.” Source location Response from NHS England
Open published response
4 Nov 2024 Neil Michael YATES · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1 Delays in sending information about prescriptions to GP surgeries 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
Neil Michael YATES · 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
Neil Michael Yates, aged 53, died in a drug-related death; the inquest recorded mixed drug toxicity and bronchopneumonia, with chronic obstructive pulmonary disease and cirrhosis also noted. The substantive concern was delays in information about prescriptions from voluntary and NHS organisations reaching GP surgeries, creating a risk that further medication could be prescribed without knowledge of existing prescriptions.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in sending information about prescriptions to GP surgeries
Wider context from the report “The delay of information relating to what has been prescribed to an individual being sent to the GP surgery by voluntary and NHS organisations.
” 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 Adopt interoperable medicine standards nationally for medication transfers at hospital admission and discharge.
Verbatim wording from the response “• National adoption of IMS to underpin the transfer of medication information at the time of hospital admission and discharge is underway.” Source location Response from NHSE
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with Integrated Care Boards to support development of local shared care records presenting medication information across providers.
Verbatim wording from the response “• NHS England have worked with local Integrated Care Boards (ICBs) to support the development of “local shared care records.” This provides the opportunity for local systems to present medication information across multiple providers.” Source location Response from NHSE
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use interoperable medicine standards in a local shared care record through an NHS Trust.
Verbatim wording from the response “• The first NHS Trust has used the IMS as part of the local shared care record.” Source location Response from NHSE
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support wider Trust adoption of interoperable medicine standards through an Information Standards Notice and national digital medicines programmes.
Verbatim wording from the response “• An Information Standards Notice (ISN) for Trusts is supporting wider adoption of IMS which have been incorporated into national digital medicines programmes.” Source location Response from NHSE
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enable supplying professionals to electronically record specified prescription-only medicines in GP records through GP Connect.
Verbatim wording from the response “• The GP Connect interface, where prescription only medication supplies made from specific settings (e.g. community pharmacies) without being prescribed directly by the GP, can now be electronically recorded into the GP record by the supplying professional.” Source location Response from NHSE
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require GP IT suppliers to deliver interoperable medicine standard requirements by June 2025.
Verbatim wording from the response “• GP IT suppliers are now required to deliver the requirements set out in the IMS by June 2025.” Source location Response from NHSE
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Define and test interoperable medicine standards and make them available to IT system suppliers.
Verbatim wording from the response “• A core set of fully “interoperable medicine standards” (IMS) have been defined and tested by early adopters and are available to IT system suppliers.” Source location Response from NHSE
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the medicines specification for the Transfer of Care initiative.
Verbatim wording from the response “• Work is currently underway to update the medicines specification of the Transfer of Care initiative, i.e. the mechanism to send information from secondary care to primary care.” Source location Response from NHSE
Open published response
Concerns raised 1 Failure to share learning and improvements in practice across prisons nationally 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
Wayne Anthony BAYLEY · 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
Wayne Anthony Bayley died in HMP Pentonville approximately ten hours after a restraint. His death involved acute chest syndrome, hypoxia, chronic sickle cell lung disease and sickle cell disease; the principal concern was that learning and improvements relating to the care of prisoners with underlying health conditions may not have been shared nationally.
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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 share learning and improvements in practice across prisons nationally
Wider context from the report “However, I am not at all clear that this work has been replicated nationally . Whilst PPG provides healthcare in 57 prisons, I understand that there are over double that number in England & Wales. I did hear evidence of the work of University College London Hospital in setting up an innovative outreach pilot. Nevertheless, my concern remains that learning and improvements in practice may not have been shared across the country .
” 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 learning from this case to strengthen service-specification requirements for assessing and managing sickle cell anaemia and other long-term conditions.
Verbatim wording from the response “NHS England is in the process of reviewing all current service specifications and I can assure you that the learning from this case will be used to strengthen this in relation to requirements around assessment and management of not only sickle cell anaemia, but all long-term conditions.” Source location Response from NHSE
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Present Wayne’s case and share London region’s resulting action with the Health and Justice Oversight Delivery Group and regional commissioners.
Verbatim wording from the response “Finally, Wayne’s case will be presented to the Health and Justice Oversight Delivery Group (HJDOG) and shared with NHS England’s regional commissioners. The action taken by the London region will also be shared with the HJDOG. HJDOG is the senior leadership forum, which holds responsibility for the oversight of delivery and continuous improvement in Health and Justice commissioned services, through both the national and regional teams, with a focus on improving health outcomes and reducing variation across England.” Source location Response from NHSE
Open published response
29 Oct 2024 Lee Armstrong · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 3 Lack of ambulance call-handler access to patients' medical records View source Failure to share information supplied to 111 online with ambulance call handlers View source Failure to elicit callers' existing medical conditions 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
Lee Armstrong · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lee Armstrong became unwell on 30 January 2024 and, after an initial ambulance-service call, became increasingly unwell before a further call led to an ambulance attending. He suffered an Addisonian Crisis, cardiac arrest and severe brain injury, and died on 2 February 2024. Concerns included the failure of the NHS Pathways system to ask about existing medical conditions, the lack of sharing of information supplied through 111 online with ambulance call handlers, and call handlers' lack of access to relevant medical records.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of ambulance call-handler access to patients' medical records
Wider context from the report “(3) I note that NWAS call handlers are not provided with access to (even an abridged version) of a patient's medical records . I am concerned that this means that call handlers cannot see relevant details of medical history .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 share information supplied to 111 online with ambulance call handlers
Wider context from the report “(2) The evidence indicates that information supplied to 111 online is not shared with NWAS . This may mean that a caller expects that their medical history and condition are known by ambulance call handlers when this is not the case . This risks such callers not volunteering details of the medical history .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 callers' existing medical conditions
Wider context from the report “(1) The evidence indicates that knowledge that Mr Armstrong suffered from Addison's Disease would have dramatically altered the response to the call. However, the NHS Pathways system does not ask callers to indicate whether they have any existing conditions . Instead, the onus is placed on patients to identify potentially relevant conditions . However, Mr Armstrong had indicated that he was confused. I am concerned that expecting a patient to volunteer crucial information about their condition, especially where that condition may cause confusion, places similar patients at risk .
” 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 Health advisors are not expected to interpret comprehensive medical records; limited history questions and clinical escalation are considered safer and more effective.
Verbatim wording from the response “Although comprehensive system training is provided, it is not within the scope or remit of the Health Advisor to understand or interpret the full range of medical elements as would be encountered in summary medical records, or from access to information on current medications. It is not safe or effective to expect this staff group to make sense of such information and it could add confusion or delays and cause harm if incorrect conclusions were drawn. It is for these reasons that questions on past medical history or pharmacology are only asked where it is deemed that a clear understanding can be sought and where it might make a difference to the outcome.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS Pathways limits past medical history questions because broader questioning could delay assessment without changing the triage outcome.
Verbatim wording from the response “Past medical history and triage using NHS Pathways
The NHS Pathways system is symptom-based. This means that the presenting clinical picture drives the assessment. Where pre-existing conditions may alter the outcome of symptom assessment, these conditions are enquired about after the initial assessment. Such enquiry is limited to these circumstances because detailed or unnecessary enquiry into past medical history may delay assessment – not only of the caller in question, but globally across the system by affecting average call lengths – without impacting upon the disposition reached.” 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 NHS 111 online does not transfer information when advising users to call 999 because further telephone assessment is deliberately required before ambulance dispatch.
Verbatim wording from the response “It is correct that where, as in Lee’s case, the disposition is to ring 999 there is no transfer of information from 111 online to the 999 service, and following the advice and dialling 999 is reliant on the user following the instructions. NHS 111 online is a self-service, digital remote triage service for the public and is designed for anonymous use. It is unassisted, meaning there is no health advisor or 111 clinician input to probe and validate the call 999 outcomes. This means there is no automated ambulance dispatch facility. The advice to ‘call 999’ occurs where the triage indicates potential high acuity presenting symptoms, and leads to the user/patient being assessed further over the phone and advised if an ambulance is required.” Source location Response from NHS England
Open published response
25 Oct 2024 Frank Steve Rios OSPINA · Prevention of Future Deaths report West London
View report summary
Concerns raised 4 Failure to provide accessible multilingual communications for arranging visits View source Restriction of Rule 35(2) report generation to general practitioners View source Failure to make Rule 35(2) reports when detainees are suspected of suicidal intentions View source Failure to control and document access to closed visits 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
Frank Steve Rios OSPINA · 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
Frank Steve Rios OSPINA died by suicide in detention, with the cause of death recorded as ligature compression of the neck and coronary heart disease. The report raised concerns about the failure to make a Rule 35(2) report after apparent suicide attempts, inconsistent understanding of the reporting process, the conduct and oversight of a closed family visit, and difficulties faced by his non-English-speaking mother in arranging visits and telephone 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 Failure to provide accessible multilingual communications for arranging visits
Wider context from the report “(3) Frank's mother does not speak English and found it very difficult to arrange a visit . In fact rather than successfully navigate the system, she just turned up and was permitted to see her son as set out above. Telephone calls were not facilitated with an interpreter. The web site where visits should be booked is entirely and only in English. This is a facility that by definition detains foreign nationals and predictably some of the family members do not speak English. A quick check of the local authority website (Hammersmith and Fulham) revealed a full immediate translation facility into over 100 languages, and so this is readily available technology. The Home Office and MITIE should consider the communications currently available to relatives trying to visit their loved ones and whether these can be improved by reasonable adjustments.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Restriction of Rule 35(2) report generation to general practitioners
Wider context from the report “(1) During the inquest evidence was heard about the use of Detention services order 09/2016 Detention centre rule 35 (2)
The purpose of rule 35 of the Detention Centre Rules 2001, as set out in Detention - general guidance (chapter 55), is “to ensure that particularly vulnerable detainees are brought to the attention of those with direct responsibility for authorising, maintaining and reviewing detention.
Rule 35 (2) states
2. ‘The medical practitioner shall report to the manager on the case of any detained person he suspects of having suicidal intentions, and the detained person shall be placed under special observation for so long as those suspicions remain, and a record of his treatment and condition shall be kept throughout that time in a manner to be determined by the Secretary of State.
‘The manager shall send a copy of any report under paragraphs (1), (2) or (3) to the Secretary of State without delay.
Despite Frank Ospina being witnessed as having made an attempt to take his life, and self-reporting a further attempt during his detention, no R35 report was made.
The GP evidence was that there was a long waiting list of 4 weeks of over 100 individuals who were dealt with in separate dedicated surgeries, that he had only made "a small number" of R35 (2) reports and that he would usually await and rely on additional evidence such as that from a Consultant Psychiatrist before submitting a R35 (2) report. In contrast, the Home Office evidence was that they were "surprised" that a R35 report had not been submitted. If it had been it would have been considered by a responsible officer within 2 working days.
There was a clear mismatch between the healthcare and Home Office expectations and practical application of the R35 provisions. HMC was advised that this is under review currently by the Home Office and NHS England and so this report is written to inform and assist that review process by raising the concerns from this inquiry. HMC would also question the restriction of the report having to be generated by a general practitioner, although detainees were seen by a multi-disciplinary team of healthcare professionals, many of whom could potentially carry out this task.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 Rule 35(2) reports when detainees are suspected of suicidal intentions
Wider context from the report “(1) During the inquest evidence was heard about the use of Detention services order 09/2016 Detention centre rule 35 (2)
The purpose of rule 35 of the Detention Centre Rules 2001, as set out in Detention - general guidance (chapter 55), is “to ensure that particularly vulnerable detainees are brought to the attention of those with direct responsibility for authorising, maintaining and reviewing detention.
Rule 35 (2) states
2. ‘The medical practitioner shall report to the manager on the case of any detained person he suspects of having suicidal intentions, and the detained person shall be placed under special observation for so long as those suspicions remain, and a record of his treatment and condition shall be kept throughout that time in a manner to be determined by the Secretary of State.
‘The manager shall send a copy of any report under paragraphs (1), (2) or (3) to the Secretary of State without delay.
Despite Frank Ospina being witnessed as having made an attempt to take his life, and self-reporting a further attempt during his detention, no R35 report was made.
The GP evidence was that there was a long waiting list of 4 weeks of over 100 individuals who were dealt with in separate dedicated surgeries, that he had only made "a small number" of R35 (2) reports and that he would usually await and rely on additional evidence such as that from a Consultant Psychiatrist before submitting a R35 (2) report. In contrast, the Home Office evidence was that they were "surprised" that a R35 report had not been submitted. If it had been it would have been considered by a responsible officer within 2 working days.
There was a clear mismatch between the healthcare and Home Office expectations and practical application of the R35 provisions. HMC was advised that this is under review currently by the Home Office and NHS England and so this report is written to inform and assist that review process by raising the concerns from this inquiry. HMC would also question the restriction of the report having to be generated by a general practitioner, although detainees were seen by a multi-disciplinary team of healthcare professionals, many of whom could potentially carry out this task.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 control and document access to closed visits
Wider context from the report “(2) Visits. The inquest was advised that Frank Ospina's mother visited him in the Heathrow Immigration Removal Centre on one occasion, and that was conducted as a "closed" visit.
Her son was accompanied by 2 Officers and their meeting held behind a glass screen where no physical contact was possible. The Officers were overhearing the family conversation and making notes.
MITIE who are responsible for the day to day running of the IRC were unaware that a "closed" visit had occurred and apologised for this, confirming it was inappropriate and Frank Ospina and his mother should have been allowed to meet in the usual communal area where they could have embraced and had a private conversation. This was the last time Frank Ospina was seen alive by his mother and the visit greatly distressed her.
HMC is concerned that any "closed" visits could take place seemingly without the knowledge and consent of the Duty Manager , that no documentation had to be presented and the "closed visit" room was accessible even though rarely required (the inquest was advised it had not been used at all during the past few months).
” 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 Develop and disseminate clinical guidance advocating a multidisciplinary approach to Detention Centre Rule 35 and Short-Term Holding Facility Rule 32 assessments.
Verbatim wording from the response “The NHS England Health and Justice Clinical Reference Group developed Detention Centre Rule 35 and Short-Term Holding Facility Rule 32 clinical guidance, which advocates this multidisciplinary approach. This guidance was disseminated to all IRC healthcare providers via an online event chaired by the NHS England Health & Justice National Clinical Lead in April 2024. The IRC Partnership Group provides the governance and oversight of the attainment of the NHS England and Home Office Detention joint priorities and assures the national system of the quality and consistency of healthcare provisions and reduction of health inequalities.” 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 Jointly develop a stakeholder engagement session to share revised assessment requirements with IRC providers and operators before full implementation.
Verbatim wording from the response “NHS England is working with the Home Office policy team to amend the Adults at Risk policy and Rule 35 assessment process. The aim of this work is to move the assessments towards a multidisciplinary approach, ensuring that completion of the assessment can be undertaken by a registered healthcare professional at the Immigration Removal Centre (IRC). Introducing this approach will ensure the management of safeguarding and vulnerability are not solely the responsibility of general practitioners. NHS England and the Home Office will, prior to full implementation during 2025, jointly develop a stakeholder engagement session to share the revised requirements with IRC providers and operators.” 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 Amend the Adults at Risk policy and Rule 35 assessment process to support multidisciplinary assessments by registered IRC healthcare professionals.
Verbatim wording from the response “NHS England is working with the Home Office policy team to amend the Adults at Risk policy and Rule 35 assessment process. The aim of this work is to move the assessments towards a multidisciplinary approach, ensuring that completion of the assessment can be undertaken by a registered healthcare professional at the Immigration Removal Centre (IRC). Introducing this approach will ensure the management of safeguarding and vulnerability are not solely the responsibility of general practitioners. NHS England and the Home Office will, prior to full implementation during 2025, jointly develop a stakeholder engagement session to share the revised requirements with IRC providers and operators.” Source location Response from NHS England
Open published response
24 Oct 2024 Amanda Jane GAINFORD · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1 Lack of clinician awareness of the ability to challenge ambulance call categorisation and request clinical review 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
Amanda Jane GAINFORD · 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
Amanda Jane GAINFORD, aged 52, sustained abdominal injuries while detained in a mental health ward and later died at Aintree Hospital on 4 November 2022 from multiorgan failure due to splenic laceration and liver cirrhosis. The inquest identified missed opportunities to provide intravenous fluids and call an ambulance earlier while she had prolonged low blood pressure. It also raised concern that clinicians were not sufficiently aware of the ability to challenge ambulance call categorisation and request a clinical review from the ambulance service.
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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 clinician awareness of the ability to challenge ambulance call categorisation and request clinical review
Wider context from the report “During the inquest the court heard evidence from the North West Ambulance Service (NWAS) witness who confirmed that call handlers for the service are not medically trained but receive basic medical training. The system used nationally to categorise calls is reliant upon questions asked and information which is input by the call handler to achieve a categorisation of a call. In this case, there was no evidence the call categorisation was incorrect, however, an ambulance was called on 3 occasions due to Amanda's condition, on the last occasion that call was made by a Doctor on the scene providing care for Amanda, who as of the opinion that he was unable to keep the patient stable due to low blood pressure over a prolonged period. The NWAS witness gave evidence to the court that had the Doctor disagreed with the category 2 classification of the call or sought to escalate his clinical concerns regarding a patient, that he had the ability to challenge that and to request a review by a clinician available to NWAS. The Doctor was unaware that he had the ability to challenge the call handler categorisation and to seek a review by a clinician at NWAS , at which point the nature and seriousness of Amanda's condition could have been further reviewed and clearly understood. At a further course attended subsequently by the Doctor he advised that of 50 Doctors in attendance, only 1 was aware of the ability to escalate concerns regarding a patient and the categorisation of a 999 call to the Ambulance service and subsequent response time . It appears that this is an important fact unknown by many clinicians which would enable a clinician to clinician review of a critical patient and the use and dispatch of ambulance resources to prevent the loss of life in critical cases which are not automatically categorised at the highest level of response.
” 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 and maintain a national framework enabling healthcare professionals to challenge ambulance call categorisation and request clinical review.
Verbatim wording from the response “Your Report raised the concern that many healthcare professionals (HCPs) were unaware of their ability to challenge ambulance call handler categorisation and seek a review by a clinician.” 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 framework advises healthcare professionals that they may challenge the assigned ambulance category or response time based on clinical concern.
Verbatim wording from the response “The Framework includes the question order for HCP requests and the information that HCPs will be asked to provide. Clinicians using the HCP process are advised of both the category of call assigned and an estimated response time based on the current activity level. They are given the option to add anything else once that information is shared and would be able to challenge the category/response based on clinical concern.” Source location Response from NHS England
Open published response
Concerns raised 2 Failure to clean injection-site skin before administering injections View source Training and national guidance failing to provide adequately current skin-disinfection requirements for injections 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
Patricia Heather Lines · 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 Heather Lines became unwell after receiving an intramuscular Vitamin B12 injection into her right shoulder and died in hospital on 23 October 2023 after developing an invasive Group A Streptococcus infection. The report states that the likely source of the infection was the injection, with bacteria introduced from the skin into deeper shoulder tissues. A principal concern was that the administering nurse did not clean the skin, in accordance with existing training and national guidance, despite evidence that alcohol cleaning reduces bacterial counts and that the supporting literature was over 20 years old.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to clean injection-site skin before administering injections
Wider context from the report “The nurse who administered the injection gave evidence that she did not clean the skin prior to administering the injection . She did not do so because she was following both her training (she quoted from an NHS e-learning module on administering intramuscular injections) and national guidance in the form of a document titled “Immunisation Against Infectious Disease”, which is also referred to as “The Green Book”.
Chapter 4 of “The Green Book” provides guidance on immunisation procedures. In relation to cleaning the skin the Green Book states as follows (at page 29):
If the skin is clean, no further cleaning is necessary. Only visibly dirty skin needs to be washed with soap and water.
It is not necessary to disinfect the skin. Studies have shown that cleaning the skin with isopropyl alcohol reduces the bacterial count, but there is evidence that disinfecting makes no difference to the incidence of bacterial complications of injections (Del Mar et al., 2001; Sutton et al., 1999).
The evidence that I heard at the inquest included that alcohol wipes are relatively cheap and their use does not give rise to any significant risk. I note that the Green Book states that cleaning the skin with alcohol reduces the bacterial count. Common sense would seem to suggest that reducing the bacterial count would reduce the risk of bacteria being inadvertently introduced into the deeper tissues during an injection. Whilst it is noted that the Green Book also makes reference to there being evidence that disinfecting makes no difference to the incidence of bacterial complications, it is also noted that the literature quoted is now over 20 years old.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Training and national guidance failing to provide adequately current skin-disinfection requirements for injections
Wider context from the report “The nurse who administered the injection gave evidence that she did not clean the skin prior to administering the injection. She did not do so because she was following both her training (she quoted from an NHS e-learning module on administering intramuscular injections) and national guidance in the form of a document titled “Immunisation Against Infectious Disease”, which is also referred to as “The Green Book”.
Chapter 4 of “The Green Book” provides guidance on immunisation procedures. In relation to cleaning the skin the Green Book states as follows (at page 29):
If the skin is clean, no further cleaning is necessary. Only visibly dirty skin needs to be washed with soap and water.
It is not necessary to disinfect the skin . Studies have shown that cleaning the skin with isopropyl alcohol reduces the bacterial count, but there is evidence that disinfecting makes no difference to the incidence of bacterial complications of injections (Del Mar et al., 2001; Sutton et al., 1999).
The evidence that I heard at the inquest included that alcohol wipes are relatively cheap and their use does not give rise to any significant risk. I note that the Green Book states that cleaning the skin with alcohol reduces the bacterial count. Common sense would seem to suggest that reducing the bacterial count would reduce the risk of bacteria being inadvertently introduced into the deeper tissues during an injection. Whilst it is noted that the Green Book also makes reference to there being evidence that disinfecting makes no difference to the incidence of bacterial complications, it is also noted that the literature quoted is now over 20 years old .
” Open source report
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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 UKHSA’s response and its implications for the relevant vaccination guidance.
Verbatim wording from the response “My response to your Report has been informed by the Infection Prevention team here at NHS England. Our own Infection Prevention and Control (IPC) guidance aligns with ‘The Green Book’ (UKHSA guidance, published on 11 September 2013), which serves as the national standard for vaccination and immunisation by injection. As you have noted in your Report, Chapter 4 of The Green Book indicates that skin preparation is unnecessary if the skin is clean and not visibly dirty. It is the responsibility of the UK Health Security Agency (UKHSA) to confirm that ‘The Green Book’ remains current and to update it when required. In addition, local policies should inform practice in specific cases (e.g. immunocompromised patients). NHS England will review the contents of UKHSA’s response once this has been received.” Source location Response from NHSE
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 Maintaining and updating additional published injection guidance falls outside NHS England’s remit.
Verbatim wording from the response “As part of our review into this case, we have identified additional sources of published guidance, some of which provide conflicting advice on the practice of cleaning a patient’s skin prior to immunisation. However, the maintenance and updating of such guidance falls outside of NHS England’s remit. Some examples include:” Source location Response from NHSE
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 UKHSA is responsible for confirming whether The Green Book remains current and updating it when required.
Verbatim wording from the response “My response to your Report has been informed by the Infection Prevention team here at NHS England. Our own Infection Prevention and Control (IPC) guidance aligns with ‘The Green Book’ (UKHSA guidance, published on 11 September 2013), which serves as the national standard for vaccination and immunisation by injection. As you have noted in your Report, Chapter 4 of The Green Book indicates that skin preparation is unnecessary if the skin is clean and not visibly dirty. It is the responsibility of the UK Health Security Agency (UKHSA) to confirm that ‘The Green Book’ remains current and to update it when required. In addition, local policies should inform practice in specific cases (e.g. immunocompromised patients). NHS England will review the contents of UKHSA’s response once this has been received.” Source location Response from NHSE
Open published response
24 Oct 2024 Aran Sean BRADBURY · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1 Failure of ambulance triage coding to consider higher-priority codes after assigning a mental-illness code 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
Aran Sean BRADBURY · 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 21 August 2023, Aran Sean Bradbury applied a ligature to his neck, suffered cardiac arrest and was taken to hospital, where he died on 25 August 2023 from hypoxic ischaemic brain injury following hanging. The report raised concern that ambulance triage coding may assign Category 3 rather than Category 2 priority to patients with a history of mental illness who have ingested substances, potentially resulting in a longer wait for an ambulance. In this case, there was a two-hour delay between the 999 call and ambulance dispatch.
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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 of ambulance triage coding to consider higher-priority codes after assigning a mental-illness code
Wider context from the report “4) I heard oral evidence that: 25-C codes refer to patients with altered levels of consciousness; Code 25-C-1 (which results to a Category 3 prioritisation) refers to patients with an altered level of consciousness and a history of mental illness; Other subsets of Code 25-C exist, including 25-C-2 which refers to patients with an altered level of consciousness who have ingested substances; and that Code 25-C-2 would result to a Category 2 prioritisation.
5) The evidence I heard was that although Mr Bradbury had ingested substances which might have resulted in a 25-C-2 coding (and therefore at Category 2 prioritisation for an ambulance), given that he also had a history of mental illness he was coded as 25-C-1 (and therefore a Category 3 priority) because the system does not allow for consideration of Codes 25-C-2, 25-C-3 etc if it had determined a 25-C-1 code based on the information provided .
6) The operation of this system as described in the evidence I heard could result in patients who might otherwise warrant a category 2 prioritisation being prioritised as Category 3 and therefore wait longer for an ambulance to attend . Patients with a history of mental illness would appear to fall within this group.
” 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 ambulance trusts requesting confirmation of compliance with guidance on 999 overdose and suicidal-ideation calls.
Verbatim wording from the response “NHS England’s ECPAG has since written to all ambulance trusts asking them to confirm full compliance with all aspects of the NHSE guidance on ‘999 overdose and suicidal ideation calls’ and asking AMPDS trusts to confirm they have ensured that any calls where a 25-C-1 (any/no suffix), 25-C-2 (any/no suffix) or 25-C-4 (any/no suffix) determinant is reached, are amended to a Category 2 if there is use of medications or substances, until a software update is implemented.” 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 Request AMPDS trusts to amend specified 25-C medication or substance calls to Category 2 until the software update is implemented.
Verbatim wording from the response “NHS England’s ECPAG has since written to all ambulance trusts asking them to confirm full compliance with all aspects of the NHSE guidance on ‘999 overdose and suicidal ideation calls’ and asking AMPDS trusts to confirm they have ensured that any calls where a 25-C-1 (any/no suffix), 25-C-2 (any/no suffix) or 25-C-4 (any/no suffix) determinant is reached, are amended to a Category 2 if there is use of medications or substances, until a software update is implemented.” 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 Existing clinical oversight safeguards for overdose and suicidal ideation calls are considered sufficient beyond initial ambulance response-category mapping.
Verbatim wording from the response “The mapping of a patient to an initial response category is only the first step; ambulance services have robust clinical oversight safeguards in place for patients presenting with overdose and suicidal ideation. EOCs follow specific principles on their respective triage tool to ensure clinical oversight is rapidly initiated. These principles have been reviewed and strengthened through several national recommendations since 2019.” Source location Response from NHS England
Open published response
Concerns raised 2 Lack of available suitable placements for people with complex needs View source Inadequacy of the Section 136 Suite 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 GORDON GERARD MORRISON · 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
Declan Morrison, who had complex care needs and required 24-hour residential care, was detained under the Mental Health Act after no suitable alternative placement could be found. He was found unresponsive after suffering catastrophic brain injuries and died in hospital on 2 April 2022. The principal concerns were the shortage of suitable community and NHS placements and the use of a Section 136 Suite considered inappropriate for his longer-term detention and complex needs.
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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 available suitable placements for people with complex needs
Wider context from the report “(1) The evidence revealed that there is currently a widespread shortage of available placements for someone with Declan’s complex needs both in the community and within the NHS .
(2) Once it was clear that Declan’s community placement had broken down in late 2021 no suitable alternative could be found . This resulted in a decline in Declan’s mental health and behaviour which ultimately necessitated his detention under the Mental Health Act. There was then nowhere suitable to detain him under Section 2 of the Mental Health Act .
(3) The Section 136 Suite was completely inappropriate. Declan’s mental health and behaviour declined further and ultimately this resulted in his death.
(4) Declan was in crisis for several months – the facilities were simply not available in the community and once detained , in order to prevent his 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 Inadequacy of the Section 136 Suite
Wider context from the report “(1) The evidence revealed that there is currently a widespread shortage of available placements for someone with Declan’s complex needs both in the community and within the NHS.
(2) Once it was clear that Declan’s community placement had broken down in late 2021 no suitable alternative could be found. This resulted in a decline in Declan’s mental health and behaviour which ultimately necessitated his detention under the Mental Health Act. There was then nowhere suitable to detain him under Section 2 of the Mental Health Act.
(3) The Section 136 Suite was completely inappropriate . Declan’s mental health and behaviour declined further and ultimately this resulted in his death.
(4) Declan was in crisis for several months – the facilities were simply not available in the community and once detained, in order to prevent his death.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commissioned six Neighbourhood Mental Health Centres providing 24/7 community support, crisis intervention, and open-access beds.
Verbatim wording from the response “NHS England has also commissioned six new Neighbourhood Mental Health Centres, offering 24/7 community support for individuals with serious mental illness. These centres integrate crisis intervention, community support, and open access beds to facilitate extra support, tailored to local needs. This includes support for people who have a learning disability and who are autistic. These Mental Health Centres in local neighbourhoods enable individuals to visit without a referral, to receive help from a range of professionals including psychiatrists, social workers, and peer support workers, and support such as psychological therapies, medication support, and assistance with related issues such as housing or employment. Each centre, led by an NHS provider, will work in partnership with people with lived experience, as well as voluntary, charity, faith and social enterprise organisations.” 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 the two-year pilot programme supporting six neighbourhood mental health centres through 2025/26.
Verbatim wording from the response “NHS England has also commissioned six new Neighbourhood Mental Health Centres, offering 24/7 community support for individuals with serious mental illness. These centres integrate crisis intervention, community support, and open access beds to facilitate extra support, tailored to local needs. This includes support for people who have a learning disability and who are autistic. These Mental Health Centres in local neighbourhoods enable individuals to visit without a referral, to receive help from a range of professionals including psychiatrists, social workers, and peer support workers, and support such as psychological therapies, medication support, and assistance with related issues such as housing or employment. Each centre, led by an NHS provider, will work in partnership with people with lived experience, as well as voluntary, charity, faith and social enterprise organisations.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Developed and published guiding principles for integrated care systems to commission appropriate community services.
Verbatim wording from the response “NHS England has worked with the Local Government Association and the Association of Directors of Adult Social Service to develop a set of guiding principles, published in 2023 (NHS England » Joint guiding principles for integrated care systems – learning disability and autism) for integrated care systems, setting out how partners in local” 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 Made £124 million available to local areas for community services preventing mental health hospital admission.
Verbatim wording from the response “In 2024/25, NHS England made available £124 million for local areas to invest in community services to help prevent the need for admission to mental health hospitals for people with a learning disability and autistic people. In line with the commitments set out in the NHS Long-Term Plan published in 2019, we would expect local areas to have community alternatives to hospital in place, including crisis and intensive support for people at greatest risk of admission.” 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 Cambridgeshire and Peterborough Integrated Care Board is the responsible commissioner for the individual’s care and service development.
Verbatim wording from the response “We note that your Report is also addressed to Cambridgeshire and Peterborough Integrated Care Board (ICB), the responsible commissioner for Declan’s care, and we are aware they have responded to the Coroner separately to outline the learning they have undertaken in response to this case and the next steps they will be taking to enhance service development for complex patients. We are aware that this includes work to better support patients under a Mental Health Act and an outline of the ICB’s work to transform services for people with mental health, learning disabilities and autism, including ensuring that there is no inappropriate detention of individuals with learning disabilities and/or who are autistic.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local areas are responsible for establishing community alternatives and support for people at risk of mental health hospital admission.
Verbatim wording from the response “In 2024/25, NHS England made available £124 million for local areas to invest in community services to help prevent the need for admission to mental health hospitals for people with a learning disability and autistic people. In line with the commitments set out in the NHS Long-Term Plan published in 2019, we would expect local areas to have community alternatives to hospital in place, including crisis and intensive support for people at greatest risk of admission.” Source location Response from NHS England
Open published response
Concerns raised 2 Failure to include corridor patient care areas in the Emergency Department nursing staffing template View source Failure to provide sufficient designated clinical space for Emergency Department patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tamara DAVIS · 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
Tamara Davis attended hospital after being unwell for five days and was treated for suspected chest infection before deteriorating and dying on 13 December 2022 from multi-organ failure associated with bronchopneumonia caused by Influenza A infection. A substantive concern was the use of an overcrowded Emergency Department corridor for patient care, where patients lacked privacy, toilet facilities and confidentiality, and where the area was not designated as a clinical area or included in the nursing staffing template.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to include corridor patient care areas in the Emergency Department nursing staffing template
Wider context from the report “During the inquest I heard evidence from clinicians at University Hospitals Sussex NHS Foundation Trust that when the Emergency Department of the Royal Sussex County Hospital, Brighton reached capacity patients would be moved and treated in the corridor as there was no clinical area available to do so. The area is not designated as a clinical area and is not included within the Nursing staffing template for the ED . When Ms Davis was treated in the Royal Sussex County Hospital, Brighton on 11 December 2022 there were, at times, more than 20 patients in that area.
Clinicians from University Hospitals Sussex NHS Foundation Trust gave evidence as to the action that is being taken by the Trust currently to (1) reduce the number of patients who are sent to the Emergency Department who could be seen by other services in the community and (2) to create an improved patient flow through the Royal Sussex County Hospital. The evidence was however that, despite these actions, the corridor remains in use for patients currently as there is insufficient space within the department to care for patients. There was no evidence as to when, and if, this practice would no longer be necessary.
I heard that the provision of care in the ED corridor meant that patients lacked privacy, toilet facilities and confidentiality. I understood from the evidence of the clinicians that they were concerned that patients were being moved into the Corridor but there appeared to be no other option when the Emergency Department exceeds capacity. I heard that in the event of a major incident University Hospitals Sussex NHS Foundation Trust would have to clear the Emergency Department, as they had done on occasion, as this would be the only way to create the necessary clinical space when the department was already over capacity and using the corridor.
I was also advised that the use of corridors to care for patients is not only an issue at the Royal Sussex County Hospital, Brighton but is used throughout the country when the capacities of Emergency Departments has been reached and there is nowhere to move patients to.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 sufficient designated clinical space for Emergency Department patients
Wider context from the report “During the inquest I heard evidence from clinicians at University Hospitals Sussex NHS Foundation Trust that when the Emergency Department of the Royal Sussex County Hospital, Brighton reached capacity patients would be moved and treated in the corridor as there was no clinical area available to do so . The area is not designated as a clinical area and is not included within the Nursing staffing template for the ED. When Ms Davis was treated in the Royal Sussex County Hospital, Brighton on 11 December 2022 there were, at times, more than 20 patients in that area.
Clinicians from University Hospitals Sussex NHS Foundation Trust gave evidence as to the action that is being taken by the Trust currently to (1) reduce the number of patients who are sent to the Emergency Department who could be seen by other services in the community and (2) to create an improved patient flow through the Royal Sussex County Hospital. The evidence was however that, despite these actions, the corridor remains in use for patients currently as there is insufficient space within the department to care for patients . There was no evidence as to when, and if, this practice would no longer be necessary.
I heard that the provision of care in the ED corridor meant that patients lacked privacy, toilet facilities and confidentiality . I understood from the evidence of the clinicians that they were concerned that patients were being moved into the Corridor but there appeared to be no other option when the Emergency Department exceeds capacity. I heard that in the event of a major incident University Hospitals Sussex NHS Foundation Trust would have to clear the Emergency Department, as they had done on occasion, as this would be the only way to create the necessary clinical space when the department was already over capacity and using the corridor.
I was also advised that the use of corridors to care for patients is not only an issue at the Royal Sussex County Hospital, Brighton but is used throughout the country when the capacities of Emergency Departments has been reached and there is nowhere to move patients to.
” 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 NHS England operating model to help regional teams support providers to eliminate Emergency Department crowding.
Verbatim wording from the response “In the meantime, NHS England is working through the operating model so that NHS England’s Regions can support providers to eliminate crowding in Emergency Departments in the longer term. Improvements are being demonstrated through NHS England’s operational planning guidance, where systems were asked to focus on areas to deliver improved patient flow, and this has included increasing the productivity of acute and non-acute hospital 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 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 Continue developing services that shift unplanned urgent activity outside acute hospitals, including proactive care, admission alternatives and improved discharge.
Verbatim wording from the response “In the meantime, NHS England is working through the operating model so that NHS England’s Regions can support providers to eliminate crowding in Emergency Departments in the longer term. Improvements are being demonstrated through NHS England’s operational planning guidance, where systems were asked to focus on areas to deliver improved patient flow, and this has included increasing the productivity of acute and non-acute hospital 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 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 Use operational planning guidance to direct systems toward improved patient flow, productivity, length of stay and clinical outcomes.
Verbatim wording from the response “In the meantime, NHS England is working through the operating model so that NHS England’s Regions can support providers to eliminate crowding in Emergency Departments in the longer term. Improvements are being demonstrated through NHS England’s operational planning guidance, where systems were asked to focus on areas to deliver improved patient flow, and this has included increasing the productivity of acute and non-acute hospital 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 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 Conduct joint regional visits and focused reviews of non-designated Emergency Department care, engaging staff, patients and relatives and providing improvement feedback.
Verbatim wording from the response “My Regional colleagues in the South East Clinical Quality Improvement team have recently visited the Emergency Departments at both University Hospitals Sussex in Worthing and Royal Sussex County Hospital as part of a programme of joint Nursing and Integrated Care Board (ICB) visits to NHS Trusts, led by their Deputy Director. The programme of visits aims to understand how and why patients are selected to reside in non-designated areas, how they are observed for deterioration, and how dignified care can be provided. These focused reviews of non-designated care practices in the Emergency Department have included engaging with staff, patients and relatives to test safety measures in place and provide detailed feedback for the organisations on areas for improvement.” 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 principles for providing safe, good-quality care in temporary escalation spaces when demand exceeds capacity.
Verbatim wording from the response “The delivery of care in temporary escalation spaces (TES) in departments experiencing patient crowding (including beds and chairs) is not acceptable and should not be considered as standard across the NHS. TES refers to care given in any unplanned settings (such as corridors) and recently NHS England have published a set of principles for supporting improved quality of care should patient demand outstrip capacity - NHS England – Principles for providing safe and good quality care in temporary escalation spaces (16 September 2024). These principles have been developed to support point-of-care staff to provide the safest, most effective and” Source location Response from NHS England
Open published response
Concerns raised 11 Lack of specialist NHS paediatric neuro-consultant oversight View source Failure to maintain comprehensive, understandable, accurate and contemporaneous medical records View source Failure to undertake regular Paediatric Early Warning Score assessments View source Deficiencies in ongoing staff training View source Deficient clinical governance of management and investigation View source Failure to conduct regular audits of clinical practice View source Failure to provide sufficiently frequent direct night-time visual observations View source Failure to ensure robust procedures are in place View source Delays in fulfilling Duty of Candour obligations View source Failure to undertake regular multidisciplinary clinical reviews View source Lack of regular independent consultant oversight and coordination of investigations and multidisciplinary management View source See 8 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
Mia Louise Gauci-Lamport · 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
Mia Louise Gauci-Lamport, who had treatment-resistant epilepsy and required full-time residential care, was found cyanotic and unresponsive at around 06.32 hours on 11 September 2023 after not being visually checked when a carer entered her room. Resuscitation was unsuccessful. The report raised concerns about inadequate night-time monitoring, incomplete medical records and insufficient clinical oversight and governance.
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 NHS paediatric neuro-consultant oversight
Wider context from the report “2. Medical Care provided to Mia
Mia’s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented.
Mia was a ‘looked after’ child with complex and challenging health needs and could not contribute or make decisions for herself. The independent investigator found regular PEWS (Paediatric Early Warning Scores) assessments were not undertaken to ensure Mia’s well-being despite it being within her care plan. There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs.
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life-limiting condition.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain comprehensive, understandable, accurate and contemporaneous medical records
Wider context from the report “2. Medical Care provided to Mia
Mia’s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented .
Mia was a ‘looked after’ child with complex and challenging health needs and could not contribute or make decisions for herself. The independent investigator found regular PEWS (Paediatric Early Warning Scores) assessments were not undertaken to ensure Mia’s well-being despite it being within her care plan. There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs.
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life-limiting condition.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake regular Paediatric Early Warning Score assessments
Wider context from the report “2. Medical Care provided to Mia
Mia’s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented.
Mia was a ‘looked after’ child with complex and challenging health needs and could not contribute or make decisions for herself. The independent investigator found regular PEWS (Paediatric Early Warning Scores) assessments were not undertaken to ensure Mia’s well-being despite it being within her care plan. There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs.
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life-limiting condition.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in ongoing staff training
Wider context from the report “3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death, delay in fulfilling the Duty of Candour’ obligations, ongoing staff training , ensuring robust procedures were in place alongside regular audits of clinical practice. These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Deficient clinical governance of management and investigation
Wider context from the report “3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death , delay in fulfilling the Duty of Candour’ obligations, ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice. These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct regular audits of clinical practice
Wider context from the report “3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death, delay in fulfilling the Duty of Candour’ obligations, ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice . These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 sufficiently frequent direct night-time visual observations
Wider context from the report “1. Lack of appropriate monitoring of Mia during the night :
Mia’s underlying illness caused seizures which were multifocal, complex and variable from tonic-clonic, myoclonic to cluster and absence seizures. Her care plan stipulated that carers should enter her room every 15 minutes to undertake visual observations throughout the night to ensure Mia was in a safe position, was breathing and not at risk of asphyxiation. However, this did not take place as frequently as specified . Moreover, it was common practice amongst some carers to review images from a video monitor placed over Mia’s cot rather than direct visualisation despite it being recognised that the monitor was insufficiently sensitive to reassure the carer that Mia was breathing, seizure free and safe from asphyxiation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 robust procedures are in place
Wider context from the report “3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death, delay in fulfilling the Duty of Candour’ obligations, ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice. These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 fulfilling Duty of Candour obligations
Wider context from the report “3. Senior management, Children’s Trust, Tadworth
The lack of a robust and adhered to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022.
The Independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death, delay in fulfilling the Duty of Candour’ obligations , ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice. These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 undertake regular multidisciplinary clinical reviews
Wider context from the report “2. Medical Care provided to Mia
Mia’s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented.
Mia was a ‘looked after’ child with complex and challenging health needs and could not contribute or make decisions for herself. The independent investigator found regular PEWS (Paediatric Early Warning Scores) assessments were not undertaken to ensure Mia’s well-being despite it being within her care plan. There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs .
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life-limiting condition.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of regular independent consultant oversight and coordination of investigations and multidisciplinary management
Wider context from the report “2. Medical Care provided to Mia
Mia’s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard in NHS general or hospital practice to ensure accurate and contemporaneous medical care was being reviewed and documented.
Mia was a ‘looked after’ child with complex and challenging health needs and could not contribute or make decisions for herself. The independent investigator found regular PEWS (Paediatric Early Warning Scores) assessments were not undertaken to ensure Mia’s well-being despite it being within her care plan. There was no documented evidence that a multidisciplinary clinical review was regularly, if at all, undertaken to ensure Mia’s risk was regularly assessed, appropriate monitoring was in place, and care provision was meeting her needs.
Mia was reviewed by a ‘privately-funded’ consultant employed by but working independently of Great Ormond Street Children’s Hospital as and when requested by the medical staff at TCT. The consultant had no terms of reference and did not take responsibility for Mia’s ongoing care and was consulted only in relation to adjustments in her medication for seizure control. Due to financial constraints the consultant’s service level agreement was temporarily terminated and not available from April to October 2023.
In this context, Mia was not under a specialist NHS paediatric neuro-consultant to ensure her ongoing medical needs conformed to expected practice nationally and for an independent consultant outside of TCT to have regular oversight and co-ordinate investigations and any further multi-disciplinary management she may need given this progressive life-limiting condition.
” 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 Tadworth Children’s Trust and stakeholders through Rapid Quality Review meetings to review care quality, identify risks, and formulate improvement plans.
Verbatim wording from the response “Even though NHS England had no direct or commissioning oversight of Mia’s care, I should like to provide you and Mia’s family with some assurance that our regional Specialised Commissioning team has been working with TCT, alongside other stakeholders, to review the quality of care being provided. This has taken the form of Rapid Quality Review (RQR) meetings in accordance with the National Quality Boards guidance on risk response and escalation in ICSs where concerns are raised about a” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England had no direct or commissioning oversight of Mia’s care because it was local-authority-funded residential care, not specialised commissioning care.
Verbatim wording from the response “Your Report raises multiple concerns in relation to the medical care and appropriate monitoring of Mia, including concerns regarding the access to clinical consultant care and a lack of adherence to her care plan within the residential care setting at Tadworth Children’s Trust (TCT). Noting you have also sent your Report to TCT and CQC, some of the concerns you raise may be better addressed by those organisations. In this response, I have addressed the matters of concern where NHS England are able to contribute and provide some assurance.” 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 Some concerns about Mia’s care are better addressed by Tadworth Children’s Trust and the Care Quality Commission.
Verbatim wording from the response “Your Report raises multiple concerns in relation to the medical care and appropriate monitoring of Mia, including concerns regarding the access to clinical consultant care and a lack of adherence to her care plan within the residential care setting at Tadworth Children’s Trust (TCT). Noting you have also sent your Report to TCT and CQC, some of the concerns you raise may be better addressed by those organisations. In this response, I have addressed the matters of concern where NHS England are able to contribute and provide some assurance.” 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 Tadworth Children’s Trust remains responsible for ensuring consistent multidisciplinary clinical support for all children in its care.
Verbatim wording from the response “Our NHS England Regional Medical Director has also offered to support with connecting TCT’s clinical team to specialists within the NHS that can offer peer support and further improvement work. However, it would remain TCT’s responsibility to ensure consistency of multi-disciplinary clinical support for all children in their care, whether accessed via NHS or privately funded.” Source location Response from NHS England
Open published response
Concerns raised 3 Failure to flag low-volume PAO practitioners View source Failure of trusts to recognise PAO as a distinct procedure View source Insufficient PAO experience among surgeons performing the procedure View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Chamali BIBI · 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
Chamali Bibi underwent a right periacetabular osteotomy on 1 March 2023 and suffered haemorrhagic shock during the procedure, followed by a stroke that evening. The principal concern was whether PAOs are being performed by sufficiently experienced surgeons, given limited procedure frequency, gaps in mentor feedback and a voluntary specialist register that may not flag outliers.
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 flag low-volume PAO practitioners
Wider context from the report “The issue that I bring to your attention is this. At inquest, I heard evidence that PAOs should only be conducted by surgeons expert in this procedure. I heard that only those undertaking this procedure frequently, with mentor feedback on the surgery taking into account the post operative imaging, can gain the necessary experience to become expert.
However, the majority of the surgeons on the specialist register are the only practitioners within their trust performing the surgery and the majority undertake fewer than ten per annum each. Further, the register is voluntary. Outliers do not appear to have been flagged.
It is not clear to me whether all trusts recognise that the PAO is a different procedure, rather than simply being a different technique.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 trusts to recognise PAO as a distinct procedure
Wider context from the report “The issue that I bring to your attention is this. At inquest, I heard evidence that PAOs should only be conducted by surgeons expert in this procedure. I heard that only those undertaking this procedure frequently, with mentor feedback on the surgery taking into account the post operative imaging, can gain the necessary experience to become expert.
However, the majority of the surgeons on the specialist register are the only practitioners within their trust performing the surgery and the majority undertake fewer than ten per annum each. Further, the register is voluntary. Outliers do not appear to have been flagged.
It is not clear to me whether all trusts recognise that the PAO is a different procedure, rather than simply being a different technique.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 PAO experience among surgeons performing the procedure
Wider context from the report “The issue that I bring to your attention is this. At inquest, I heard evidence that PAOs should only be conducted by surgeons expert in this procedure . I heard that only those undertaking this procedure frequently, with mentor feedback on the surgery taking into account the post operative imaging, can gain the necessary experience to become expert .
However, the majority of the surgeons on the specialist register are the only practitioners within their trust performing the surgery and the majority undertake fewer than ten per annum each . Further, the register is voluntary. Outliers do not appear to have been flagged.
It is not clear to me whether all trusts recognise that the PAO is a different procedure, rather than simply being a different technique.
” 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 Further information on relevant clinical and professional standards and guidance should be sought from the RCS of England or BOA.
Verbatim wording from the response “NHS England are not the responsible organisation for the relevant clinical and professional standards and guidance raised in this matter. The Coroner may wish to refer to the Royal College of Surgeons (RCS) of England or the British Orthopaedic Association (BOA) if they feel they require further information.” 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 Relevant clinical and professional standards and guidance are outside NHS England’s responsibility.
Verbatim wording from the response “NHS England are not the responsible organisation for the relevant clinical and professional standards and guidance raised in this matter. The Coroner may wish to refer to the Royal College of Surgeons (RCS) of England or the British Orthopaedic Association (BOA) if they feel they require further information.” 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 Further comment on the specific concerns is not appropriate based on the information provided and matters addressed by the Trust.
Verbatim wording from the response “It is not appropriate for NHS England to provide further comment on the concerns raised in your Report, based on the information provided. I understand from your Report that you are satisfied that Barts Health NHS Trust have addressed several matters which you felt required further attention, and undertakings were given to you in court in this respect. Your Report has also been sent to my regional colleagues in London as part of our internal Regulation 28 assurance processes. It is not therefore appropriate for NHS England to provide further comment on these specific concerns.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Trusts and orthopaedic surgeons should already recognise PAO as a specialist procedure requiring suitably trained and experienced clinicians.
Verbatim wording from the response “Your Report raises the concern that periacetabular osteotomy (PAO) procedures may not be being carried out by suitably experienced practitioners and that Trusts may not recognise it as being a specialist procedure, as opposed to a surgical technique. My response to the Coroner has been informed by specialist orthopaedic clinical opinion.” Source location Response from NHS England
Open published response
Concerns raised 4 Extremely limited doctor training on ME/CFS treatment, especially severe ME View source Lack of specialist healthcare provision for patients with severe ME View source Failure of NICE guidance to provide detailed guidance on managing severe ME at home or in the community View source Lack of current funding for ME/CFS treatment research and understanding of causes 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
Maeve Boothby O’Neill · 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
Maeve Boothby O’Neill, who had severe ME and was bedbound, died at home on 3 October 2021 after three hospital admissions during 2021. The report identified concerns about the lack of specialist care provision for severe ME, limited research funding and medical training, and insufficient guidance on managing severe ME in the home or community, including nutritional support.
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 Extremely limited doctor training on ME/CFS treatment, especially severe ME
Wider context from the report “(3) During the course of the inquest it became clear that there was extremely limited training for Doctors on ME/ CFS and how to treat it – especially in relation to severe ME .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 healthcare provision for patients with severe ME
Wider context from the report “(1) During the course of the evidence it became clear that there were no specialist hospitals or hospices, beds, wards or other health care provision in England for patients with severe Myalgic encephalopathies (ME) . This meant that the Royal Devon and Exeter Hospital had no commissioned service to treat Maeve and patients like her .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 NICE guidance to provide detailed guidance on managing severe ME at home or in the community
Wider context from the report “(4 ) During the course of the inquest it became clear that the 2021 NICE guidelines on ME did not provide any detailed guidance at all on how severe ME should be managed at home or in the community and in particular whether or not there is any necessary adaptation needed to the 2017 guidance on Nutrition support for adults : oral nutrition support , enteral tube feeding and parenteral nutrition .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 current funding for ME/CFS treatment research and understanding of causes
Wider context from the report “(2) During the course of the inquest it became clear that there was no current available funding for the research and development of treatment and further learning for understanding the causes of ME / Chronic Fatigue Syndrome (CFS) .
” 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 Undertake a stocktake of existing CFS/ME services in England.
Verbatim wording from the response “In addition, NHS England has also established a specific working group to determine if additional support can be provided to commissioners of ME/CFS services. A stock take of existing CFS/ME services in England is being undertaken as an initial step. If it is of assistance, we can provide further updates as this work progresses.” Source location Response from NHSE
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop two further ME/CFS e-learning modules covering primary-care management and severe ME/CFS management in secondary care.
Verbatim wording from the response “Your Report also raises the concern that there is limited training for doctors on ME/CFS and how to treat it, particularly for cases of severe ME. There is currently a limited evidence base for the treatment of severe ME/CFS, which does create challenge to developing educational resource. However, in May this year, in development with DHSC, NHS England published the first of three new e-learning modules. An ‘Introduction to ME/CFS’ provides an overview of the potential causes, diagnostic criteria and management strategies. A further two modules, aimed at the NHS clinical workforces, are now in development, the first of which will cover management in primary care, followed by the third module which will provide guidance on the management of severe ME/CFS in secondary care settings.” Source location Response from NHSE
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish an introductory e-learning module covering ME/CFS causes, diagnosis and management.
Verbatim wording from the response “Your Report also raises the concern that there is limited training for doctors on ME/CFS and how to treat it, particularly for cases of severe ME. There is currently a limited evidence base for the treatment of severe ME/CFS, which does create challenge to developing educational resource. However, in May this year, in development with DHSC, NHS England published the first of three new e-learning modules. An ‘Introduction to ME/CFS’ provides an overview of the potential causes, diagnostic criteria and management strategies. A further two modules, aimed at the NHS clinical workforces, are now in development, the first of which will cover management in primary care, followed by the third module which will provide guidance on the management of severe ME/CFS in secondary care settings.” Source location Response from NHSE
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a working group to determine additional support for ME/CFS service commissioners.
Verbatim wording from the response “In addition, NHS England has also established a specific working group to determine if additional support can be provided to commissioners of ME/CFS services. A stock take of existing CFS/ME services in England is being undertaken as an initial step. If it is of assistance, we can provide further updates as this work progresses.” Source location Response from NHSE
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NICE is responsible for responding to concerns about ME/CFS guidance and nutrition support for adults.
Verbatim wording from the response “It is appropriate that the National Institute for Health and Care Excellence (NICE) responds to the Coroner on your fourth concern regarding NICE guidance on ME/CFS and nutrition support for adults. NHS England has engaged with NICE on the concerns raised in your Report and will carefully consider the response from NICE in due course.” Source location Response from NHSE
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation DHSC is responsible for providing further information on the ME/CFS delivery plan and existing research investment and funding.
Verbatim wording from the response “NHS England has engaged with the Department of Health and Social Care (DHSC), who we note your Report was also addressed to, on these matters. Following a period of consultation with key stakeholders, including those with lived experience, and the publication of the interim delivery plan on ME/CFS in late 2023 under the last Government, the DHSC have confirmed to NHS England that the development of a final ME/CFS Delivery Plan to improve the experiences and outcomes for people with the condition remains a priority and that it is their intention to publish a response summary before the end of the year.” Source location Response from NHSE
Open published response
2 Oct 2024 Michael Sean Heath · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to ensure carers are informed of Mental Health Act admissions within 24 hours View source Failure to establish agreed communication means and maintain relevant patient information in an accessible central repository View source Failure to provide mental health patients with access to an independent mental health advocate View source Failure to ensure officers are trained to assess mental health-related calls and associated immediate risks View source Failure to determine when police are the appropriate agency for mental health-related enquiries View source Lack of connectivity between overseas and UK mental health services during repatriation of an ill patient View source Failure to consider wider circumstances and likely follow-on care before removing out-of-area patients from GP practice lists View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Sean Heath · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Sean Heath died on 25 August 2023 in an apartment from injuries involving his pericardial sac. The inquest jury determined that he died by taking his own life while suffering an acute mental health crisis. Principal concerns included police and mental health service responses, inter-agency communication, continuity of care after his return from Gibraltar, and access to appropriate mental health support.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure carers are informed of Mental Health Act admissions within 24 hours
Wider context from the report “In relation to the management of mental health patients that their carers are made aware of any admission under the Mental Health Act within 24 hours and those patients are supported with access to an independent mental health advocate;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 agreed communication means and maintain relevant patient information in an accessible central repository
Wider context from the report “The means of communication is known and agreed between all mental health agencies to ensure all relevant patient information is held in an accessible central repository .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 mental health patients with access to an independent mental health advocate
Wider context from the report “In relation to the management of mental health patients that their carers are made aware of any admission under the Mental Health Act within 24 hours and those patients are supported with access to an independent mental health advocate ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 officers are trained to assess mental health-related calls and associated immediate risks
Wider context from the report “In relation to Policing is the extent to which all officers are trained to assess the increasing number of calls to the police which are of a mental health nature , the risks associated with the consequences of not making the right assessment where there may be an immediate risk to life and when to accept that the police are the right agency to be involved in mental health related enquiries due to their powers of entry;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to determine when police are the appropriate agency for mental health-related enquiries
Wider context from the report “In relation to Policing is the extent to which all officers are trained to assess the increasing number of calls to the police which are of a mental health nature, the risks associated with the consequences of not making the right assessment where there may be an immediate risk to life and when to accept that the police are the right agency to be involved in mental health related enquiries due to their powers of entry ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 connectivity between overseas and UK mental health services during repatriation of an ill patient
Wider context from the report “The apparent lack of connectivity between mental health services abroad and the UK upon repatriation whilst the patient remains ill ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 wider circumstances and likely follow-on care before removing out-of-area patients from GP practice lists
Wider context from the report “That there is a risk to patients generated by a decision to remove a patient from a GP practice list where the patient resides out of geographical area for that GP practice without considering the wider circumstances and the likely follow on care ; and
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A provider cannot reasonably be expected to know about a patient’s return when the patient independently arranged travel and gave no notification.
Verbatim wording from the response “Further, where a patient makes their own arrangements to return to the UK independent of an overseas healthcare provider, there can be no expectation that a provider would be aware of the patient’s travel arrangements unless the patient themselves notifies the relevant provider of their return. In this case, it is our understanding that Michael made his own travel arrangements independent of an overseas healthcare provider, and did not notify a provider in England of his return.” Source location Response from NHSE
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Overseas healthcare providers cannot be mandated to share clinical information when patients are medically repatriated.
Verbatim wording from the response “Regarding your concern over the apparent lack of connectivity between mental health services abroad and the UK, whilst it would be NHS England’s hope that, in the patient’s best interests, when a patient is medically repatriated there will be appropriate sharing of clinical information between the discharging and receiving healthcare providers, this cannot be mandated for overseas healthcare providers.” Source location Response from NHSE
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Policing, advocacy, communication, and interagency information access should be addressed by the other individuals and organisations named in the report.
Verbatim wording from the response “We note that your Report has also been addressed to individuals including the Home Secretary and the Minister of Policing, along with organisations including the Greater Manchester Mental Health NHS Foundation Trust, North West Ambulance Service, Greater Manchester Police and Trafford Council. It is appropriate that these individuals and organisations address some of the matters of concern, namely around those issues relating to policing, advocacy and communication and access to information between the local agencies and staff involved in Michael’s care. NHS England will review and consider carefully the other responses in due course.” Source location Response from NHSE
Open published response
Concerns raised 2 Failure of bank staff to access patient notes before assessments View source Failure of computer systems to enable different NHS Trusts to access patient notes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alix Elizabeth Knowles · 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
Alix Elizabeth Knowles, aged 30, attended hospital on 8 December 2023 after attempting to cut her throat and threatening suicide, but was discharged home after a mental health assessment. In the early hours of 9 December 2023, she jumped from a bridge onto the road below and was hit by two motor vehicles. The substantive concerns were that bank staff could not access patient notes before assessments and that different NHS Trusts could not access one another’s patient notes because of incompatible computer systems.
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 bank staff to access patient notes before assessments
Wider context from the report “1. Bank Staff are not able to access patient notes before assessments ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of computer systems to enable different NHS Trusts to access patient notes
Wider context from the report “2. Different NHS Trusts are unable to access patient notes , because the computer systems used do not allow this .
” 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 Support increased electronic patient record convergence across Integrated Care Boards.
Verbatim wording from the response “The next phase of optimising digitisation in England is for the FLD programme to support increased EPR convergence across Integrated Care Boards (ICBs).” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support NHS and foundation trusts to acquire modern electronic patient record systems and improve their effectiveness after deployment.
Verbatim wording from the response “As a response to this, NHS England set up the Frontline Digitisation Programme (FLD) in 2021 and has been supporting NHS and Foundation Trusts in acquiring modern EPR systems and helping them develop their system’s effectiveness once deployed. The FLD programme comes with substantial financial and specialist IT support to bring all Trusts to an optimum level of digital maturity.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual healthcare providers, not NHS England, determine bank staff access levels to electronic patient records under local policies and risk assessments.
Verbatim wording from the response “The first concern raised in your Report was that bank staff are not able to access patient notes before assessments. Individual healthcare providers determine the access levels that different members of staff have to different parts of their electronic patient record systems. This decision will be in line with each Trust’s access policy and risk assessment, and is determined solely by individual healthcare providers. I note that you have also addressed your Report to Derby and Burton Hospital (Royal Derby Hospital) and Royal Stoke University Hospital and refer you to their responses on this matter.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local healthcare providers decide which electronic patient record systems to procure and deploy, based on local operational and financial factors.
Verbatim wording from the response “For information, local healthcare providers make the decision on which Electronic Patient Records (EPR) system to procure and deploy, and their decision may apply to either a single NHS organisation or across multiple NHS organisations within a single Integrated Care System (ICS) where convergence of EPR systems across an ICB or ICS is seen as the most beneficial model. These decisions are based on many factors including the required functionality, a system’s suitability for the service specialities on offer, user experience, cost, and ease of information sharing. Today, there are already many examples where EPR records are shared seamlessly between provider organisations to enhance care provision.” Source location Response from NHS England
Open published response
1 Oct 2024 Ryan James Richard Campbell · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of a full suite of cardiac diagnostic imaging equipment at Stepping Hill Hospital View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ryan James Richard Campbell · 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
Ryan Campbell experienced persistent chest pain and underwent medical investigations, but further cardiac imaging was still awaited when he died. The report identified delays associated with the absence of a full suite of cardiac diagnostic imaging equipment at Stepping Hill Hospital, particularly CT or MR angiograms, and the need to switch treatment centres.
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 full suite of cardiac diagnostic imaging equipment at Stepping Hill Hospital
Wider context from the report “The absence of a full suite of cardiac diagnostic imaging equipment at Stepping Hill Hospital, particularly CT or MR angiograms , contributes to delays in diagnosis for patients and the risk of delays is heightened by having to switch treatment centres. This lack of a range of equipment is inconsistent with providing a full cardiology service to patients .
” 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 Manchester University NHS Foundation Trust is the regional provider responsible for delivering CT coronary angiograms requested for Stockport patients.
Verbatim wording from the response “Stockport NHS Foundation Trust are not commissioned for CT or MR angiograms. In Ryan’s case, the CT Coronary Angiogram (CTCA) scan that was requested following his admission to the Acute Medical unit (AMU) in December 2023 is delivered at Wythenshawe Hospital (part of Manchester University NHS Foundation Trust). Manchester University NHS Foundation Trust (MFT) have always been the regional provider for this. Some other NHS hospitals in the region do have their own CTCA service (for example, Salford Royal Hospital) but do not accept external referrals.” Source location Response from NHSE
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Stepping Hill Hospital is not an outlier because centralisation of specialist cardiac imaging services is longstanding and regionally widespread.
Verbatim wording from the response “Stockport NHS Foundation Trust is not an outlier in terms of being a district general hospital with a cardiology service that does not include a full suite of cardiac diagnostic imaging equipment, particularly CT or MR angiograms. The centralisation of specialist services like this is longstanding and is not unique to Stockport NHS Foundation Trust or the North West region.” Source location Response from NHSE
Open published response
26 Sep 2024 Charne Nikita Petit · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Detention of patients in general hospitals without a section while awaiting a mental health bed View source Lack of mental health hospital beds for assessment, medical review and treatment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Charne Nikita Petit · 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
Charne Nikita Petit suffered psychotic delusions and, after a psychotic breakdown on 26 March 2023, was assessed as meeting the requirements for detention under section 2 of the Mental Health Act. No mental health hospital bed was available, and she was discharged on 31 March without assessment followed by medical treatment in a mental health hospital. She died by suicide on 12 May 2023; the narrative conclusion stated that the lack of a mental health hospital bed more than minimally contributed to her death. Concerns also included the effective detention of patients in general hospitals while awaiting mental health beds.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Detention of patients in general hospitals without a section while awaiting a mental health bed
Wider context from the report “(2) The Court heard that owing to a shortage of mental health beds patients who have been assessed by 2 s12 consultant psychiatrists to require detention after a mental health act assessment are being effectively detained in general hospitals without a section, awaiting a bed , because they cannot be placed under section unless a mental health bed is available.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of mental health hospital beds for assessment, medical review and treatment
Wider context from the report “(1) Evidence given by the court appointed expert consultant psychiatrist was that Ms Petit was not adequately medicalised and that she needed assessment and medical review with optimisation of treatment in a mental health hospital. Her response to treatment needed to be observed. This is what a s2 admission is designed to effect. The lack of a bed in a mental health hospital denied Ms Petit this opportunity for optimal treatment.
” 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 Direct systems to reduce average adult acute mental health ward stays and improve timely access to local beds.
Verbatim wording from the response “In some local areas there is a need for more beds. This is being addressed in part through investment in new units and additionally as part of a whole system approach. This was supported by the NHS Long Term Plan (LTP), which saw an additional £2.3bn funding invested in mental health services from 2019/20 – 2023/24, around £1.3bn 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. NHS England’s 2024/25 priorities and operational planning guidance continues this focus on improving patient flow as a key priority – with systems directed to reduce the average length of stay in adult acute mental health wards and in order to deliver more timely access to local beds.” Source location Response from NHSE
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest in new mental health units and community, crisis, and acute services to improve access and reduce avoidable admissions.
Verbatim wording from the response “In some local areas there is a need for more beds. This is being addressed in part through investment in new units and additionally as part of a whole system approach. This was supported by the NHS Long Term Plan (LTP), which saw an additional £2.3bn funding invested in mental health services from 2019/20 – 2023/24, around £1.3bn 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. NHS England’s 2024/25 priorities and operational planning guidance continues this focus on improving patient flow as a key priority – with systems directed to reduce the average length of stay in adult acute mental health wards and in order to deliver more timely access to local beds.” Source location Response from NHSE
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 recurrent funding to integrated care boards to recommission inpatient care in line with evidence-based therapeutic local models.
Verbatim wording from the response “This is being supplemented by a further £42m recurrent investment from 2024/25 for all ICBs in the country to recommission inpatient care in line with local models that provide the best evidence of therapeutic support” Source location Response from NHSE
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Surrey and Borders Partnership Trust is responsible for responding to concerns about medicalisation, observation, and inpatient mental health provision.
Verbatim wording from the response “It is appropriate that Surrey and Borders Partnership Trust respond to your first concern regarding Charne not being properly medicalised or observed, as well as their inpatient mental health provision. I note that your Report was also addressed to the Trust and NHS England has asked to be sighted on their response to the Coroner. We have also engaged with Surrey Heartlands Integrated Care System, who we are aware are working with and monitoring improvements with the provider.” Source location Response from NHSE
Open published response
20 Sep 2024 Susan Dear · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 4 Unavailability of sufficient emergency ambulances to meet demand View source Public misunderstanding of when to call 999 causing emergency ambulance resources to be wasted View source Chronic understaffing of emergency ambulance response services View source Delays in hospital handover of ambulance patients View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Susan Dear · 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
Susan Dear developed abdominal pain and, after a prolonged wait for an ambulance, was driven to hospital by her family, where she was recognised as deceased shortly after arrival on 4 January 2023. The principal concerns were severe ambulance delays caused by insufficient available resources, chronic staffing and capacity pressures, hospital handover delays, and continuing risk that emergency ambulance demand would outstrip resources.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unavailability of sufficient emergency ambulances to meet demand
Wider context from the report “(1) South Central Ambulance Service (‘SCAS’)’s internal investigation established that there had been no missed opportunity to send an ambulance during the time that Susan was waiting overnight on 3 to 4 January 2023 as none was available ; and
(2) overnight between 3-4 January 2023 patient’s lives were put at risk because SCAS did not have ambulances available to meet the level of demand resulting in severe delay and ambulance response times far outside the national expected standards; and
(3) this was not unprecedented but was reflective of a picture of a chronic situation whereby there was a continuing risk that demand for emergency ambulances would outstrip resources and SCAS were unable to reassure me this was a situation that had been resolved; and
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Public misunderstanding of when to call 999 causing emergency ambulance resources to be wasted
Wider context from the report “(7) resources were being wasted due to ignorance of some of members of the public engaging with the service , and the inquest heard that it was unlikely this would improve substantially without a programme of public education regarding when it is appropriate to call 999, and when it is not .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Chronic understaffing of emergency ambulance response services
Wider context from the report “(5) SCAS’s service was operating at under the number of planned staff for that night , (despite the service taking all reasonable steps to meet requirements) due to chronic understaffing of the service with recruitment and retention issues with paramedic and other emergency response staff that the inquest heard are problems nationally; and
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in hospital handover of ambulance patients
Wider context from the report “(6) handover delays at the Royal Berkshire Hospital and the Wexham Park Hospital were found to be a substantial root cause of the problem (due to ambulance staff being delayed at hospital with patients who could not be admitted to Accident & Emergency as other patients were unable to be admitted to the wards until beds were available) and that this was a problem that required improvement at a national level with changes to the social care system to ease the discharge of patients who required care in the community from the wards back into the community; and
” 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 Improve hospital patient flow and reduce ambulance handover delays through discharge and provider-coordination measures.
Verbatim wording from the response “Work has also focused on the need to increase ambulance capacity through growing the workforce, improving flow through hospitals and reducing handover delays, speeding up discharges from hospital and expanding new services in the community; all of which support improved patient flow. The NHS is also working more closely with local authorities to improve the timely discharge of patients and has developed discharge metrics to monitor performance improvements.” Source location Response from NHSE
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Run national public education campaigns on appropriate use of 999 and alternative NHS services.
Verbatim wording from the response “There are national efforts underway to educate the public on when it is appropriate to call 999. NHS England runs a series of national public education campaigns signposting to the range of different services available. These also include resources around symptoms such as those which indicate a possible stroke or heart attack and require emergency treatment, as well as how and when to use NHS 111, a GP and pharmacist.” Source location Response from NHSE
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use Key Lines of Enquiry to help ambulance and acute providers identify opportunities to reduce handover delays and improve patient flow.
Verbatim wording from the response “Within Emergency Departments, the NHS standard contract states that all handovers of patients between ambulances and A&E must take place within 15 minutes, with none taking more than 30 minutes. The clock begins when an ambulance arrives outside an A&E department and stops when a clinical handover has been fully completed to A&E staff. Key Lines of Enquiry (KLOEs) have previously been developed by NHS England to support ambulance and acute providers to identify key opportunities to reduce ambulance handover delays and improve patient flow, as outlined in the UEC Recovery Plan (2023).” Source location Response from NHSE
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase ambulance capacity through workforce growth and additional vehicles.
Verbatim wording from the response “Work has also focused on the need to increase ambulance capacity through growing the workforce, improving flow through hospitals and reducing handover delays, speeding up discharges from hospital and expanding new services in the community; all of which support improved patient flow. The NHS is also working more closely with local authorities to improve the timely discharge of patients and has developed discharge metrics to monitor performance improvements.” Source location Response from NHSE
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for addressing ongoing handover delays rests with the responsible integrated care boards commissioning the hospital emergency department services.
Verbatim wording from the response “My regional colleagues are also in the process of engaging with Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board (BOB ICB) and Frimley ICB,” Source location Response from NHSE
Open published response
16 Sep 2024 Samuel Finlay Parkin · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 8 Inadequate understanding of malrotation symptoms and diagnostic tests View source Failure to obtain fresh specialist review of gastroenterology re-referrals View source Inadequate safety-netting for apparently benign abdominal conditions View source Lack of formal consideration and dissemination of learning points View source Failure of ultrasound reporting to avoid false reassurance regarding malrotation View source Failure of communication between clinical teams and within referrals View source Inadequate understanding of ultrasound limitations in assessing malrotation View source Reliance on informal rather than formal learning about malrotation View source See 5 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
Samuel Finlay Parkin · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Samuel Finlay Parkin died on 16 September 2022 from hypoxic brain injury following a cardiac arrest caused by midgut volvulus. The volvulus resulted from undiagnosed intestinal malrotation, which had been present since birth and was not identified despite repeated symptoms and hospital attendances. The principal concerns included failure to undertake appropriate diagnostic testing, false reassurance from ultrasound reporting, inadequate safety-netting advice, and communication and learning issues between clinical teams.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequate understanding of malrotation symptoms and diagnostic tests
Wider context from the report “3. Following Sam’s death, St George’s has reduced the “threshold” for requesting of upper GI contrast studies in intermittent abdominal pain and intermittent vomiting. Given the serious nature of the potential risk that malrotation carries (namely of volvulus occurring) I consider action is required across the NHS, following St George’s lead, to ensure that the symptoms of and diagnostic tests for malrotation, particularly in older children is understood . Where the learning in St George’s is informal, I consider action is required to ensure that formal learning takes place within St George’s.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 fresh specialist review of gastroenterology re-referrals
Wider context from the report “5. One of the learning actions taken by St George’s is that re-referrals to gastroenterology are reviewed by another consultant in order that a fresh assessment/second opinion may occur , followed by an MDT discussion and the option of transferring back to the original consultant. St George’s feels this may help increase the detection of atypical/unusual presentation of GI conditions , including a later presentation of malrotation. Action is required so that this learning point is considered across the NHS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequate safety-netting for apparently benign abdominal conditions
Wider context from the report “4. St George’s has implemented a change in ‘safety netting’ advice for those with what is thought to be benign abdominal conditions from Paediatric ED (using QR codes), from wards and outpatient clinic. Advice is given inviting that “benign abdominal diagnosis“ does not exclude conditions requiring urgent surgical/medical review. This action has been taken for the reasons set out above and action should be taken to ensure the wider NHS considers this learning point .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of formal consideration and dissemination of learning points
Wider context from the report “1. St George’s have noted a number of learning outcomes in the course of their M&M process and the Child Death Analysis Form. Whilst I heard evidence of training and informal discussions amongst colleagues both at St George’s and regionally, I consider that action is required to ensure that those learning points are formally considered and disseminated throughout St George’s and more widely in the NHS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of ultrasound reporting to avoid false reassurance regarding malrotation
Wider context from the report “2. In the course of the evidence it became clear that the inclusion of a comment in the ultrasound report that the SMA/SMV axis was normal gave false reassurance regarding malrotation . The consultant paediatric radiologist was clear that she was not looking for malrotation on the USS (as it was not listed as a potential diagnosis on the ultrasound request), that USS cannot be used to exclude malrotation and that noting that the axis is normal was simply a comment on the anatomy seen and was not the radiologist providing information relating to whether or not malrotation was present. It is recorded in the notes of the M&M meeting which took place following Sam’s death and in the evidence that I heard, that although clinicians understood that USS is not the diagnostic test for malrotation and that malrotation will not be seen on an USS in circa 25% of cases, the recording of the axis being normal gave a false reassurance . St George’s has changed their practice of reporting of USS to avoid potential confusion in the future. I consider action is required to ensure proper understanding of the limitations of USS in looking for malrotation, in particular in older children, and to avoid any similar confusion regarding the reporting of USS both in St George’s and across the NHS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of communication between clinical teams and within referrals
Wider context from the report “6. The evidence before me suggested that there may have been a miscommunication or misunderstandings between the surgical, paediatric and paediatric gastroenterology teams regarding what had and had not been considered and excluded by each during Sam’s admission in 2015. In particular, St George’s written answers to Mr and Mrs Parkin’s question regarding whether there was miscommunication between the treating clinicians was simply “yes”. St George’s has therefore implemented an inpatient (written) referral form to the GI service. Action is required by St George’s and the wider NHS to consider/implement ways to minimise the possibility of miscommunication between teams/in referrals of all disciplines.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 understanding of ultrasound limitations in assessing malrotation
Wider context from the report “2. In the course of the evidence it became clear that the inclusion of a comment in the ultrasound report that the SMA/SMV axis was normal gave false reassurance regarding malrotation. The consultant paediatric radiologist was clear that she was not looking for malrotation on the USS (as it was not listed as a potential diagnosis on the ultrasound request), that USS cannot be used to exclude malrotation and that noting that the axis is normal was simply a comment on the anatomy seen and was not the radiologist providing information relating to whether or not malrotation was present. It is recorded in the notes of the M&M meeting which took place following Sam’s death and in the evidence that I heard, that although clinicians understood that USS is not the diagnostic test for malrotation and that malrotation will not be seen on an USS in circa 25% of cases, the recording of the axis being normal gave a false reassurance. St George’s has changed their practice of reporting of USS to avoid potential confusion in the future. I consider action is required to ensure proper understanding of the limitations of USS in looking for malrotation, in particular in older children , and to avoid any similar confusion regarding the reporting of USS both in St George’s and across the NHS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Reliance on informal rather than formal learning about malrotation
Wider context from the report “3. Following Sam’s death, St George’s has reduced the “threshold” for requesting of upper GI contrast studies in intermittent abdominal pain and intermittent vomiting. Given the serious nature of the potential risk that malrotation carries (namely of volvulus occurring) I consider action is required across the NHS, following St George’s lead, to ensure that the symptoms of and diagnostic tests for malrotation, particularly in older children is understood. Where the learning in St George’s is informal, I consider action is required to ensure that formal learning takes place within St George’s.
” 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 Update the national paediatric gastroenterology service specification to reference second-opinion guidance and strengthen multidisciplinary communication and discussion of unexpected investigation results.
Verbatim wording from the response “NHS England Specialised Commissioning will soon begin work to update the published national service specification on Paediatric Gastroenterology, Hepatology and Nutrition which outlines standards for specialised paediatric gastroenterology services. The updated service specification will reference the guidance produced on the provision of second opinions and will also ensure that the importance of communication between multi-disciplinary teams, including surgical, paediatric and paediatric gastroenterology teams, is highlighted. This will include the need for multi-disciplinary discussion for all patients where the results of investigations are not as anticipated.” 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 Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning across the NHS nationally and regionally.
Verbatim wording from the response “I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Samuel, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local aspects of Samuel’s care fall outside the national policy and programmes addressed within NHS England’s remit.
Verbatim wording from the response “Your Report raised concerns over the understanding of limitations in using ultrasound to diagnose or rule out malrotation, and the threshold for additional diagnostic tests, particularly in older children. You also raised that there may have been miscommunication between the surgical, paediatric and paediatric gastroenterology teams. My response to the Coroner focuses only on the relevant national policy or programmes that sit within NHS England’s remit. NHS England’s National Specialty Adviser for Gastroenterology, Hepatology and Nutrition has been consulted on your Report and has contributed to this response.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust should respond to concerns about its local management of Samuel’s care and provide further information.
Verbatim wording from the response “Many of the concerns raised in your Report are local to St George’s University Hospitals NHS Foundation Trust and their management of Samuel’s care, and it is appropriate that they respond to the Coroner on the matters raised. NHS England has been sighted on and has considered the Trust’s response. We note and welcome that the Trust have taken a number of learnings and actions from Samuel’s care, to include rewriting their local guidance on the management of abdominal pain in children, holding monthly Paediatric Gastroenterology Radiology meetings, and ensuring regular training around the limitations of ultrasound scans in looking for malrotation. We note that they are also leading on a dedicated malrotation session at the British Society of Paediatric Radiology. We refer the Coroner to the Trust for further information.” Source location Response from NHS England
Open published response
3 Sep 2024 Samsam Haji Ali Ateye · Prevention of Future Deaths report West London
View report summary
Concerns raised 1 Failure of the Covid-19 testing policy before valve replacement surgery 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
Samsam Haji Ali Ateye · 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
Samsam Haji Ali Ateye died at Harefield Hospital on 12 May 2023 after developing sepsis and multi-organ failure following aortic valve replacement surgery. She had tested positive for Covid-19 on the morning of surgery, with subsequent hospital tests also positive. The substantive concern was the policy for Covid-19 testing before cardiac, specifically valve replacement, surgery.
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 Covid-19 testing policy before valve replacement surgery
Wider context from the report “The policy for testing for Covid-19 before cardiac surgery, specifically valve replacement surgery..
” 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 advice on COVID-19 testing for elective-care pre-admission patients, including risk-based decisions with clinical teams.
Verbatim wording from the response “NHS England published advice on COVID-19 testing for elective care pre-admission patients in early 2022. This can be found here: NHS England » COVID-19 standard operating procedure: testing for elective care pre-admission patient” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual NHS Trusts are responsible for implementing COVID-19 risk-management and consent processes and providing their current pre-operative testing position.
Verbatim wording from the response “The document advises that a risk-based approach should be taken between patients and clinical teams in all cases, including where test results are positive. Individual NHS Trusts are responsible for implementing and following processes to manage COVID-19 risks and appropriately consent patients.” Source location Response from NHS England
Open published response
Concerns raised 1 Variability in on-call Neonatology Consultant attendance times View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Felix Burton HARTLEY · 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
Felix Burton Hartley was born without a heartbeat on 19 February 2023, was resuscitated after around 20 minutes without a heartbeat, and later could not recover from hypoxia and chorioamnionitis. The concern was that variable attendance times for the on-call Neonatology Consultant, covering two geographically separated hospitals, could create a risk of future deaths, although the report did not find the consultant’s attendance time causative or contributory to Felix’s death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Variability in on-call Neonatology Consultant attendance times
Wider context from the report “In this case, I heard that over the weekend and overnight Neonatology Consultants are not available immediately on site at either the Princess Royal Hospital, Haywards Heath or the Royal Sussex County Hospital in Brighton . I heard that on-call Consultants over the weekend are on site at Brighton for some of the period but for the majority they are contactable by telephone in the first instance only . I heard that the Trust position is that this is not unusual in many settings as Consultants are not intended to be the first responders to emergency calls.
At University Hospitals Sussex NHS Foundation Trust (“the Trust”), the on-call Consultant covers both the Princess Royal Hospital and the Royal Sussex County Hospital . These two sites are not close in proximity, and I heard that the traffic impacts on the time it would take for a Consultant to attend . The on-call Consultant does not always have access to an emergency vehicle and if called to attend either site would use their own vehicle and be subject to the usual road traffic laws . I heard that the Trust practice, as opposed to Policy, is that the on-call Consultant cannot be more than 30 minutes from either Brighton or Haywards Heath. The Trust facilitates accommodation at Brighton for the on-call Consultant so that they are within 30 minutes of Brighton if required.
I was told that the arrangements for Neonatal care at the Princess Royal are in accordance with the British Association of Perinatal Medicine guidelines and that there is no national guidance as to the time that an on-call Neonatology Consultant should be expected to attend a hospital in the event of an emergency or as to whether multiple sites can be covered by one on-call Consultant. Whilst I did not find the timing of the attendance of the on-call Consultant causative or contributory in relation to Felix’s death, I am concerned that the time period in which attendance is made may vary and create a risk of future deaths .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS Trusts determine their own out-of-hours neonatal consultant response-time policies under consultants’ terms and conditions.
Verbatim wording from the response “NHS Trusts exercise their own policies for out of hours, on call response times. This is linked to the Terms and Conditions for all NHS Consultants. My colleagues in the South East have been asked to engage with University Hospitals Sussex NHS Foundation Trust and Sussex Health and Care Integrated Care Board on the concerns raised in your Report for assurance purposes. NHS England will also consider the Trust’s responses to your Report carefully in due course.” Source location Response from NHS England
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations