29 Aug 2024 Kasey Beech · Prevention of Future Deaths report Inner South London
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Concerns raised 2 Streaming patients without current chest pain to a MedOCC or equivalent service despite risk of sudden deterioration View source Failure to assess potentially life-threatening non-cardiac causes alongside cardiac causes of pain View source
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AI-generated summary
Kasey Beech · 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
Kasey Beech attended Medway Maritime Hospital with difficulty breathing and chest pain, was directed to a service with a reported three-hour wait, and later suffered a cardiac arrest after her breathing suddenly worsened. She died at St Thomas’ Hospital on 13 October 2021 following treatment. The report raises concerns that the STREAMing model’s focus on current cardiac-sounding chest pain may delay consideration of other immediately life-threatening causes of deterioration, including infective exacerbation of asthma.
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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 Streaming patients without current chest pain to a MedOCC or equivalent service despite risk of sudden deterioration
Wider context from the report “The focus of the current STREAMing guidance regarding the assessment of new non-injury ambulatory patients able to speak in complete sentences without becoming out of breath is on chest pain. The assessment relates to current chest pain and diagnostic investigations are in turn centred on whether there is a cardiac cause. Such patients who do not present with current chest pain are sent to the MedOCC.
However:
(i) pain can fluctuate over time and may not always be concurrent with the initial assessment;
(ii) pain may be masked by analgesia taken prior to assessment; and
(iii) the focus on a cardiac cause itself risks diverting a clinician from the wider question of identifying the cause of the pain. The consideration of differentials that may be immediately life-threatening, or place the patient at risk of a sudden deterioration (e.g. infective exacerbation of asthma) may be delayed, or not given adequate attention as a consequence.
While it is understood that a cardiac issue is high risk and requires prompt diagnosis, and that the exclusion of a cardiac cause causing current chest pain is also diagnostically helpful, I am concerned that the prioritisation of current cardiac-sounding chest-pain and the streaming to a MedOCC/equivalent service may be to the detriment of other patients who are nonetheless at risk of sudden deterioration and therefore creates a risk of future deaths (in both cardiac and non-cardiac patients).
It is understood that the current national guidelines are under review.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 potentially life-threatening non-cardiac causes alongside cardiac causes of pain
Wider context from the report “The focus of the current STREAMing guidance regarding the assessment of new non-injury ambulatory patients able to speak in complete sentences without becoming out of breath is on chest pain. The assessment relates to current chest pain and diagnostic investigations are in turn centred on whether there is a cardiac cause. Such patients who do not present with current chest pain are sent to the MedOCC.
However:
(i) pain can fluctuate over time and may not always be concurrent with the initial assessment;
(ii) pain may be masked by analgesia taken prior to assessment; and
(iii) the focus on a cardiac cause itself risks diverting a clinician from the wider question of identifying the cause of the pain. The consideration of differentials that may be immediately life-threatening, or place the patient at risk of a sudden deterioration (e.g. infective exacerbation of asthma) may be delayed, or not given adequate attention as a consequence.
While it is understood that a cardiac issue is high risk and requires prompt diagnosis, and that the exclusion of a cardiac cause causing current chest pain is also diagnostically helpful, I am concerned that the prioritisation of current cardiac-sounding chest-pain and the streaming to a MedOCC/equivalent service may be to the detriment of other patients who are nonetheless at risk of sudden deterioration and therefore creates a risk of future deaths (in both cardiac and non-cardiac patients).
It is understood that the current national guidelines are under review.
” 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 Introduce the new initial assessment model at sites across England.
Verbatim wording from the response “NHS England is currently developing a new initial assessment model in collaboration with the Royal College of Emergency Medicine (RCEM), the RCN, the FEN, the Emergency Nurse Consultant Group, and lay (patient) representation. This new model has been successfully introduced in more than 20 sites across England and is specifically focused on improving patient safety. This new model has been successful in bringing down the time to initial assessment to below 15 minutes in sites where it has been implemented.” Source location Response from NHS England
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How this respondent action was interpreted
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PFD Monitor interpretation Develop a new initial assessment model collaboratively with emergency care, nursing and patient representatives to improve patient safety.
Verbatim wording from the response “NHS England is currently developing a new initial assessment model in collaboration with the Royal College of Emergency Medicine (RCEM), the RCN, the FEN, the Emergency Nurse Consultant Group, and lay (patient) representation. This new model has been successfully introduced in more than 20 sites across England and is specifically focused on improving patient safety. This new model has been successful in bringing down the time to initial assessment to below 15 minutes in sites where it has been implemented.” Source location Response from NHS England
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How this respondent position was interpreted
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PFD Monitor interpretation Modifying the STREAMing pathway would probably not have predicted the rapid deterioration or altered the initial assessment outcome.
Verbatim wording from the response “In this case, Kasey deteriorated rapidly after leaving the MedOCC. It does not appear that modification of the STREAMing pathway would have been likely to have predicted that or altered the outcome of the initial assessment.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The STREAMing pathway does not unduly prioritise cardiac-sounding chest pain, and directing this patient to MedOCC was appropriate after low-risk assessment.
Verbatim wording from the response “Following their review, I am advised by the National Clinical Director that the STREAMing pathway in use by Medway Maritime Hospital does not have an undue prioritisation of chest pain (particularly cardiac-sounding chest pain). As indicated above, the general condition of the patient, any signs of breathlessness, their ability to talk in sentences and their ability to walk unaided are all assessed. In this tragic case, the initial assessments all pointed towards a low-risk situation for which direction to the MedOCC was appropriate. A low risk initial assessment does not completely rule out the possibility of future deterioration but usually indicates the lack of a need for immediate treatment.” Source location Response from NHS England
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Concerns raised 5 Allergy plans failing to distinguish lip swelling as a potential anaphylaxis symptom View source Insufficient education of parents and patients on safe AAI use when in doubt View source Failure to recognise inability to swallow as a sign of anaphylaxis in dental settings View source Lack of sufficiently clear distinction between anaphylactic and mild reactions View source Unavailability of AAI stock in chemists for emergencies View source See 2 more concerns
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AI-generated summary
Hannah Enola Ayamo Jacobs · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Hannah Enola Ayamo Jacobs, aged 13, developed anaphylactic symptoms after being served a dairy hot chocolate despite her reported dairy allergy and later died following cardiac arrest. The concerns included dental staff not recognising excessive salivation as inability to swallow and a sign of anaphylaxis, possible misunderstanding of symptoms by her mother, and the availability and use of adrenaline auto-injectors during shortages.
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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 Allergy plans failing to distinguish lip swelling as a potential anaphylaxis symptom
Wider context from the report “• The other symptom Hannah demonstrated was swelling of her lips which is listed on allergy plans as a mild to moderate symptom and thus provided a false sense of reassurance to her mother that cetirizine was what she needed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 education of parents and patients on safe AAI use when in doubt
Wider context from the report “• The risk of future deaths in the context of anaphylaxis remains in the absence of further consideration of what constitutes an anaphylactic reaction as opposed to a mild reaction, and the education of parents and patients of the safety of using AAIs (adrenaline auto injectors) IF IN DOUBT .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise inability to swallow as a sign of anaphylaxis in dental settings
Wider context from the report “• The evidence at the inquest referred to allergy action plans discussed in the healthcare settings and given to parents and patients. Hannah displayed what appeared to be excessive salivation at the dentist which her paediatric consultant (who gave evidence) said, with the benefit of hindsight was actually a manifestation of her inability to swallow. This is a sign of anaphylaxis This was not recognised by dental staff as an inability to swallow and thus of anaphylaxis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 sufficiently clear distinction between anaphylactic and mild reactions
Wider context from the report “• The risk of future deaths in the context of anaphylaxis remains in the absence of further consideration of what constitutes an anaphylactic reaction as opposed to a mild reaction , and the education of parents and patients of the safety of using AAIs (adrenaline auto injectors) IF IN DOUBT.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 AAI stock in chemists for emergencies
Wider context from the report “• I was made aware there had been a shortage of AAI at the time but a vial of adrenaline was available at the chemist. However, it takes time to draw up. I am not sure if (assuming no national shortage) all chemists have AAI in stock for emergencies .
” 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 Provide national colleagues with updates on the regional review of adrenaline auto-injector use and supply.
Verbatim wording from the response “The Pharmacy and Medicines Optimisation Team have been reviewing the use of AAIs and their supply. The detail of this work is still being finalised but my regional colleagues in London have been asked to ensure the national team are provided with updates on this work.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the use and supply of adrenaline auto-injectors.
Verbatim wording from the response “The Pharmacy and Medicines Optimisation Team have been reviewing the use of AAIs and their supply. The detail of this work is still being finalised but my regional colleagues in London have been asked to ensure the national team are provided with updates on this work.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Excess salivation is not listed as anaphylaxis in national guidance, so dental staff reasonably did not interpret it as early anaphylaxis.
Verbatim wording from the response “1. The evidence at the inquest referred to allergy action plans discussed in the healthcare settings and given to parents and patients. Hannah displayed what appeared to be excessive salivation at the dentist which her paediatric consultant (who gave evidence) said, with the benefit of hindsight was a manifestation of her inability to swallow. This is a sign of anaphylaxis. This was not recognised by dental staff as an inability to swallow and thus of anaphylaxis.” Source location Response from NHS England
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13 Aug 2024 Margaret HUNTLEY · Prevention of Future Deaths report Teesside and Hartlepool
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Concerns raised 7 Insufficient awareness of Steroid Emergency Cards View source Insufficient usage of Steroid Emergency Cards View source Lack of Ambulance Service staff understanding of steroid medication importance and required actions View source Failure of GPs to routinely request Ambulance Service health-condition alerts View source Lack of triage guidance for responding when patients report prescribed steroid medication View source Inadequate GP awareness of the ability to request Ambulance Service health-condition alerts View source Lack of triage guidance for establishing detailed steroid prescription information View source See 4 more concerns
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AI-generated summary
Margaret HUNTLEY · 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
Margaret Huntley died on 10 December 2022 after deteriorating with multi-organ failure associated with dehydration, lack of exogenous steroids and Covid-19 infection. The report identifies delays in recognising her need for steroid medication and in prescribing and administering it. Concerns included ambulance staff understanding and triage guidance regarding steroid medication, use of Steroid Emergency Cards, and GP awareness of ambulance-service patient alerts.
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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 Insufficient awareness of Steroid Emergency Cards
Wider context from the report “3. It is unclear as to whether Margaret Huntley had been issued with a Steroid Emergency Card and/or information around use of such a Card. I am concerned that there needs to be improved usage, and awareness, of Steroid Emergency Cards .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 usage of Steroid Emergency Cards
Wider context from the report “3. It is unclear as to whether Margaret Huntley had been issued with a Steroid Emergency Card and/or information around use of such a Card. I am concerned that there needs to be improved usage , and awareness, of Steroid Emergency Cards .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 Service staff understanding of steroid medication importance and required actions
Wider context from the report “1. There is a lack of understanding amongst (non-clinical and clinical) Ambulance Service staff as to the importance of steroid medication and the steps to be taken should a patient (a) report that they are prescribed steroid medication and/or (b) present with symptoms potentially consistent with steroid insufficiency/Addison’s Crisis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 GPs to routinely request Ambulance Service health-condition alerts
Wider context from the report “4. It was confirmed in evidence that it is possible for GPs to request that an alert is placed on to the Ambulance Service’s system(s) to alert Ambulance Service staff to specific patient health conditions, such as steroid insufficiency. I am concerned that (a) there is inadequate awareness of this ability amongst GP’s; (b) this action is not routinely being taken by GPs .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of triage guidance for responding when patients report prescribed steroid medication
Wider context from the report “2. There is not, within the NHS Pathways system or otherwise, guidance or processes for Ambulance Service staff triaging calls, including non-clinically qualified staff, to follow regarding (a) the importance of steroid medication and the need to establish, if a patient raises during a call that they are prescribed steroid medication, detailed information regarding that prescription to include the type of prescription and the reasons for it; (b) actions to be taken or processes to follow should a patient raise during a call that they are prescribed steroid medication .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequate GP awareness of the ability to request Ambulance Service health-condition alerts
Wider context from the report “4. It was confirmed in evidence that it is possible for GPs to request that an alert is placed on to the Ambulance Service’s system(s) to alert Ambulance Service staff to specific patient health conditions, such as steroid insufficiency. I am concerned that (a) there is inadequate awareness of this ability amongst GP’s ; (b) this action is not routinely being taken by GPs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of triage guidance for establishing detailed steroid prescription information
Wider context from the report “2. There is not, within the NHS Pathways system or otherwise, guidance or processes for Ambulance Service staff triaging calls, including non-clinically qualified staff, to follow regarding (a) the importance of steroid medication and the need to establish, if a patient raises during a call that they are prescribed steroid medication, detailed information regarding that prescription to include the type of prescription and the reasons for it ; (b) actions to be taken or processes to follow should a patient raise during a call that they are prescribed steroid medication.
” 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 Issue a National Patient Safety Alert introducing the Steroid Emergency Card to support early recognition and treatment of adult adrenal crisis.
Verbatim wording from the response “We note that your concerns are not limited to adrenal insufficiency, but that you have also raised a concern over the awareness and usage of Steroid Emergency Cards. NHS England issued a National Patient Safety Alert in August 2020 regarding the introduction of a new Steroid Emergency Card to support early recognition and treatment of adrenal crisis in adults. The Alert is available here: https://www.england.nhs.uk/publication/national-patient-safety-alert-steroid-emergency-card-to-support-early-recognition-and-treatment-of-adrenal-crisis-in-adults/.” 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 Have the National Primary Care Team consider whether action is required to improve GP awareness of alerting ambulance staff to steroid insufficiency.
Verbatim wording from the response “My colleagues from NHS England’s National Primary Care Team have been asked to consider this concern and whether any actions are required. I also note that you have sent your Report to the Royal College of General Practitioners, and we would welcome their input and advice on this issue.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review NHS Pathways content and classify callers declaring a Steroid Emergency Card as complex calls requiring clinical input.
Verbatim wording from the response “The Alert prompted a review of the content in the NHS Pathways system when a patient notifies the call taker that they have a steroid card. It was agreed that, should the patient declare that they have been issued with a steroid card, this would meet the criteria for a “complex call” which would require clinical input.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Association of Ambulance Chief Executives is the appropriate organisation to provide further information on ambulance-service concerns.
Verbatim wording from the response “I note that you have also sent your Report to the AACE, who would be the appropriate organisation to provide further information on this.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The North East and North Cumbria Integrated Care Board will respond directly to the Coroner regarding the concerns raised.
Verbatim wording from the response “My regional North West colleagues have also engaged with North East and North Cumbria Integrated Care Board (hereafter “ICB”) on the concerns raised in your Report, who we understand will be responding to the Coroner directly.” Source location Response from NHS England
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PFD Monitor interpretation The Care Quality Commission is responsible for ensuring NHS providers implement the actions required by the National Patient Safety Alert.
Verbatim wording from the response “It is the responsibility of the Care Quality Commission (CQC) to ensure that the actions within an alert have been actioned by NHS provider organisations. However, it is NHS England’s understanding that all Trusts are now compliant with this particular Alert.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation All Trusts are understood to comply with the National Patient Safety Alert on steroid emergency cards.
Verbatim wording from the response “It is the responsibility of the Care Quality Commission (CQC) to ensure that the actions within an alert have been actioned by NHS provider organisations. However, it is NHS England’s understanding that all Trusts are now compliant with this particular Alert.” Source location Response from NHS England
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Concerns raised 12 Failure to provide formal written LDS mental health assessments to police View source Lack of a documented LDS mental health plan for custody View source Unavailability of appropriate LDS-police liaison templates View source Lack of local or national procedures for obtaining mental health assessments during intoxication View source Difficulty obtaining collateral mental health information from other services View source Failure of LDS and police information sharing about custody mental health presentation View source Unavailability of a 24-hour LDS service in custody View source Lack of formal police documentation of family concerns about mental health deterioration View source Lack of formal written handovers of mental health presentation between police officers View source Lack of guidelines for undertaking formal mental health assessments in intoxicated individuals View source Lack of formal documentation procedures for LDS and police custody care View source Lack of police decision-making guidelines for further mental health assessment or Appropriate Adult support View source See 9 more concerns
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AI-generated summary
Miles Ethan Hurley · 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
Miles Ethan Hurley died at 5.58am on 10 July 2022 after intentionally driving his father’s car towards an HGV lorry while experiencing a psychotic episode. The report identified concerns about inadequate communication and documentation between police officers, the Liaison Diversion Service and mental health services, including the handling of family information and mental health assessments while he was intoxicated. It also identified gaps in guidance, availability and procedures for mental health assessment, appropriate adult support and ongoing care in custody.
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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 provide formal written LDS mental health assessments to police
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 documented LDS mental health plan for custody
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody .
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 appropriate LDS-police liaison templates
Wider context from the report “4. Memorandum of Understanding between Midlands Partnership University NHS Foundation Trust, Sussex Police and Mitie
The MOU does not adequately address the practical issues facing an LDS and the police services to ensure appropriate management of mental health assessment and ongoing care whilst an individual is in Custody. There is an absence of local or national ‘Standard Operating Procedures’ or guidelines as to when to obtain a mental health assessment if an individual is intoxicated, a lack of formal documentation procedures, or steps to be taken to encourage further sharing of available information between the LDS service and the police (the LDS practitioner was not fully informed of Miles’s presentation at arrest, was not informed of the concerns raised by the family regarding Miles’s acute deterioration in his mental health and had no access to police records to be better informed). Nor are there any appropriate templates available with regard to liaison between LDS and the police to ensure consistency and accuracy of available evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of local or national procedures for obtaining mental health assessments during intoxication
Wider context from the report “4. Memorandum of Understanding between Midlands Partnership University NHS Foundation Trust, Sussex Police and Mitie
The MOU does not adequately address the practical issues facing an LDS and the police services to ensure appropriate management of mental health assessment and ongoing care whilst an individual is in Custody. There is an absence of local or national ‘Standard Operating Procedures’ or guidelines as to when to obtain a mental health assessment if an individual is intoxicated , a lack of formal documentation procedures, or steps to be taken to encourage further sharing of available information between the LDS service and the police (the LDS practitioner was not fully informed of Miles’s presentation at arrest, was not informed of the concerns raised by the family regarding Miles’s acute deterioration in his mental health and had no access to police records to be better informed). Nor are there any appropriate templates available with regard to liaison between LDS and the police to ensure consistency and accuracy of available evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Difficulty obtaining collateral mental health information from other services
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 LDS and police information sharing about custody mental health presentation
Wider context from the report “4. Memorandum of Understanding between Midlands Partnership University NHS Foundation Trust, Sussex Police and Mitie
The MOU does not adequately address the practical issues facing an LDS and the police services to ensure appropriate management of mental health assessment and ongoing care whilst an individual is in Custody. There is an absence of local or national ‘Standard Operating Procedures’ or guidelines as to when to obtain a mental health assessment if an individual is intoxicated, a lack of formal documentation procedures, or steps to be taken to encourage further sharing of available information between the LDS service and the police (the LDS practitioner was not fully informed of Miles’s presentation at arrest , was not informed of the concerns raised by the family regarding Miles’s acute deterioration in his mental health and had no access to police records to be better informed ). Nor are there any appropriate templates available with regard to liaison between LDS and the police to ensure consistency and accuracy of available evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 a 24-hour LDS service in custody
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 police documentation of family concerns about mental health deterioration
Wider context from the report “2. Lack of relevant Documentation by the Police
Throughout Mr Hurley’s time in custody on the 9th July 2022, his parents spoke to multiple police officers and allied staff on the phone and on attending the custody suite to inform them of their concerns over their son’s sudden deterioration in his mental health on a background of longstanding extreme social anxiety. Whilst this was generally known by the officers within the custody suite, there was no formal documentation, either individually or collectively of these concerns to inform and assist police officers in their decision making .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of formal written handovers of mental health presentation between police officers
Wider context from the report “1. Lack of effective Communication between police officers
The absence of a formal written handover between police officers regarding how an individual is presenting to be able to more accurately assess and appropriately direct assessment and care, particularly for first time offenders such as Miles who was not known to the police. Prior to and at the time of his arrest he was recognised by members of the public and the arresting police officers as showing significant signs of disturbance in his mental health with incongruent speech, inappropriate behavioural affect, and delusional beliefs such as thinking he was playing ‘Grand Theft Auto’ whilst driving recklessly, on a background of intoxication. The extent and the severity of his mental health difficulties was not adequately conveyed through standard ‘word of mouth’ communication between police officers , complicated by Mr Hurley appearing to be more contained and less obviously mentally unwell in custody.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidelines for undertaking formal mental health assessments in intoxicated individuals
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 documentation procedures for LDS and police custody care
Wider context from the report “4. Memorandum of Understanding between Midlands Partnership University NHS Foundation Trust, Sussex Police and Mitie
The MOU does not adequately address the practical issues facing an LDS and the police services to ensure appropriate management of mental health assessment and ongoing care whilst an individual is in Custody. There is an absence of local or national ‘Standard Operating Procedures’ or guidelines as to when to obtain a mental health assessment if an individual is intoxicated, a lack of formal documentation procedures , or steps to be taken to encourage further sharing of available information between the LDS service and the police (the LDS practitioner was not fully informed of Miles’s presentation at arrest, was not informed of the concerns raised by the family regarding Miles’s acute deterioration in his mental health and had no access to police records to be better informed). Nor are there any appropriate templates available with regard to liaison between LDS and the police to ensure consistency and accuracy of available evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 police decision-making guidelines for further mental health assessment or Appropriate Adult support
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” 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 a standard template and guidance with NPCC and CPS for transferring relevant Liaison and Diversion assessment information to police.
Verbatim wording from the response “‘NHS England to provide clear guidance to practitioners on what information should be uploaded to police custody logs to ensure consistency and relevance for decision-makers (e.g. custody welfare, bail, police and court outcomes). To be achieved in collaboration with the CPS and local police services.’” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing 24-hour Police Custody Healthcare services address mental health crises in custody, so Liaison and Diversion services are not required to operate 24 hours.
Verbatim wording from the response “5. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing Faculty of Forensic and Legal Medicine guidelines address mental health assessments of intoxicated detainees with substance use disorders.
Verbatim wording from the response “3. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained.” 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 Police Custody Healthcare services are responsible for developing and delivering mental health care plans for detainees in crisis.
Verbatim wording from the response “This is also covered in my response to points 4 and 5 below. The responsibility for the care of those in mental health crisis, requiring the development and delivery of a ‘care plan,’ rests with the Police Custody Healthcare (PCHC) service, who will be able to respond more fully to this point.” 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 Police Custody Healthcare services are responsible for conducting formal mental health assessments when detainees are perceived to be in crisis.
Verbatim wording from the response “NHS England does not publish clinical guidelines specific to the delivery of L&D services. My response to point 3 above provides further detail regarding clinical guidelines.” 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 Sussex Partnership Trust’s Mental Health Helpline is best placed to respond about family information not being shared with the commissioned Liaison and Diversion service.
Verbatim wording from the response “7. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services.” 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 Police Custody Healthcare services are responsible for advising police about intoxication, mental health crisis and related assessment decisions.
Verbatim wording from the response “6. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult.” 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 Police Custody Healthcare services are responsible for intoxication issues, fitness advice and pre-release assessments, rather than NHS England’s Liaison and Diversion service.
Verbatim wording from the response “Responsibility for responding to issues of intoxication and for providing advice to the police on an individual’s fitness to detain, fitness for interview and for conducting pre-release assessments lies with the PCHC service.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England does not publish clinical guidelines specific to Liaison and Diversion service delivery.
Verbatim wording from the response “4. A lack of guidelines to support an LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability.” Source location Response from NHS England
Open published response
7 Aug 2024 Martyn Harvey Stringer · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 1 Insufficient availability of suitable placements for people requiring compulsory treatment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Martyn Harvey Stringer · 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
Martyn Harvey Stringer was detained by police after being found at a location where he had ostensibly gone to take his own life, and was assessed as liable for detention under Section 2 of the Mental Health Act. No suitable mental health placement was found, and he later left home and stepped in front of a lorry; he died on 29 March 2023 from multi-organ failure and polytrauma resulting from a road traffic collision. The principal concern was the lack of suitable beds and placements for people requiring compulsory mental health treatment, including the decision not to offer an available Health Based Place of Safety bed to Martyn.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of suitable placements for people requiring compulsory treatment
Wider context from the report “As you will note from the Conclusion, an application for compulsory detention for Martyn could not be completed due to the unavailability of beds despite extensive searches nationally .
My findings were that: ‘It is the case that a Health Based Place of Safety bed did become available but a decision was taken that due to anticipated demand for potential patients not to offer this to Martyn.’
And also that: ‘in my view highly likely that Martyn would have benefited from a further admission to hospital – as he had previously – and he would have been prevented from further relapse and ultimately taking the actions he did on the morning of the 27 March.’
I heard evidence from experience mental health professionals that the lack of beds for those requiring detention under the Mental Health Act was a frequent occurrence .
In my view, you should consider a review of sufficiency of provision for suitable placements for those requiring compulsory 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 Establish a South East Quality Transformation Programme for urgent and emergency care flow, improving mental health crisis and acute pathway access, quality and capacity.
Verbatim wording from the response “NHS England’s South East region have also established a Quality Transformation Programme relating to Urgent and Emergency Care and Flow. The aim of this programme is to improve access and quality of the mental health crisis and acute adult pathway, including improving patient flow and capacity. The region is engaged with the national Quality Transformation Programme designed to help systems transform their current service offer. The national programme is built upon the cornerstones of good mental healthcare, continuity of care, therapeutic relationships and a relentless commitment to mental health care, meeting the needs of all people.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest £2.3 billion in mental health services, including adult community, crisis and acute services, through the NHS Long Term Plan.
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, however, this should be considered as part of a transformational approach. This is supported by the NHS Long Term Plan (LTP), which has seen an additional £2.3 billion funding invested in mental health services from 2019/20 to 2023/24, around £1.3 billion of which is for adult community, crisis and acute mental health services to help people get quicker access to the care they need, and to 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
×
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 increase local bed capacity.
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, however, this should be considered as part of a transformational approach. This is supported by the NHS Long Term Plan (LTP), which has seen an additional £2.3 billion funding invested in mental health services from 2019/20 to 2023/24, around £1.3 billion of which is for adult community, crisis and acute mental health services to help people get quicker access to the care they need, and to 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
×
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 £42 million recurrent investment to enable Integrated Care Boards to recommission inpatient care in line with local 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
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make £1.6 billion available through the Better Care Fund to support mental health inpatient services and wider system capacity.
Verbatim wording from the response “To address the wider system issues that impact on health services, a further £1.6 billion has been made available via the Better Care Fund from 2023-2025. This funding can be used to support mental health inpatient services as well as the wider system,” Source location Response from NHS England
Open published response
Concerns raised 6 Lack of clinical staff knowledge of the Acute Abdominal Pain Pathway View source Lack of a clearly documented and recorded process for patient self-discharge View source Failure to maintain a signed record of patient self-discharge View source Failure of the hospital SI process to include information from family and other interested persons View source Failure to record vomiting before hospital discharge View source Failure of the Acute Abdominal Pain Pathway documentation to provide sufficient clarity View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Megan Ceris Williams · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Megan Ceris Williams developed abdominal pain and repeated vomiting between 1 and 5 May 2022, attended hospital twice, and died at home on 5 May 2022 after becoming breathless and losing consciousness. The inquest identified an undiagnosed small bowel obstruction apparently caused by adhesions from previous abdominal surgery. Concerns included possible missed opportunities for investigation, limited staff knowledge and clarity of the Acute Abdominal Pain Pathway, the lack of a signed self-discharge record, and the hospital investigation process not including information from family members.
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 clinical staff knowledge of the Acute Abdominal Pain Pathway
Wider context from the report “Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.
It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction.
The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022.
The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene.
The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged.
The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning.
The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family.
(a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP) .
(b) Given what was said about how clear the AAPP was, that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians.
(c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise.
(d) There was not a clearly documented and recorded process for patients who self-discharge from 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 Lack of a clearly documented and recorded process for patient self-discharge
Wider context from the report “Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.
It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction.
The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022.
The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene.
The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged.
The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning.
The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family.
(a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP).
(b) Given what was said about how clear the AAPP was, that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians.
(c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise.
(d) There was not a clearly documented and recorded process for patients who self-discharge from 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 maintain a signed record of patient self-discharge
Wider context from the report “Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.
It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction.
The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022.
The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene.
The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged.
The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning.
The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family.
(a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP).
(b) Given what was said about how clear the AAPP was, that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians.
(c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise.
(d) There was not a clearly documented and recorded process for patients who self-discharge from 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 of the hospital SI process to include information from family and other interested persons
Wider context from the report “Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.
It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction.
The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022.
The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene.
The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged.
The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning.
The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family .
(a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP).
(b) Given what was said about how clear the AAPP was, that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians.
(c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise .
(d) There was not a clearly documented and recorded process for patients who self-discharge from 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 record vomiting before hospital discharge
Wider context from the report “Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.
It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction.
The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022.
The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene.
The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged.
The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning.
The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family.
(a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP).
(b) Given what was said about how clear the AAPP was, that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians.
(c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise.
(d) There was not a clearly documented and recorded process for patients who self-discharge from 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 of the Acute Abdominal Pain Pathway documentation to provide sufficient clarity
Wider context from the report “Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.
It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction.
The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022.
The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene.
The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged.
The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning.
The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family.
(a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP).
(b) Given what was said about how clear the AAPP was , that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians.
(c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise.
(d) There was not a clearly documented and recorded process for patients who self-discharge from hospital.
” 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 East Kent Hospitals University NHS Foundation Trust should respond to and address the concerns.
Verbatim wording from the response “I note that you have also addressed your Report to East Kent Hospitals University NHS Foundation Trust (EKHT), and it is appropriate that they respond to each of the concerns raised by the Coroner, as these concerns do not fall under NHS England’s remit and are all local issues for the Trust to address.” 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 concerns are local Trust issues outside NHS England’s remit.
Verbatim wording from the response “I note that you have also addressed your Report to East Kent Hospitals University NHS Foundation Trust (EKHT), and it is appropriate that they respond to each of the concerns raised by the Coroner, as these concerns do not fall under NHS England’s remit and are all local issues for the Trust to address.” Source location Response from NHS England
Open published response
23 Jul 2024 Nathan Tesla George Scantlebury · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1 Lack of suitable placements for high-risk children with complex mental health needs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nathan Tesla George Scantlebury · 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
Nathan Scantlebury, aged 16, died in hospital shortly after being found unresponsive with a ████████ tight around his neck on 25 September 2019. The principal concerns were the lack of suitable placements for children with complex mental health needs and failures relating to the suitability and management of his placement and care arrangements.
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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 suitable placements for high-risk children with complex mental health needs
Wider context from the report “The lack of availability of suitable placements for high risk children with complex mental health needs which is both a local and a national issue which has been ongoing for a number of years.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue operational planning guidance requiring systems to provide general adolescent and psychiatric intensive care capacity for local populations.
Verbatim wording from the response “• The NHS Operational Planning Guidance 2022/23 outlined the need for Mental Health Provider Collaboratives and Integrated Care Systems (ICSs) to ensure the provision of General Adolescent and Psychiatric Intensive Care Units to meet the needs of their local population.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission and complete a review of the children’s inpatient care model, including international comparisons, family views and pathway pressures.
Verbatim wording from the response “In 2022, NHS England (NHSE) commissioned a new Quality Improvement Programme and one of its priorities was to undertake a review of the CYP’s inpatient model, recognising the continued pathway pressures and quality and safety challenges. The review included how our English model compares internationally, the views of children, young people and their families and requests from local teams to work together to improve the model of care. The findings of the evidence review presented and consolidated a future vision for CYPMH inpatient care, and now forms the cornerstone of the CYPMH Transformation Programme, which has resulted in a review of the service specification and the development of a new clinical model, which considers the needs of a young person across the whole pathway of care.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the service specification and develop a new clinical model covering the whole children’s mental health care pathway.
Verbatim wording from the response “In 2022, NHS England (NHSE) commissioned a new Quality Improvement Programme and one of its priorities was to undertake a review of the CYP’s inpatient model, recognising the continued pathway pressures and quality and safety challenges. The review included how our English model compares internationally, the views of children, young people and their families and requests from local teams to work together to improve the model of care. The findings of the evidence review presented and consolidated a future vision for CYPMH inpatient care, and now forms the cornerstone of the CYPMH Transformation Programme, which has resulted in a review of the service specification and the development of a new clinical model, which considers the needs of a young person across the whole pathway of care.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish Youth Intensive Psychological Practitioner roles in inpatient multidisciplinary teams through a pilot with Exeter University.
Verbatim wording from the response “The CYPMH Clinical Reference Group has developed an inpatient strategy which provides an evidence base to support services when considering their workforce challenges and team composition. A new Youth Intensive Psychological Practitioner pilot (YIPP) is now entering its third year and in partnership with Exeter University has established roles in inpatient Multi-Disciplinary Teams (MDTs) to complement the team. There has been a refresh of the Care (Education) and Treatment Review (CETR) policy, and an escalation policy has been agreed with all NHS-Led Provider Collaboratives and regional teams.” 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 capital and revenue funding in localised inpatient and alternative-to-inpatient provision over three years.
Verbatim wording from the response “NHS England has sought to improve the availability of local inpatient care for CYP through a number of actions:” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with health and education departments to meet children’s mental health needs fairly across community, placement and inpatient settings.
Verbatim wording from the response “Children and young people’s mental health interventions can take place in many contexts and will depend on the clinical needs of the child as to whether interventions are delivered in the community, whilst the child is in a placement, or in an inpatient setting. NHSE are working with the Department for Health and Social Care (DHSC) and Department for Education (DfE) to ensure that the needs of children in different settings are met fairly and equitably.” Source location Response from NHS England
Open published response
17 Jul 2024 David Nicholas ALMOND · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to provide clinicians with access to GP records across differing IT systems and geographical boundaries View source Failure to recognise the need for follow-up medical review after a negative x-ray View source Failure of differing NHS IT systems to support timely access to GP-record information View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Nicholas ALMOND · 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
David Nicholas Almond was diagnosed with thrombophilia and deep vein thrombosis but was not placed on lifelong anticoagulation. After developing breathlessness that was investigated with an X-ray, he collapsed and was found to have a massive pulmonary embolism, dying in hospital on 5 January 2024. The principal concerns were incomplete access to and recognition of relevant GP records, and failure to arrange appropriate follow-up after the negative X-ray.
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 clinicians with access to GP records across differing IT systems and geographical boundaries
Wider context from the report “1. The inquest heard evidence that Macclesfield Hospital was part of East Cheshire NHS Trust and served a wide area a significant part of the area served was outside the footprint of the trust for example the High Peak in Derbyshire. The inquest was told that trust doctors were able to access GP records for patient’s registered with GPs in East Cheshire but not patients registered outside this area . The inquest was told there were discussions about how to try to resolve this but no firm steps or progress on this by the Trust .
As a consequence doctors at the hospital were limited in understanding a patient’s history and crucial information was not always fully recognised/available .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the need for follow-up medical review after a negative x-ray
Wider context from the report “3. The inquest heard evidence that in September 2023 when he went to his GP practice he did not see a doctor. It was not recognised by the practitioner who saw him that there may need to be a follow-up appointment or a recommendation that he return to see a doctor should the x ray be negative given his history and presentation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 differing NHS IT systems to support timely access to GP-record information
Wider context from the report “2. The inquest was told that this inability to access information in GP records was a problem across the NHS due to differing IT systems and caused difficulties in providing effective and timely care to patients .
” 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 the National Care Records Service, including national services that enable authorised staff to access relevant patient information across care settings.
Verbatim wording from the response “The National Care Records Service (NCRS) is the successor to the Summary Care Record application (SCRa) and by design removes a large amount of the reported barriers to adoption within many care settings, including the private sector. The NCRS provides a quick, secure way for health and care workers to access national patient information, to improve clinical decision making and healthcare outcomes. It is free to use and includes additional features and services beyond the legacy SCRa product. It provides access to a number of centrally provisioned national digital services that” 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 East Cheshire NHS Trust is responsible for responding to concerns about its recording, sharing and access arrangements.
Verbatim wording from the response “My response to your concerns focuses on those areas of concern that fall under the remit of national NHS England policy or programme work. Your concerns relating to East Cheshire NHS Trust’s recording sharing and access arrangements, along with your concerns about the care provided at the GP surgery, are more appropriately answered by the two organisations. The Standard General Medical Services (‘GMS’) Contract also sets out the requirements on GP Practices. Practices should provide enough appointments to meet the reasonable need of their patients, and provision of appointments and advice or care should consider their patients’ preferences where appropriate.” 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 GP surgery is responsible for responding to concerns about the care it provided and appointment access arrangements.
Verbatim wording from the response “My response to your concerns focuses on those areas of concern that fall under the remit of national NHS England policy or programme work. Your concerns relating to East Cheshire NHS Trust’s recording sharing and access arrangements, along with your concerns about the care provided at the GP surgery, are more appropriately answered by the two organisations. The Standard General Medical Services (‘GMS’) Contract also sets out the requirements on GP Practices. Practices should provide enough appointments to meet the reasonable need of their patients, and provision of appointments and advice or care should consider their patients’ preferences where appropriate.” 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 Integrated Care Boards are responsible for delivering Shared Care Records.
Verbatim wording from the response “Responsibility for delivering Shared Care Records sits with local Integrated Care Boards (ICBs). Each ICB’s Shared Care Records are developed in response to the health and care needs of the local area, existing systems, and future planning. This means some of their Shared Care Records are available to neighbouring ICBs, while others are only supported within their own ICB. Future plans include making Shared Care Records link together regardless of where you live or receive care in England. Further information on Integrated Care Boards and Systems can be found here: NHS England » What are integrated care systems?” Source location Response from NHS England
Open published response
15 Jul 2024 Josh Andrew Smith · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 2 Failure to achieve target ambulance response standards for Category 1 and Category 2 calls View source Failure to achieve the 15-minute ambulance hospital handover target View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Josh Andrew Smith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Josh Andrew Smith had longstanding medical complications following quadriplegia from a 2009 road traffic incident. He was found unresponsive and not breathing on 19 December 2022, was diagnosed with hypoxic brain injury, bronchopneumonia and influenza A, and died on 22 December 2022 despite treatment. Concerns included continuing ambulance response delays and hospital handover delays, with response standards and the 15-minute handover target not being achieved.
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 achieve target ambulance response standards for Category 1 and Category 2 calls
Wider context from the report “I heard evidenced that whilst the Yorkshire Ambulance Service have taken a number of steps within their powers to try to reduce the delays experienced by patients waiting for an ambulance within the community, that those delays continue .
Specifically, I was told that the response standards for both Category 1 and Category 2 calls (for the year to date) , whilst improved from the time of Mr Smith’s death, still remain outside of the target response standards (both on average and at the 90ᵗʰ centile) .
The evidence heard was that the national target for hospital handover by the ambulance service, of 15 minutes, is still not being achieved. Evidence suggested that whilst there has and continues to be efforts made by the ambulance service and acute hospitals to increase the speed at which ambulances handover their patients, that delays in this process continue to impact upon the speed of the ambulance response to patients waiting within the community.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 achieve the 15-minute ambulance hospital handover target
Wider context from the report “I heard evidenced that whilst the Yorkshire Ambulance Service have taken a number of steps within their powers to try to reduce the delays experienced by patients waiting for an ambulance within the community, that those delays continue.
Specifically, I was told that the response standards for both Category 1 and Category 2 calls (for the year to date), whilst improved from the time of Mr Smith’s death, still remain outside of the target response standards (both on average and at the 90ᵗʰ centile).
The evidence heard was that the national target for hospital handover by the ambulance service, of 15 minutes, is still not being achieved . Evidence suggested that whilst there has and continues to be efforts made by the ambulance service and acute hospitals to increase the speed at which ambulances handover their patients, that delays in this process continue to impact upon the speed of the ambulance response to patients waiting within the community .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Focus national work on increasing ambulance capacity through workforce growth.
Verbatim wording from the response “National work has also focused on the need to increase ambulance capacity through growing the workforce, improve flow through hospitals and reduce handover delays, speed up discharges from hospital and expand 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 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 Speed hospital discharges to support improved patient flow.
Verbatim wording from the response “National work has also focused on the need to increase ambulance capacity through growing the workforce, improve flow through hospitals and reduce handover delays, speed up discharges from hospital and expand 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 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 Improve patient flow through hospitals and reduce ambulance handover delays.
Verbatim wording from the response “National work has also focused on the need to increase ambulance capacity through growing the workforce, improve flow through hospitals and reduce handover delays, speed up discharges from hospital and expand 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 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 West Yorkshire Integrated Care Board is responsible for responding directly on local and system measures addressing patient flow and ambulance handover concerns.
Verbatim wording from the response “My regional colleagues in the North East & Yorkshire have also engaged with colleagues at the West Yorkshire Integrated Care Board (WYICB) in relation to your concerns, who have advised us of several measures underway to improve flow and ambulance delivery. I understand that WYICB are responding directly to the Coroner, and I refer you to their response for further information on local and system steps.” Source location Response from NHS England
Open published response
12 Jul 2024 Judith Maike OBHOLZER · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 6 Lack of clarity in referral and crisis-support processes for patients receiving private and NHS treatment View source Unavailability of GP registration and contact details to medical practitioners View source Failure to share medical notes and information between private practitioners and NHS providers View source Unclear urgent and crisis referral pathways from private practitioners to NHS services View source Failure to assess NHS mental health provision independently of interim private support View source Pressure on NHS mental health services View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Judith Maike OBHOLZER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Obholzer died by suicide on 12 July 2023 after jumping in front of a moving train, following a significant period of worsening depression and anxiety. Concerns included delays in NHS mental-health assessment and waiting-list placement, unclear routes for private practitioners to obtain NHS crisis support, difficulties contacting her GP, and the absence of shared medical notes between private and NHS providers.
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 clarity in referral and crisis-support processes for patients receiving private and NHS treatment
Wider context from the report “1. In the course of the evidence it was confirmed that there is a significant pressure on NHS mental health services. It seems likely that there will be an increase in patients obtaining private support while waiting for NHS support (and often only being able to afford such support for a limited time and to a limited extent and doing so only while waiting for NHS support), as happened in this case. Consideration should be given to ensuring that there is sufficient clarity in processes such as referrals and crisis support where private practitioners are providing treatment as well as the NHS , ensuring sharing of information and notes where relevant and necessary and ensuring that the NHS provision is not assessed as unnecessary simply because someone has obtained private support as an interim measure.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 GP registration and contact details to medical practitioners
Wider context from the report “3. In the course of the evidence it was confirmed that the private consultant psychiatrist was unable to send the urgent letter to Mrs Obholzer’s GP in part because their details had not been provided . Consideration should be given to ensuring that all medical practitioners (private and NHS) can access GP registration details for patients and GP contact details to avoid delays where there is an urgent need to contact a person’s GP.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 medical notes and information between private practitioners and NHS providers
Wider context from the report “4. In the course of the evidence it was confirmed that there is no sharing of medical notes between private practitioners and NHS providers . This (along with other factors) led to delays in a treatment plan being set by Wandsworth SPA as they had to obtain further details regarding Mrs Obholzer’s CBT from Mrs Obholzer rather than being able to access the notes through a shared system . Consideration should be given to ensuring a system is in place to allow the sharing of medical information between practitioners across Trusts and also between NHS and Private providers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unclear urgent and crisis referral pathways from private practitioners to NHS services
Wider context from the report “2. In the course of the evidence the private consultant psychiatrist gave evidence that he was unable to refer patients directly to NHS provided crisis teams as a direct alternative to informal treatment at a private hospital. The evidence from the South West London and St George’s Mental Health Trust was that direct referrals can be made although the evidence on the exact mechanism was unclear . In Mrs Obholzer’s case, the (apparent) lack of ability of the private consultant psychiatrist to directly refer to the crisis team meant that she did not receive the community crisis support alternative to hospital admission that she required. Consideration should be given to ensuring that the pathway for urgent/crisis referrals from private practitioners to the NHS are clear to all (both for this area and throughout the country) and, if it is not already the case, to ensuring a process that allows private practitioners to arrange crisis support through the NHS directly.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 NHS mental health provision independently of interim private support
Wider context from the report “1. In the course of the evidence it was confirmed that there is a significant pressure on NHS mental health services. It seems likely that there will be an increase in patients obtaining private support while waiting for NHS support (and often only being able to afford such support for a limited time and to a limited extent and doing so only while waiting for NHS support), as happened in this case. Consideration should be given to ensuring that there is sufficient clarity in processes such as referrals and crisis support where private practitioners are providing treatment as well as the NHS, ensuring sharing of information and notes where relevant and necessary and ensuring that the NHS provision is not assessed as unnecessary simply because someone has obtained private support as an interim measure .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Pressure on NHS mental health services
Wider context from the report “1. In the course of the evidence it was confirmed that there is a significant pressure on NHS mental health services . It seems likely that there will be an increase in patients obtaining private support while waiting for NHS support (and often only being able to afford such support for a limited time and to a limited extent and doing so only while waiting for NHS support), as happened in this case. Consideration should be given to ensuring that there is sufficient clarity in processes such as referrals and crisis support where private practitioners are providing treatment as well as the NHS, ensuring sharing of information and notes where relevant and necessary and ensuring that the NHS provision is not assessed as unnecessary simply because someone has obtained private support as an interim measure.
” 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 Expand urgent and emergency mental health care and access to crisis services.
Verbatim wording from the response “As part of its Long Term Plan commitments to improve mental health care, NHS England has increased investment in adult and older adult community mental health services by £1 billion per year since 2019/20. Commitments in the plan have also included a significant expansion of urgent and emergency mental health care and access to crisis services.” 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 Review the interface between NHS and non-NHS-funded independent health providers.
Verbatim wording from the response “Work is also in progress to review the interface between the NHS and non-NHS funded independent health providers. This work is in its infancy, but NHS England can provide an update to the Coroner in due course if this would assist. We understand that the Care Quality Commission (CQC) are also undertaking work regarding standards for online care and are exploring opportunities for better sharing of information both into private sector providers and receiving information back to the patient’s registered GP practice from private providers.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase annual investment in adult and older adult community mental health services by £1 billion from 2019/20.
Verbatim wording from the response “As part of its Long Term Plan commitments to improve mental health care, NHS England has increased investment in adult and older adult community mental health services by £1 billion per year since 2019/20. Commitments in the plan have also included a significant expansion of urgent and emergency mental health care and access to crisis services.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with an Expert Advisory Committee to seek approval for independent-sector rollout and consider its scope, exclusions, constraints, and caveats.
Verbatim wording from the response “The SCR Team at NHS England have undertaken significant work with a number of private sector organisations, including a range of private hospitals and privately funded healthcare services trialling the use of SCRs within settings where they have previously been unavailable, and this work continues. The Team will work with an Expert Advisory Committee to seek full rollout approval within the independent/private sector and consider the scope of this approval and any specific exclusions, constraints, or caveats.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue trialling Summary Care Record access with private hospitals and privately funded healthcare services.
Verbatim wording from the response “The SCR Team at NHS England have undertaken significant work with a number of private sector organisations, including a range of private hospitals and privately funded healthcare services trialling the use of SCRs within settings where they have previously been unavailable, and this work continues. The Team will work with an Expert Advisory Committee to seek full rollout approval within the independent/private sector and consider the scope of this approval and any specific exclusions, constraints, or caveats.” 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 relevant NHS mental health trust is responsible for providing further information about its emergency referral signposting for private providers.
Verbatim wording from the response “NHS England has also engaged with South West London and St George’s Mental Health NHS Trust. They have advised us that at the time Judith required NHS crisis support, their website provided clear signposting for private providers needing to make an emergency mental health referral. Since receiving your Report, we also note that they have made this more visually prominent on the website. I will refer you to the Trust for further information, who I understand are issuing their own response to you.” 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 Responsibility for delivering shared care records sits with local Integrated Care Boards.
Verbatim wording from the response “Responsibility for delivering shared care records sits with local Integrated Care Boards (ICBs). Each ICB’s shared care records are developed in response to the health and care needs of the local area, existing systems, and future planning. This means some of their shared care records are available to neighbouring ICBs, while others are only supported within their own ICB. Future plans include making shared care records link together regardless of where you live or receive care in England. Further information on Integrated Care Boards and Systems can be found here: NHS England » What are integrated care systems?” Source location Response from NHS England
Open published response
Concerns raised 1 Failure to ensure availability of appropriate cannulae without supply shortages View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Trevor Walton · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Trevor Walton died on 13 July 2023 after an aortic cannula became dislodged during coronary artery bypass surgery, causing prolonged interruption of blood flow to his brain and an ischaemic hypoxic brain injury. The report raised concerns that supply issues led to the use of a shorter-tip cannula, which contributed to its dislodgement, and that supply shortages may force surgeons to use sub-optimal equipment, creating an avoidable risk of serious harm or death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure availability of appropriate cannulae without supply shortages
Wider context from the report “(1) The surgeon’s preferred choice of cannula was not available for the procedure due to supply issues.
(2) A cannula with a shorter tip was therefore used for the procedure.
(3) The cannula type contributed to its dislodgement from the lumen of the aorta and to Mr Walton’s death.
(4) An arterial catheter is a basic and inexpensive medical device used daily in a hospital setting.
(5) Operating surgeons are best placed to decide on the most appropriate equipment to use and should not be restricted in that choice by supply shortages.
(6) Using sub-optimal medical equipment poses an avoidable risk to patients of significant harm including death.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop defined triggers for NHS Resilience involvement in medical supply disruptions.
Verbatim wording from the response “Nationally, NHS Resilience gets involved in supply disruptions where they receive an escalation. These come in from either NHS Trusts (via NHS England’s Emergency Preparedness, Resilience and Response (EPRR) Teams), the Department of Health and Social Care’s (DHSC’s) National Supply Disruption Response (NSDR) Team or, less frequently, from NHS Supply Chain or NHS England’s Patient Safety Team.” 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 Local organisations, not NHS Supply Chain, must decide whether listed alternative medical products are suitable for use.
Verbatim wording from the response “NHS Supply Chain’s listing of alternative products is limited in scope and does not constitute advice. Decisions on the use of alternative products must be taken at local level.” 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 No national escalation or DHSC referral was identified for the cannula shortage as causing operational or patient-safety risks.
Verbatim wording from the response “Regarding this specific case and the Medtronic cannula product that was unavailable, NHS England does not believe (from a search dating back to 2021) that there was any escalation of a shortage to the national team, nor a referral from DHSC’s NSDR” Source location Response from NHSE
Open published response
2 Jul 2024 James Neil COCKBURN · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Delays in patients waiting to see a cardiologist View source Shortage of suitably qualified professionals to carry out essential cardiac tests View source Failure of separate trust IT systems to transmit test information into the other trust’s patient records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 3
Action
Deliver the Long-Term Workforce Plan, including expanded education, training, recruitment, retention, and strategic workforce planning.
Stated in progressThe respondent said that this action was in progress when they made their response on 4 July 2024. View source
Action
Collaborate across patient-safety and digital-clinical-safety teams to extract learning from EPR incidents and provide scenarios for evaluating systems and processes.
Stated plannedThe respondent said that this action was planned when they made their response on 4 July 2024. View source
Action
Support local services to recover elective care, reduce waiting times, improve diagnostic turnaround, and create additional capacity for complex and urgent care.
Stated plannedThe respondent said that this action was planned when they made their response on 4 July 2024. View source
×
AI-generated summary
James Neil COCKBURN · 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
James Neil Cockburn had severe aortic stenosis and was awaiting assessment for suitability for open heart surgery when he suffered a myocardial infarction and died at home on 26 May 2023. The report identified delays in cardiology appointments and essential tests, together with communication delays between NHS trusts caused by separate IT systems, as substantive concerns affecting treatment planning and decision-making.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in patients waiting to see a cardiologist
Wider context from the report “The inquest heard that despite the referral being in August 2022 he had to wait months for his appointment due to the demand on cardiac services . This was significant across Greater Manchester but reflected a national picture of significant delays in patients waiting to see a cardiologist . As a consequence patient/s with cardiac issues are subject to delays in treatment plans and decision making regarding suitability for potentially lifesaving surgical procedures. In Mr Cockburn’s case he died whilst waiting assessment for his suitability for open heart surgery. It was 9 months since the first referral.
The position the inquest was told is exacerbated due to significant wait times for essential tests such as trans oesophageal echocardiograms to be carried out due to a shortage of suitably quailed professionals to carry them out.
In his case the position was further exacerbated by delays in communication between two different trusts – NCA and MUFT. Their IT systems are completely separate and cannot transmit information into the others patient records easily. This meant that it was almost a month before the system at MUFT was updated with the test results from Salford Royal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Shortage of suitably qualified professionals to carry out essential cardiac tests
Wider context from the report “The inquest heard that despite the referral being in August 2022 he had to wait months for his appointment due to the demand on cardiac services. This was significant across Greater Manchester but reflected a national picture of significant delays in patients waiting to see a cardiologist. As a consequence patient/s with cardiac issues are subject to delays in treatment plans and decision making regarding suitability for potentially lifesaving surgical procedures. In Mr Cockburn’s case he died whilst waiting assessment for his suitability for open heart surgery. It was 9 months since the first referral.
The position the inquest was told is exacerbated due to significant wait times for essential tests such as trans oesophageal echocardiograms to be carried out due to a shortage of suitably quailed professionals to carry them out .
In his case the position was further exacerbated by delays in communication between two different trusts – NCA and MUFT. Their IT systems are completely separate and cannot transmit information into the others patient records easily. This meant that it was almost a month before the system at MUFT was updated with the test results from Salford Royal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 separate trust IT systems to transmit test information into the other trust’s patient records
Wider context from the report “The inquest heard that despite the referral being in August 2022 he had to wait months for his appointment due to the demand on cardiac services. This was significant across Greater Manchester but reflected a national picture of significant delays in patients waiting to see a cardiologist. As a consequence patient/s with cardiac issues are subject to delays in treatment plans and decision making regarding suitability for potentially lifesaving surgical procedures. In Mr Cockburn’s case he died whilst waiting assessment for his suitability for open heart surgery. It was 9 months since the first referral.
The position the inquest was told is exacerbated due to significant wait times for essential tests such as trans oesophageal echocardiograms to be carried out due to a shortage of suitably quailed professionals to carry them out.
In his case the position was further exacerbated by delays in communication between two different trusts – NCA and MUFT . Their IT systems are completely separate and cannot transmit information into the others patient records easily . This meant that it was almost a month before the system at MUFT was updated with the test results from Salford Royal .
” 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 Deliver the Long-Term Workforce Plan, including expanded education, training, recruitment, retention, and strategic workforce planning.
Verbatim wording from the response “NHS England is working at a national level to deliver the Long-Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Collaborate across patient-safety and digital-clinical-safety teams to extract learning from EPR incidents and provide scenarios for evaluating systems and processes.
Verbatim wording from the response “Future plans include collaboration between the NHS England Patient Safety and Digital Clinical Safety Teams to take learning from incidents concerning EPR related patient safety and other relevant digital implementations, and to provide scenarios that Trusts can use to evaluate their systems and processes when preparing for their EPR implementations.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support local services to recover elective care, reduce waiting times, improve diagnostic turnaround, and create additional capacity for complex and urgent care.
Verbatim wording from the response “In February 2022, NHS England published the Delivery plan for tackling the COVID-19 backlog of elective care which sets out that the NHS is working to recover elective care over a three-year period. The plan includes the ambition to bring down waiting times for elective care, as well as improving diagnostic turnaround times and pathways. This includes plans to support local areas to create extra capacity within NHS services to focus on more complex areas, such as cardiac surgery, and improve the service provision for the most clinically urgent patients.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS Trusts, rather than NHS England, are responsible for ensuring safe staffing levels in day-to-day hospital operations.
Verbatim wording from the response “These actions will aim to close anticipated staffing shortfalls in the NHS in the long term, however NHS Trusts have a responsibility to ensure safe staffing levels in the current day to day operation of their hospitals. This is in line with CQC Regulation 18, which states that providers must deploy enough suitably qualified, competent and experienced staff to enable them to meet all other regulatory requirements.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing EPR optimisation programmes at MUFT and NCA are considered sufficient to address concerns about separate clinical information systems.
Verbatim wording from the response “In 2022, MUFT secured funding to support levelling up capabilities following the acquisition of the North Manchester General Hospital site, to ensure the same level of EPR maturity as the other nine hospital sites within MUFT.” Source location Response from NHS England
Open published response
27 Jun 2024 Emily Rose Collishaw · Prevention of Future Deaths report Outer South London
View report summary
Concerns raised 3 Delays in organizations agreeing their roles View source Insufficient support to maintain physical health and promote abstinence View source Delays in accessing residential rehabilitation care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Emily Rose Collishaw · 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
Emily Rose Collishaw, who was aged 35, was found dead in her flat on 6 September 2023 in non-suspicious circumstances. She had alcohol dependency and had been receiving mental health and substance misuse support, but was awaiting an inpatient rehabilitation placement. Concerns included delays and insufficient coordination and support, particularly the prolonged wait for residential rehabilitation and the associated risks to patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in organizations agreeing their roles
Wider context from the report “1. Emily’s mother reported that it took some time for the organizations working with her daughter to agree their roles and that the degree of support was insufficient to maintain her physical health or promote abstinence over such a long period of six months before she died. The family felt that the referral for residential care should have been made earlier, especially as her housing situation was a risk to her health. It was accepted that Emily did not engage consistently but did reduce intake on a number of occasions, only to relapse.
2. The inquest heard from professionals that the period of waiting for a residential rehabilitation placement was about three months, but could be as long as seven months. Evidence was heard from the manager of the Pier Project that the delay in accessing residential care had been progressively getting longer over the last 10 years, which posed risks such as sudden death to patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient support to maintain physical health and promote abstinence
Wider context from the report “1. Emily’s mother reported that it took some time for the organizations working with her daughter to agree their roles and that the degree of support was insufficient to maintain her physical health or promote abstinence over such a long period of six months before she died. The family felt that the referral for residential care should have been made earlier, especially as her housing situation was a risk to her health. It was accepted that Emily did not engage consistently but did reduce intake on a number of occasions, only to relapse.
2. The inquest heard from professionals that the period of waiting for a residential rehabilitation placement was about three months, but could be as long as seven months. Evidence was heard from the manager of the Pier Project that the delay in accessing residential care had been progressively getting longer over the last 10 years, which posed risks such as sudden death to patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in accessing residential rehabilitation care
Wider context from the report “1. Emily’s mother reported that it took some time for the organizations working with her daughter to agree their roles and that the degree of support was insufficient to maintain her physical health or promote abstinence over such a long period of six months before she died. The family felt that the referral for residential care should have been made earlier, especially as her housing situation was a risk to her health. It was accepted that Emily did not engage consistently but did reduce intake on a number of occasions, only to relapse.
2. The inquest heard from professionals that the period of waiting for a residential rehabilitation placement was about three months, but could be as long as seven months . Evidence was heard from the manager of the Pier Project that the delay in accessing residential care had been progressively getting longer over the last 10 years , which posed risks such as sudden death to patients.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for commissioning the Pier Road Project and drug and alcohol rehabilitation services sits with local government.
Verbatim wording from the response “The PRP is commissioned locally by the Local Authority, London Borough of Bexley, as is usual for drug and alcohol rehabilitation services for which responsibility sits with local government, overseen by the Department of Health and Social Care (DHSC). I note that you have also addressed your Report to the DHSC, as well as the Department of Levelling Up, Housing and Communities, and it would be more appropriate for the government to comment on your concerns about wait times for residential rehabilitation placements.” 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 information on Emily’s care coordination should be obtained from South East London Integrated Care Board.
Verbatim wording from the response “NHS England has been engaging with South East London Integrated Care Board (SEL ICB), and we note you have also sent your Report to. We are advised by SEL ICB that Mental Health colleagues have reviewed Emily’s care and consider that there is evidence of coordination between the Home Treatment Team and the Pier Road Project (PRP) interface, to include joint visits and information sharing, as well as consultation with the family. I would refer you to SEL ICB’s full response to your Report for 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 Government should address concerns about waiting times for residential rehabilitation placements.
Verbatim wording from the response “The PRP is commissioned locally by the Local Authority, London Borough of Bexley, as is usual for drug and alcohol rehabilitation services for which responsibility sits with local government, overseen by the Department of Health and Social Care (DHSC). I note that you have also addressed your Report to the DHSC, as well as the Department of Levelling Up, Housing and Communities, and it would be more appropriate for the government to comment on your concerns about wait times for residential rehabilitation placements.” Source location Response from NHS England
Open published response
26 Jun 2024 Michelle Patricia Moore · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 6 Absence of training and learning on hormone levels, HRT, antidepressants and holistic care View source Lack of understanding and appreciation of the link between menopause and mental health decline View source Lack of continuity and joined-up care between menopause and mental health treatment View source Absence of guidance or published policy on joined-up care for women experiencing menopause View source Lack of understanding and appreciation of the menopause and its effects on women View source Absence of guidance or published policy on the link between menopause and mental health decline View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michelle Patricia Moore · 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
Michelle Patricia Moore, who had a longstanding history of anxiety and an acute deterioration in her mental health, was found deceased at home on 31 October 2023. The inquest concluded with a short-form conclusion of suicide, with the medical cause of death recorded as compression of the neck and suspension by a ligature. The principal concerns were a lack of continuity and joined-up care between treatment for menopausal symptoms and mental health care, and an apparent absence of guidance, training and policy concerning links between menopause and mental health decline.
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 Absence of training and learning on hormone levels, HRT, antidepressants and holistic care
Wider context from the report “There appeared to be a lack of continuity and joined-up care between those trying to treat Mrs Moore’s menopausal symptoms and those trying to treat her mental health presentation and this suggested:
(a) A lack of understanding and appreciation of the menopause and the effect this hormonal change and/or imbalance may have on women; and
(b) A lack of understanding and appreciation of a potential link between menopause and a woman experiencing mental health decline.
I referred in questioning to the recognised mental health conditions of Post Natal Depression (PND) and Post Natal Psychosis (PNP) where it appears to be more widely understood and appreciated amongst treating professionals that childbirth and the hormonal imbalance/upheaval can acutely affect a woman’s mental wellbeing and state of mind. However, the same awareness and/or appreciation does not appear to exist when, later in life, a woman may suffer a mental health decline due to acute hormonal changes brought about by the menopause (whether or not this is treated with HRT).
There appears to be a complete absence of national and/or local guidance or published policy (none was brought to my attention on questioning of the clinicians) concerning:
(a) The potential for a link between menopause and mental health decline.
(b) The need for joined-up care between those trying to treat women at this stage of their lives.
(c) Training and learning around hormone levels, HRT and antidepressants and the potential for a holistic approach to inform awareness and understanding.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 understanding and appreciation of the link between menopause and mental health decline
Wider context from the report “There appeared to be a lack of continuity and joined-up care between those trying to treat Mrs Moore’s menopausal symptoms and those trying to treat her mental health presentation and this suggested:
(a) A lack of understanding and appreciation of the menopause and the effect this hormonal change and/or imbalance may have on women; and
(b) A lack of understanding and appreciation of a potential link between menopause and a woman experiencing mental health decline.
I referred in questioning to the recognised mental health conditions of Post Natal Depression (PND) and Post Natal Psychosis (PNP) where it appears to be more widely understood and appreciated amongst treating professionals that childbirth and the hormonal imbalance/upheaval can acutely affect a woman’s mental wellbeing and state of mind. However, the same awareness and/or appreciation does not appear to exist when, later in life, a woman may suffer a mental health decline due to acute hormonal changes brought about by the menopause (whether or not this is treated with HRT).
There appears to be a complete absence of national and/or local guidance or published policy (none was brought to my attention on questioning of the clinicians) concerning:
(a) The potential for a link between menopause and mental health decline.
(b) The need for joined-up care between those trying to treat women at this stage of their lives.
(c) Training and learning around hormone levels, HRT and antidepressants and the potential for a holistic approach to inform awareness and understanding.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 continuity and joined-up care between menopause and mental health treatment
Wider context from the report “There appeared to be a lack of continuity and joined-up care between those trying to treat Mrs Moore’s menopausal symptoms and those trying to treat her mental health presentation and this suggested:
(a) A lack of understanding and appreciation of the menopause and the effect this hormonal change and/or imbalance may have on women; and
(b) A lack of understanding and appreciation of a potential link between menopause and a woman experiencing mental health decline.
I referred in questioning to the recognised mental health conditions of Post Natal Depression (PND) and Post Natal Psychosis (PNP) where it appears to be more widely understood and appreciated amongst treating professionals that childbirth and the hormonal imbalance/upheaval can acutely affect a woman’s mental wellbeing and state of mind. However, the same awareness and/or appreciation does not appear to exist when, later in life, a woman may suffer a mental health decline due to acute hormonal changes brought about by the menopause (whether or not this is treated with HRT).
There appears to be a complete absence of national and/or local guidance or published policy (none was brought to my attention on questioning of the clinicians) concerning:
(a) The potential for a link between menopause and mental health decline.
(b) The need for joined-up care between those trying to treat women at this stage of their lives.
(c) Training and learning around hormone levels, HRT and antidepressants and the potential for a holistic approach to inform awareness and understanding.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Absence of guidance or published policy on joined-up care for women experiencing menopause
Wider context from the report “There appeared to be a lack of continuity and joined-up care between those trying to treat Mrs Moore’s menopausal symptoms and those trying to treat her mental health presentation and this suggested:
(a) A lack of understanding and appreciation of the menopause and the effect this hormonal change and/or imbalance may have on women; and
(b) A lack of understanding and appreciation of a potential link between menopause and a woman experiencing mental health decline.
I referred in questioning to the recognised mental health conditions of Post Natal Depression (PND) and Post Natal Psychosis (PNP) where it appears to be more widely understood and appreciated amongst treating professionals that childbirth and the hormonal imbalance/upheaval can acutely affect a woman’s mental wellbeing and state of mind. However, the same awareness and/or appreciation does not appear to exist when, later in life, a woman may suffer a mental health decline due to acute hormonal changes brought about by the menopause (whether or not this is treated with HRT).
There appears to be a complete absence of national and/or local guidance or published policy (none was brought to my attention on questioning of the clinicians) concerning:
(a) The potential for a link between menopause and mental health decline.
(b) The need for joined-up care between those trying to treat women at this stage of their lives.
(c) Training and learning around hormone levels, HRT and antidepressants and the potential for a holistic approach to inform awareness and understanding.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 understanding and appreciation of the menopause and its effects on women
Wider context from the report “There appeared to be a lack of continuity and joined-up care between those trying to treat Mrs Moore’s menopausal symptoms and those trying to treat her mental health presentation and this suggested:
(a) A lack of understanding and appreciation of the menopause and the effect this hormonal change and/or imbalance may have on women ; and
(b) A lack of understanding and appreciation of a potential link between menopause and a woman experiencing mental health decline.
I referred in questioning to the recognised mental health conditions of Post Natal Depression (PND) and Post Natal Psychosis (PNP) where it appears to be more widely understood and appreciated amongst treating professionals that childbirth and the hormonal imbalance/upheaval can acutely affect a woman’s mental wellbeing and state of mind. However, the same awareness and/or appreciation does not appear to exist when, later in life, a woman may suffer a mental health decline due to acute hormonal changes brought about by the menopause (whether or not this is treated with HRT).
There appears to be a complete absence of national and/or local guidance or published policy (none was brought to my attention on questioning of the clinicians) concerning:
(a) The potential for a link between menopause and mental health decline.
(b) The need for joined-up care between those trying to treat women at this stage of their lives.
(c) Training and learning around hormone levels, HRT and antidepressants and the potential for a holistic approach to inform awareness and understanding.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Absence of guidance or published policy on the link between menopause and mental health decline
Wider context from the report “There appeared to be a lack of continuity and joined-up care between those trying to treat Mrs Moore’s menopausal symptoms and those trying to treat her mental health presentation and this suggested:
(a) A lack of understanding and appreciation of the menopause and the effect this hormonal change and/or imbalance may have on women; and
(b) A lack of understanding and appreciation of a potential link between menopause and a woman experiencing mental health decline.
I referred in questioning to the recognised mental health conditions of Post Natal Depression (PND) and Post Natal Psychosis (PNP) where it appears to be more widely understood and appreciated amongst treating professionals that childbirth and the hormonal imbalance/upheaval can acutely affect a woman’s mental wellbeing and state of mind. However, the same awareness and/or appreciation does not appear to exist when, later in life, a woman may suffer a mental health decline due to acute hormonal changes brought about by the menopause (whether or not this is treated with HRT).
There appears to be a complete absence of national and/or local guidance or published policy (none was brought to my attention on questioning of the clinicians) concerning:
(a) The potential for a link between menopause and mental health decline.
(b) The need for joined-up care between those trying to treat women at this stage of their lives.
(c) Training and learning around hormone levels, HRT and antidepressants and the potential for a holistic approach to inform awareness and understanding.
” 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 a toolkit enabling local areas to provide menopause information, events and group consultations for healthcare-professional learning.
Verbatim wording from the response “Women’s health hubs are in the process of being rolled out, which will offer specialist menopause care to more women when they need it. A toolkit that supports local areas to provide menopause information, events and group consultations is also under development to improve access to provide a forum for learning for other healthcare professionals.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support development of tools and interventions to upskill GPs in menopause care and improve access to treatments.
Verbatim wording from the response “NHS England is currently supporting the development of a range of tools and interventions that will help to upskill more GPs in providing menopause care, and to improve access to treatments that can be helpful. GPs are well placed to take a holistic approach to mental health assessment, including menopause as one of the potential causes of mental distress or a decline in mental health.” 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 Women are not universally or uniformly at risk of psychological symptoms during the menopause transition.
Verbatim wording from the response “It is acknowledged that mental health problems can decline in women of menopausal age. There are often biological, social and psychological reasons why women may experience mental health problems at this stage in their lives. Changes in hormones during the menopause can cause existing mental health problems to worsen or can cause women to experience symptoms afresh. This means that women often need some help with their mental health as well as their physical health during the menopause. However, women are not universally or uniformly at risk of psychological symptoms over the menopause transition.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NICE is best placed to provide further information about national guidance on menopause and mental health decline.
Verbatim wording from the response “Your Report also raised concerns about a lack of national guidance regarding the issues of menopause and mental health decline. I am aware that your Report has also been sent to the National Institute for Health and Care Excellence (NICE) and the Somerset NHS Foundation Trust. I have not yet had sight of their responses, but I would like to refer you to the NICE guidance on menopause diagnosis and management [NICE guideline NG23], which was published on 12 November 2015. This guideline recommends it is explained to women that they may experience a variety of symptoms associated with menopause, including low mood or anxiety, and sets out some of the available treatments, including HRT and cognitive behavioural therapy. NICE will be best placed to provide you with further information around national guidance.” Source location Response from NHS England
Open published response
19 Jun 2024 Aaron James DEELEY · Prevention of Future Deaths report Essex
View report summary
Concerns raised 5 Confusing and incomplete policy for placing patients awaiting Mental Health Act assessment under 1:1 observation View source Lack of a joint protocol for working between the two Trusts on Mental Health Act assessment referrals View source Lack of Responsible Clinician allocation for vulnerable patients held pending Mental Health Act assessment View source Lack of specialist mental health training among acute care healthcare professionals for mental health assessment View source Failure of Mental Health Liaison to attend acute wards and assess presenting self-harm risks during the assessment waiting period View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Aaron James DEELEY · 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
Aaron James Deeley died after deliberately exiting a defective second-floor hospital window on 14 January 2022, sustaining multiple traumatic injuries. The report identified concerns about safeguarding and the removal of 1:1 observation, as well as gaps and confusion in arrangements for patients awaiting a Mental Health Act assessment while receiving physical healthcare.
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 Confusing and incomplete policy for placing patients awaiting Mental Health Act assessment under 1:1 observation
Wider context from the report “While a patient is admitted to an acute Trust ward for treatment for physical health treatment and is being held under section 5 (2) Mental Health Act for a Mental Health Act assessment due to concerns the patient presents a risk to themselves or others with a mental disorder, it permits the patient to be held for a maximum period of 72 hours.
a. Patients admitted into the Accident & Emergency department detained under various sections of the Mental Health Act have a Responsible Clinician allocated. Patients who are not under section have access to the Mental Health Liaison Team.
b. Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental health Act.
c. During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm.
d. The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm.
e. There was confusion at the acute Trust as to what regime was required to ensure that a patient awaiting Mental Health Act assessment could be put under 1:1 observation. The Trust policy was confusing and did not cover patients like Aaron Deeley.
f. There is no joint protocol to cover the working between the two Trusts on this issue as the referral for Mental Health Act assessment goes outside of both organisations.
There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a joint protocol for working between the two Trusts on Mental Health Act assessment referrals
Wider context from the report “While a patient is admitted to an acute Trust ward for treatment for physical health treatment and is being held under section 5 (2) Mental Health Act for a Mental Health Act assessment due to concerns the patient presents a risk to themselves or others with a mental disorder, it permits the patient to be held for a maximum period of 72 hours.
a. Patients admitted into the Accident & Emergency department detained under various sections of the Mental Health Act have a Responsible Clinician allocated. Patients who are not under section have access to the Mental Health Liaison Team.
b. Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental health Act.
c. During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm.
d. The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm.
e. There was confusion at the acute Trust as to what regime was required to ensure that a patient awaiting Mental Health Act assessment could be put under 1:1 observation. The Trust policy was confusing and did not cover patients like Aaron Deeley.
f. There is no joint protocol to cover the working between the two Trusts on this issue as the referral for Mental Health Act assessment goes outside of both organisations.
There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of Responsible Clinician allocation for vulnerable patients held pending Mental Health Act assessment
Wider context from the report “While a patient is admitted to an acute Trust ward for treatment for physical health treatment and is being held under section 5 (2) Mental Health Act for a Mental Health Act assessment due to concerns the patient presents a risk to themselves or others with a mental disorder, it permits the patient to be held for a maximum period of 72 hours.
a. Patients admitted into the Accident & Emergency department detained under various sections of the Mental Health Act have a Responsible Clinician allocated. Patients who are not under section have access to the Mental Health Liaison Team.
b. Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental health Act .
c. During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm.
d. The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm.
e. There was confusion at the acute Trust as to what regime was required to ensure that a patient awaiting Mental Health Act assessment could be put under 1:1 observation. The Trust policy was confusing and did not cover patients like Aaron Deeley.
f. There is no joint protocol to cover the working between the two Trusts on this issue as the referral for Mental Health Act assessment goes outside of both organisations.
There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of specialist mental health training among acute care healthcare professionals for mental health assessment
Wider context from the report “While a patient is admitted to an acute Trust ward for treatment for physical health treatment and is being held under section 5 (2) Mental Health Act for a Mental Health Act assessment due to concerns the patient presents a risk to themselves or others with a mental disorder, it permits the patient to be held for a maximum period of 72 hours.
a. Patients admitted into the Accident & Emergency department detained under various sections of the Mental Health Act have a Responsible Clinician allocated. Patients who are not under section have access to the Mental Health Liaison Team.
b. Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental health Act.
c. During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm.
d. The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm.
e. There was confusion at the acute Trust as to what regime was required to ensure that a patient awaiting Mental Health Act assessment could be put under 1:1 observation. The Trust policy was confusing and did not cover patients like Aaron Deeley.
f. There is no joint protocol to cover the working between the two Trusts on this issue as the referral for Mental Health Act assessment goes outside of both organisations.
There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of Mental Health Liaison to attend acute wards and assess presenting self-harm risks during the assessment waiting period
Wider context from the report “While a patient is admitted to an acute Trust ward for treatment for physical health treatment and is being held under section 5 (2) Mental Health Act for a Mental Health Act assessment due to concerns the patient presents a risk to themselves or others with a mental disorder, it permits the patient to be held for a maximum period of 72 hours.
a. Patients admitted into the Accident & Emergency department detained under various sections of the Mental Health Act have a Responsible Clinician allocated. Patients who are not under section have access to the Mental Health Liaison Team.
b. Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental health Act.
c. During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm.
d. The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm.
e. There was confusion at the acute Trust as to what regime was required to ensure that a patient awaiting Mental Health Act assessment could be put under 1:1 observation. The Trust policy was confusing and did not cover patients like Aaron Deeley.
f. There is no joint protocol to cover the working between the two Trusts on this issue as the referral for Mental Health Act assessment goes outside of both organisations.
There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety.
” Open source report
19 Jun 2024 Chloe HUNT · Prevention of Future Deaths report Essex
View report summary
Concerns raised 10 Failure to document low oxygen saturation and oxygen prescription View source Failure to recognise deteriorating clinical condition View source Delay in recording the first heart rhythm during resuscitation View source Failure to assess the need for anaesthesia when planning repeated foreign-body removal procedures View source Lack of urgency in treating the patient View source Failure to consider the complexities of foreign-body removal when selecting endoscopic or surgical treatment View source Failure to investigate the underlying cause of persistent tachycardia and low blood pressure View source Failure to recognise changing oxygen requirements and heart rate as signs of deterioration View source Failure to factor complex trauma and difficulty being in hospital into treatment planning View source Failure to consider the whole clinical picture alongside NEWS Scores View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Chloe HUNT · 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
Chloe Hunt died in hospital on 15 March 2022 after swallowing pens that caused gastrointestinal obstruction and a fatal cardiac arrhythmia secondary to metabolic derangement. The concerns included insufficient consideration of her trauma-related difficulties in hospital, delays and inadequate planning for removal of the pens, and failure to recognise and respond to her deteriorating clinical condition.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to document low oxygen saturation and oxygen prescription
Wider context from the report “f. Chloe’s low oxygen saturation level and the prescription of Oxygen was not documented on 14 March .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise deteriorating clinical condition
Wider context from the report “c. There was a lack of urgency in treating Chloe and lack of recognition of her deteriorating clinical 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 Delay in recording the first heart rhythm during resuscitation
Wider context from the report “g. From the timing of the recognition of Chloe’s in-hospital cardiac arrest there was approximately 10 minutes before the first heart rhythm was recorded during the resuscitation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 the need for anaesthesia when planning repeated foreign-body removal procedures
Wider context from the report “b. The requirement for reintubation after each pen removal and the difficulty for a patient to tolerate multiple procedures without anaesthetic was not considered for Chloe on referral for removal , or whether this might need to be converted to a procedure under anaesthetic .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 urgency in treating the patient
Wider context from the report “c. There was a lack of urgency in treating Chloe and lack of recognition of her deteriorating clinical 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 consider the complexities of foreign-body removal when selecting endoscopic or surgical treatment
Wider context from the report “a. Imaging established Chloe had swallowed 3 full-sized pens, 2 free in her stomach and 1 was impacted in her duodenum. There was a lack of consideration of the complexities of removal to guide whether the removal should be endoscopic or surgical. Endoscopy could not be converted into a procedure under anaesthetic in the interventional radiology suite.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate the underlying cause of persistent tachycardia and low blood pressure
Wider context from the report “d. Chloe was tachycardic throughout her admission with low blood pressure and there was no investigation of the underlying cause in a young otherwise physically healthy woman. NEWS Scores should not replace consideration of the whole clinical picture for a patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise changing oxygen requirements and heart rate as signs of deterioration
Wider context from the report “e. In the hours before Chloe’s death, she required oxygen for the first-time that was administered for approximately 75 minutes and Chloe’s heart rate reduced to normal for several hours for the first time in her admission. This reduction was not sustained, and her heart rated elevated later. These changes were not recognised as signs Chloe was a deteriorating patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 factor complex trauma and difficulty being in hospital into treatment planning
Wider context from the report “a. Chloe explained on 11 March 2022 in Accident & Emergency to the doctor her background of complex trauma and how difficult she found it to be in hospital. This was not factored into a plan for 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 consider the whole clinical picture alongside NEWS Scores
Wider context from the report “d. Chloe was tachycardic throughout her admission with low blood pressure and there was no investigation of the underlying cause in a young otherwise physically healthy woman. NEWS Scores should not replace consideration of the whole clinical picture for a patient.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Concerns about care at Colchester General Hospital fall outside NHS England’s remit.
Verbatim wording from the response “Your Report raises concerns with the care provided to Chloe whilst she was a patient at Colchester General Hospital. It is appropriate that East Suffolk & North Essex NHS Foundation Trust respond to your concerns, which do not fall under NHS England’s remit.” 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 East Suffolk & North Essex NHS Foundation Trust is responsible for responding to concerns about care at Colchester General Hospital.
Verbatim wording from the response “Your Report raises concerns with the care provided to Chloe whilst she was a patient at Colchester General Hospital. It is appropriate that East Suffolk & North Essex NHS Foundation Trust respond to your concerns, which do not fall under NHS England’s remit.” Source location Response from NHS England
Open published response
Concerns raised 1 Failure of the medication-ending alert system to draw attention to prescription review when no prescribing clinician accesses the patient’s record View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
William Richard STOCKIL · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
William Richard Stockil was admitted to hospital after being found on the floor at home following a long lie, with rhabdomyolysis and dehydration. An electronic prescription error and ineffective alerts resulted in his antibiotics stopping before further antibiotics were prescribed when signs of infection developed; he died from pneumonia. The report identified a risk that medications may cease when they should be continued if no prescribing clinician accesses the patient’s 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 Failure of the medication-ending alert system to draw attention to prescription review when no prescribing clinician accesses the patient’s record
Wider context from the report “The system has been changed since the death of Mr Stockil in that alerts of medication ending are now only sent to clinicians who have the right to prescribe in order that alerts are seen by the correct staff. It is no longer the case that the alerts can be sent to any clinicians who do not have the ability to address prescriptions.
The current version of the system generates alerts when anyone with a prescribing right accesses the patient’s records.
This means that an alert will only be shown to a prescriber and only if they access the patient’s records. Therefore, it was accepted that there was a risk that the alerting system would not operate to draw attention to the need for prescription review before the medication ceases if no prescribing clinician accesses a patient’s record .
This creates a risk that medications will cease when they should be continued and creates a risk of future deaths.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage Oracle Corporation UK Limited on the electronic prescribing alerting concerns raised in the Report.
Verbatim wording from the response “NHS England will be engaging with Oracle Corporation UK Limited on the issues raised. I note that you have also addressed your Report to Oracle Corporation UK Limited, and we have been sighted on their response to you dated 27 June 2024. We note that they state they have not found any defect or fault with their software, and that they are open to exploring with RSFT whether any configuration changes, alterations to working practices and additional training may assist to further mitigate any clinical risks. Any identified learnings could be facilitated through their dedicated User Groups and/or general guidance could also be provided on how to best design” 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 Consider incorporating a test script addressing the prescribing alerting issue into future ePRaSE iterations.
Verbatim wording from the response “The NHS Digital Medicines Programme commissions a system called the e-Prescribing Risk and Safety Evaluation (ePRaSE), which is a tool that supports NHS Trusts in configuring their Electronic Prescribing and Medicines Administration (ePMA) systems, to mitigate prescribing risks and improve safety. There could be scope to incorporate a test script to explore this issue in future iterations of ePRaSE, and this will be considered by the team.” Source location Response from NHS England
Open published response
Concerns raised 8 National scarcity of specialist personality-disorder rehabilitation beds View source Variation in admission criteria and exclusions across specialist personality-disorder rehabilitation units View source Underfunding of local mental health beds View source Over-reliance by the NHS on independent mental health-bed providers View source Delays in transferring patients from out-of-area independent-provider hospitals View source Funding allocation failing to secure available specialist rehabilitation beds for identified patients View source Home teams’ inability to commission or make funding decisions for specialist personality-disorder placements View source Delays in funding approval for specialist rehabilitation beds View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Amina Ahmed Ismail · 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
Amina Ahmed Ismail, aged 19, died on 15 September 2023 at Pankhurst Ward, Priory Hospital Cheadle, after self-ligaturing; the medical cause of death was ligature strangulation. The report describes her prolonged stay in a PICU, deterioration in her mental health, shortages of appropriate specialist care beds, and delays in arranging and funding a suitable placement as concerns contributing to the circumstances of her 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 National scarcity of specialist personality-disorder rehabilitation beds
Wider context from the report “This is now the third inquest (two within the past 8 months) I have heard where the delayed transfer of an out-of-area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Two of those cases involving prolonged stays on PICU units; in this case some 13 months and in the other, some 11 months.
These cases illustrate,
a) Underfunding for local mental health beds.
It took some 6 weeks in 2022 to transfer Amina from the PD specialist placement at Nield House (where the treating team felt that they could not keep Amina safe) to a PICU some 90 miles from home.
Further, there were no local PICU beds available for transfer out of The Priory, Cheadle in May/June/July 2023 when a PD placement could not be found.
b) An over-reliance by the NHS on independent providers for mental health beds whether general acute beds, PICU beds or specialist units.
c) A national scarcity of specialist PD rehabilitation units
The inquest heard evidence from two treating psychiatrists in Amina’s history (Nield House and The Priory), FTB PACT assessor, and the court appointed independent expert that there was, and is, a national shortage of specialist PD rehabilitation units/beds , paraphrasing,
‘rehabilitation beds for female patients with PD are limited – demand exceeding what is available nationally ’.
‘shortage of rehabilitation placements nationally – impeding on young persons’ mental health treatments’
‘simply not enough beds (NHS or Independent) to cater for such complex patients as Amina – transfers not being accepted by such units even if not full because the acuity of their existing patients’.
‘PD rehabilitation beds are scarce – spread nationally often in isolated units far from home, family and the local/home team. Each having its own admission criteria/exclusions, such as the possible need for NGT feeding’.
Following the PACT assessment FTB, in early 2023, were only able to find two PD units that had a bed available. One of them, Eleanor House, was re-opening its doors having voluntarily closed at the end of 2022. It had 14 beds available. However, its extant CQC rating was overall inadequate and it was in the process of appealing a Notice of Decision. The other, Cygnet Alders, declined the referral.
Three other units were identified as possibilities but each declined a referral, without any assessment, based on the acuity of their own patients.
Just 5 beds available over a period 6-7months, before Fern Unit accepted Amina.
In the meantime Amina remained in a PICU, some 90 miles from home which was wholly unsuited to her presentation and unable (through no fault of its own) to deliver the care and therapy that she needed resulting in a deterioration in her mental state with increasing risks/incidents of self-harm.
d) A funding process for rehabilitation units that is not fit for purpose.
The inquest heard evidence about the funding set-up for secondary mental health care in the Birmingham area, which is replicated nationally.
The ICB commissioned FTB to provide secondary mental health services, both community and in-patient. FTB are able to commission NHS and independent sector acute beds and PICU’s, both in and out of area. However, FTB are not able to commission specialist placement, including PD units. These are commissioned/funded directly by the ICB upon application by the FTB; having found a unit that would accept a patient.
This system, for funding specialist/rehabilitation beds, is inadequate; particularly in light of the shortage of such specialist/rehabilitation beds. The inquest heard evidence that the process from application to funding approval takes weeks, sometimes months. In this case it took from 13.03.23 to 04.05.23 for a negative outcome.
The shortage of beds/units means that when a bed becomes available there are a number of patients in competition for it. The beds are not kept open for any particular patient and, in essence, allocation becomes a race on funding.
It is surprising that a ‘home team’ (in this case FTB) commissioned by an ICB to provide secondary mental health services is not permitted to make its own funding decisions for specialist units, as it can for acute wards and PICU’s. As can be seen from the evidence Amina was able to be transferred within 24hrs once a PICU accepted her on 01.08.23, albeit it took a wholly unsatisfactory 6 weeks to find a PICU bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Variation in admission criteria and exclusions across specialist personality-disorder rehabilitation units
Wider context from the report “This is now the third inquest (two within the past 8 months) I have heard where the delayed transfer of an out-of-area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Two of those cases involving prolonged stays on PICU units; in this case some 13 months and in the other, some 11 months.
These cases illustrate,
a) Underfunding for local mental health beds.
It took some 6 weeks in 2022 to transfer Amina from the PD specialist placement at Nield House (where the treating team felt that they could not keep Amina safe) to a PICU some 90 miles from home.
Further, there were no local PICU beds available for transfer out of The Priory, Cheadle in May/June/July 2023 when a PD placement could not be found.
b) An over-reliance by the NHS on independent providers for mental health beds whether general acute beds, PICU beds or specialist units.
c) A national scarcity of specialist PD rehabilitation units
The inquest heard evidence from two treating psychiatrists in Amina’s history (Nield House and The Priory), FTB PACT assessor, and the court appointed independent expert that there was, and is, a national shortage of specialist PD rehabilitation units/beds, paraphrasing,
‘rehabilitation beds for female patients with PD are limited – demand exceeding what is available nationally’.
‘shortage of rehabilitation placements nationally – impeding on young persons’ mental health treatments’
‘simply not enough beds (NHS or Independent) to cater for such complex patients as Amina – transfers not being accepted by such units even if not full because the acuity of their existing patients’.
‘PD rehabilitation beds are scarce – spread nationally often in isolated units far from home, family and the local/home team. Each having its own admission criteria/exclusions, such as the possible need for NGT feeding ’.
Following the PACT assessment FTB, in early 2023, were only able to find two PD units that had a bed available. One of them, Eleanor House, was re-opening its doors having voluntarily closed at the end of 2022. It had 14 beds available. However, its extant CQC rating was overall inadequate and it was in the process of appealing a Notice of Decision. The other, Cygnet Alders, declined the referral.
Three other units were identified as possibilities but each declined a referral, without any assessment, based on the acuity of their own patients.
Just 5 beds available over a period 6-7months, before Fern Unit accepted Amina.
In the meantime Amina remained in a PICU, some 90 miles from home which was wholly unsuited to her presentation and unable (through no fault of its own) to deliver the care and therapy that she needed resulting in a deterioration in her mental state with increasing risks/incidents of self-harm.
d) A funding process for rehabilitation units that is not fit for purpose.
The inquest heard evidence about the funding set-up for secondary mental health care in the Birmingham area, which is replicated nationally.
The ICB commissioned FTB to provide secondary mental health services, both community and in-patient. FTB are able to commission NHS and independent sector acute beds and PICU’s, both in and out of area. However, FTB are not able to commission specialist placement, including PD units. These are commissioned/funded directly by the ICB upon application by the FTB; having found a unit that would accept a patient.
This system, for funding specialist/rehabilitation beds, is inadequate; particularly in light of the shortage of such specialist/rehabilitation beds. The inquest heard evidence that the process from application to funding approval takes weeks, sometimes months. In this case it took from 13.03.23 to 04.05.23 for a negative outcome.
The shortage of beds/units means that when a bed becomes available there are a number of patients in competition for it. The beds are not kept open for any particular patient and, in essence, allocation becomes a race on funding.
It is surprising that a ‘home team’ (in this case FTB) commissioned by an ICB to provide secondary mental health services is not permitted to make its own funding decisions for specialist units, as it can for acute wards and PICU’s. As can be seen from the evidence Amina was able to be transferred within 24hrs once a PICU accepted her on 01.08.23, albeit it took a wholly unsatisfactory 6 weeks to find a PICU bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Underfunding of local mental health beds
Wider context from the report “This is now the third inquest (two within the past 8 months) I have heard where the delayed transfer of an out-of-area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Two of those cases involving prolonged stays on PICU units; in this case some 13 months and in the other, some 11 months.
These cases illustrate,
a) Underfunding for local mental health beds.
It took some 6 weeks in 2022 to transfer Amina from the PD specialist placement at Nield House (where the treating team felt that they could not keep Amina safe) to a PICU some 90 miles from home.
Further, there were no local PICU beds available for transfer out of The Priory, Cheadle in May/June/July 2023 when a PD placement could not be found.
b) An over-reliance by the NHS on independent providers for mental health beds whether general acute beds, PICU beds or specialist units.
c) A national scarcity of specialist PD rehabilitation units
The inquest heard evidence from two treating psychiatrists in Amina’s history (Nield House and The Priory), FTB PACT assessor, and the court appointed independent expert that there was, and is, a national shortage of specialist PD rehabilitation units/beds, paraphrasing,
‘rehabilitation beds for female patients with PD are limited – demand exceeding what is available nationally’.
‘shortage of rehabilitation placements nationally – impeding on young persons’ mental health treatments’
‘simply not enough beds (NHS or Independent) to cater for such complex patients as Amina – transfers not being accepted by such units even if not full because the acuity of their existing patients’.
‘PD rehabilitation beds are scarce – spread nationally often in isolated units far from home, family and the local/home team. Each having its own admission criteria/exclusions, such as the possible need for NGT feeding’.
Following the PACT assessment FTB, in early 2023, were only able to find two PD units that had a bed available. One of them, Eleanor House, was re-opening its doors having voluntarily closed at the end of 2022. It had 14 beds available. However, its extant CQC rating was overall inadequate and it was in the process of appealing a Notice of Decision. The other, Cygnet Alders, declined the referral.
Three other units were identified as possibilities but each declined a referral, without any assessment, based on the acuity of their own patients.
Just 5 beds available over a period 6-7months, before Fern Unit accepted Amina.
In the meantime Amina remained in a PICU, some 90 miles from home which was wholly unsuited to her presentation and unable (through no fault of its own) to deliver the care and therapy that she needed resulting in a deterioration in her mental state with increasing risks/incidents of self-harm.
d) A funding process for rehabilitation units that is not fit for purpose.
The inquest heard evidence about the funding set-up for secondary mental health care in the Birmingham area, which is replicated nationally.
The ICB commissioned FTB to provide secondary mental health services, both community and in-patient. FTB are able to commission NHS and independent sector acute beds and PICU’s, both in and out of area. However, FTB are not able to commission specialist placement, including PD units. These are commissioned/funded directly by the ICB upon application by the FTB; having found a unit that would accept a patient.
This system, for funding specialist/rehabilitation beds, is inadequate; particularly in light of the shortage of such specialist/rehabilitation beds. The inquest heard evidence that the process from application to funding approval takes weeks, sometimes months. In this case it took from 13.03.23 to 04.05.23 for a negative outcome.
The shortage of beds/units means that when a bed becomes available there are a number of patients in competition for it. The beds are not kept open for any particular patient and, in essence, allocation becomes a race on funding.
It is surprising that a ‘home team’ (in this case FTB) commissioned by an ICB to provide secondary mental health services is not permitted to make its own funding decisions for specialist units, as it can for acute wards and PICU’s. As can be seen from the evidence Amina was able to be transferred within 24hrs once a PICU accepted her on 01.08.23, albeit it took a wholly unsatisfactory 6 weeks to find a PICU bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Over-reliance by the NHS on independent mental health-bed providers
Wider context from the report “This is now the third inquest (two within the past 8 months) I have heard where the delayed transfer of an out-of-area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Two of those cases involving prolonged stays on PICU units; in this case some 13 months and in the other, some 11 months.
These cases illustrate,
a) Underfunding for local mental health beds.
It took some 6 weeks in 2022 to transfer Amina from the PD specialist placement at Nield House (where the treating team felt that they could not keep Amina safe) to a PICU some 90 miles from home.
Further, there were no local PICU beds available for transfer out of The Priory, Cheadle in May/June/July 2023 when a PD placement could not be found.
b) An over-reliance by the NHS on independent providers for mental health beds whether general acute beds, PICU beds or specialist units.
c) A national scarcity of specialist PD rehabilitation units
The inquest heard evidence from two treating psychiatrists in Amina’s history (Nield House and The Priory), FTB PACT assessor, and the court appointed independent expert that there was, and is, a national shortage of specialist PD rehabilitation units/beds, paraphrasing,
‘rehabilitation beds for female patients with PD are limited – demand exceeding what is available nationally’.
‘shortage of rehabilitation placements nationally – impeding on young persons’ mental health treatments’
‘simply not enough beds (NHS or Independent) to cater for such complex patients as Amina – transfers not being accepted by such units even if not full because the acuity of their existing patients’.
‘PD rehabilitation beds are scarce – spread nationally often in isolated units far from home, family and the local/home team. Each having its own admission criteria/exclusions, such as the possible need for NGT feeding’.
Following the PACT assessment FTB, in early 2023, were only able to find two PD units that had a bed available. One of them, Eleanor House, was re-opening its doors having voluntarily closed at the end of 2022. It had 14 beds available. However, its extant CQC rating was overall inadequate and it was in the process of appealing a Notice of Decision. The other, Cygnet Alders, declined the referral.
Three other units were identified as possibilities but each declined a referral, without any assessment, based on the acuity of their own patients.
Just 5 beds available over a period 6-7months, before Fern Unit accepted Amina.
In the meantime Amina remained in a PICU, some 90 miles from home which was wholly unsuited to her presentation and unable (through no fault of its own) to deliver the care and therapy that she needed resulting in a deterioration in her mental state with increasing risks/incidents of self-harm.
d) A funding process for rehabilitation units that is not fit for purpose.
The inquest heard evidence about the funding set-up for secondary mental health care in the Birmingham area, which is replicated nationally.
The ICB commissioned FTB to provide secondary mental health services, both community and in-patient. FTB are able to commission NHS and independent sector acute beds and PICU’s, both in and out of area. However, FTB are not able to commission specialist placement, including PD units. These are commissioned/funded directly by the ICB upon application by the FTB; having found a unit that would accept a patient.
This system, for funding specialist/rehabilitation beds, is inadequate; particularly in light of the shortage of such specialist/rehabilitation beds. The inquest heard evidence that the process from application to funding approval takes weeks, sometimes months. In this case it took from 13.03.23 to 04.05.23 for a negative outcome.
The shortage of beds/units means that when a bed becomes available there are a number of patients in competition for it. The beds are not kept open for any particular patient and, in essence, allocation becomes a race on funding.
It is surprising that a ‘home team’ (in this case FTB) commissioned by an ICB to provide secondary mental health services is not permitted to make its own funding decisions for specialist units, as it can for acute wards and PICU’s. As can be seen from the evidence Amina was able to be transferred within 24hrs once a PICU accepted her on 01.08.23, albeit it took a wholly unsatisfactory 6 weeks to find a PICU bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring patients from out-of-area independent-provider hospitals
Wider context from the report “This is now the third inquest (two within the past 8 months) I have heard where the delayed transfer of an out-of-area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Two of those cases involving prolonged stays on PICU units ; in this case some 13 months and in the other, some 11 months.
These cases illustrate,
a) Underfunding for local mental health beds.
It took some 6 weeks in 2022 to transfer Amina from the PD specialist placement at Nield House (where the treating team felt that they could not keep Amina safe) to a PICU some 90 miles from home.
Further, there were no local PICU beds available for transfer out of The Priory, Cheadle in May/June/July 2023 when a PD placement could not be found.
b) An over-reliance by the NHS on independent providers for mental health beds whether general acute beds, PICU beds or specialist units.
c) A national scarcity of specialist PD rehabilitation units
The inquest heard evidence from two treating psychiatrists in Amina’s history (Nield House and The Priory), FTB PACT assessor, and the court appointed independent expert that there was, and is, a national shortage of specialist PD rehabilitation units/beds, paraphrasing,
‘rehabilitation beds for female patients with PD are limited – demand exceeding what is available nationally’.
‘shortage of rehabilitation placements nationally – impeding on young persons’ mental health treatments’
‘simply not enough beds (NHS or Independent) to cater for such complex patients as Amina – transfers not being accepted by such units even if not full because the acuity of their existing patients’.
‘PD rehabilitation beds are scarce – spread nationally often in isolated units far from home, family and the local/home team. Each having its own admission criteria/exclusions, such as the possible need for NGT feeding’.
Following the PACT assessment FTB, in early 2023, were only able to find two PD units that had a bed available. One of them, Eleanor House, was re-opening its doors having voluntarily closed at the end of 2022. It had 14 beds available. However, its extant CQC rating was overall inadequate and it was in the process of appealing a Notice of Decision. The other, Cygnet Alders, declined the referral.
Three other units were identified as possibilities but each declined a referral, without any assessment, based on the acuity of their own patients.
Just 5 beds available over a period 6-7months, before Fern Unit accepted Amina.
In the meantime Amina remained in a PICU, some 90 miles from home which was wholly unsuited to her presentation and unable (through no fault of its own) to deliver the care and therapy that she needed resulting in a deterioration in her mental state with increasing risks/incidents of self-harm.
d) A funding process for rehabilitation units that is not fit for purpose.
The inquest heard evidence about the funding set-up for secondary mental health care in the Birmingham area, which is replicated nationally.
The ICB commissioned FTB to provide secondary mental health services, both community and in-patient. FTB are able to commission NHS and independent sector acute beds and PICU’s, both in and out of area. However, FTB are not able to commission specialist placement, including PD units. These are commissioned/funded directly by the ICB upon application by the FTB; having found a unit that would accept a patient.
This system, for funding specialist/rehabilitation beds, is inadequate; particularly in light of the shortage of such specialist/rehabilitation beds. The inquest heard evidence that the process from application to funding approval takes weeks, sometimes months. In this case it took from 13.03.23 to 04.05.23 for a negative outcome.
The shortage of beds/units means that when a bed becomes available there are a number of patients in competition for it. The beds are not kept open for any particular patient and, in essence, allocation becomes a race on funding.
It is surprising that a ‘home team’ (in this case FTB) commissioned by an ICB to provide secondary mental health services is not permitted to make its own funding decisions for specialist units, as it can for acute wards and PICU’s. As can be seen from the evidence Amina was able to be transferred within 24hrs once a PICU accepted her on 01.08.23, albeit it took a wholly unsatisfactory 6 weeks to find a PICU bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Funding allocation failing to secure available specialist rehabilitation beds for identified patients
Wider context from the report “This is now the third inquest (two within the past 8 months) I have heard where the delayed transfer of an out-of-area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Two of those cases involving prolonged stays on PICU units; in this case some 13 months and in the other, some 11 months.
These cases illustrate,
a) Underfunding for local mental health beds.
It took some 6 weeks in 2022 to transfer Amina from the PD specialist placement at Nield House (where the treating team felt that they could not keep Amina safe) to a PICU some 90 miles from home.
Further, there were no local PICU beds available for transfer out of The Priory, Cheadle in May/June/July 2023 when a PD placement could not be found.
b) An over-reliance by the NHS on independent providers for mental health beds whether general acute beds, PICU beds or specialist units.
c) A national scarcity of specialist PD rehabilitation units
The inquest heard evidence from two treating psychiatrists in Amina’s history (Nield House and The Priory), FTB PACT assessor, and the court appointed independent expert that there was, and is, a national shortage of specialist PD rehabilitation units/beds, paraphrasing,
‘rehabilitation beds for female patients with PD are limited – demand exceeding what is available nationally’.
‘shortage of rehabilitation placements nationally – impeding on young persons’ mental health treatments’
‘simply not enough beds (NHS or Independent) to cater for such complex patients as Amina – transfers not being accepted by such units even if not full because the acuity of their existing patients’.
‘PD rehabilitation beds are scarce – spread nationally often in isolated units far from home, family and the local/home team. Each having its own admission criteria/exclusions, such as the possible need for NGT feeding’.
Following the PACT assessment FTB, in early 2023, were only able to find two PD units that had a bed available. One of them, Eleanor House, was re-opening its doors having voluntarily closed at the end of 2022. It had 14 beds available. However, its extant CQC rating was overall inadequate and it was in the process of appealing a Notice of Decision. The other, Cygnet Alders, declined the referral.
Three other units were identified as possibilities but each declined a referral, without any assessment, based on the acuity of their own patients.
Just 5 beds available over a period 6-7months, before Fern Unit accepted Amina.
In the meantime Amina remained in a PICU, some 90 miles from home which was wholly unsuited to her presentation and unable (through no fault of its own) to deliver the care and therapy that she needed resulting in a deterioration in her mental state with increasing risks/incidents of self-harm.
d) A funding process for rehabilitation units that is not fit for purpose.
The inquest heard evidence about the funding set-up for secondary mental health care in the Birmingham area, which is replicated nationally.
The ICB commissioned FTB to provide secondary mental health services, both community and in-patient. FTB are able to commission NHS and independent sector acute beds and PICU’s, both in and out of area. However, FTB are not able to commission specialist placement, including PD units. These are commissioned/funded directly by the ICB upon application by the FTB; having found a unit that would accept a patient.
This system, for funding specialist/rehabilitation beds, is inadequate; particularly in light of the shortage of such specialist/rehabilitation beds. The inquest heard evidence that the process from application to funding approval takes weeks, sometimes months. In this case it took from 13.03.23 to 04.05.23 for a negative outcome.
The shortage of beds/units means that when a bed becomes available there are a number of patients in competition for it . The beds are not kept open for any particular patient and, in essence, allocation becomes a race on funding .
It is surprising that a ‘home team’ (in this case FTB) commissioned by an ICB to provide secondary mental health services is not permitted to make its own funding decisions for specialist units, as it can for acute wards and PICU’s. As can be seen from the evidence Amina was able to be transferred within 24hrs once a PICU accepted her on 01.08.23, albeit it took a wholly unsatisfactory 6 weeks to find a PICU bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Home teams’ inability to commission or make funding decisions for specialist personality-disorder placements
Wider context from the report “This is now the third inquest (two within the past 8 months) I have heard where the delayed transfer of an out-of-area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Two of those cases involving prolonged stays on PICU units; in this case some 13 months and in the other, some 11 months.
These cases illustrate,
a) Underfunding for local mental health beds.
It took some 6 weeks in 2022 to transfer Amina from the PD specialist placement at Nield House (where the treating team felt that they could not keep Amina safe) to a PICU some 90 miles from home.
Further, there were no local PICU beds available for transfer out of The Priory, Cheadle in May/June/July 2023 when a PD placement could not be found.
b) An over-reliance by the NHS on independent providers for mental health beds whether general acute beds, PICU beds or specialist units.
c) A national scarcity of specialist PD rehabilitation units
The inquest heard evidence from two treating psychiatrists in Amina’s history (Nield House and The Priory), FTB PACT assessor, and the court appointed independent expert that there was, and is, a national shortage of specialist PD rehabilitation units/beds, paraphrasing,
‘rehabilitation beds for female patients with PD are limited – demand exceeding what is available nationally’.
‘shortage of rehabilitation placements nationally – impeding on young persons’ mental health treatments’
‘simply not enough beds (NHS or Independent) to cater for such complex patients as Amina – transfers not being accepted by such units even if not full because the acuity of their existing patients’.
‘PD rehabilitation beds are scarce – spread nationally often in isolated units far from home, family and the local/home team. Each having its own admission criteria/exclusions, such as the possible need for NGT feeding’.
Following the PACT assessment FTB, in early 2023, were only able to find two PD units that had a bed available. One of them, Eleanor House, was re-opening its doors having voluntarily closed at the end of 2022. It had 14 beds available. However, its extant CQC rating was overall inadequate and it was in the process of appealing a Notice of Decision. The other, Cygnet Alders, declined the referral.
Three other units were identified as possibilities but each declined a referral, without any assessment, based on the acuity of their own patients.
Just 5 beds available over a period 6-7months, before Fern Unit accepted Amina.
In the meantime Amina remained in a PICU, some 90 miles from home which was wholly unsuited to her presentation and unable (through no fault of its own) to deliver the care and therapy that she needed resulting in a deterioration in her mental state with increasing risks/incidents of self-harm.
d) A funding process for rehabilitation units that is not fit for purpose.
The inquest heard evidence about the funding set-up for secondary mental health care in the Birmingham area, which is replicated nationally.
The ICB commissioned FTB to provide secondary mental health services, both community and in-patient. FTB are able to commission NHS and independent sector acute beds and PICU’s, both in and out of area. However, FTB are not able to commission specialist placement, including PD units . These are commissioned/funded directly by the ICB upon application by the FTB ; having found a unit that would accept a patient.
This system, for funding specialist/rehabilitation beds, is inadequate; particularly in light of the shortage of such specialist/rehabilitation beds. The inquest heard evidence that the process from application to funding approval takes weeks, sometimes months. In this case it took from 13.03.23 to 04.05.23 for a negative outcome.
The shortage of beds/units means that when a bed becomes available there are a number of patients in competition for it. The beds are not kept open for any particular patient and, in essence, allocation becomes a race on funding.
It is surprising that a ‘home team’ (in this case FTB) commissioned by an ICB to provide secondary mental health services is not permitted to make its own funding decisions for specialist units, as it can for acute wards and PICU’s. As can be seen from the evidence Amina was able to be transferred within 24hrs once a PICU accepted her on 01.08.23, albeit it took a wholly unsatisfactory 6 weeks to find a PICU bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 funding approval for specialist rehabilitation beds
Wider context from the report “This is now the third inquest (two within the past 8 months) I have heard where the delayed transfer of an out-of-area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Two of those cases involving prolonged stays on PICU units; in this case some 13 months and in the other, some 11 months.
These cases illustrate,
a) Underfunding for local mental health beds.
It took some 6 weeks in 2022 to transfer Amina from the PD specialist placement at Nield House (where the treating team felt that they could not keep Amina safe) to a PICU some 90 miles from home.
Further, there were no local PICU beds available for transfer out of The Priory, Cheadle in May/June/July 2023 when a PD placement could not be found.
b) An over-reliance by the NHS on independent providers for mental health beds whether general acute beds, PICU beds or specialist units.
c) A national scarcity of specialist PD rehabilitation units
The inquest heard evidence from two treating psychiatrists in Amina’s history (Nield House and The Priory), FTB PACT assessor, and the court appointed independent expert that there was, and is, a national shortage of specialist PD rehabilitation units/beds, paraphrasing,
‘rehabilitation beds for female patients with PD are limited – demand exceeding what is available nationally’.
‘shortage of rehabilitation placements nationally – impeding on young persons’ mental health treatments’
‘simply not enough beds (NHS or Independent) to cater for such complex patients as Amina – transfers not being accepted by such units even if not full because the acuity of their existing patients’.
‘PD rehabilitation beds are scarce – spread nationally often in isolated units far from home, family and the local/home team. Each having its own admission criteria/exclusions, such as the possible need for NGT feeding’.
Following the PACT assessment FTB, in early 2023, were only able to find two PD units that had a bed available. One of them, Eleanor House, was re-opening its doors having voluntarily closed at the end of 2022. It had 14 beds available. However, its extant CQC rating was overall inadequate and it was in the process of appealing a Notice of Decision. The other, Cygnet Alders, declined the referral.
Three other units were identified as possibilities but each declined a referral, without any assessment, based on the acuity of their own patients.
Just 5 beds available over a period 6-7months, before Fern Unit accepted Amina.
In the meantime Amina remained in a PICU, some 90 miles from home which was wholly unsuited to her presentation and unable (through no fault of its own) to deliver the care and therapy that she needed resulting in a deterioration in her mental state with increasing risks/incidents of self-harm.
d) A funding process for rehabilitation units that is not fit for purpose.
The inquest heard evidence about the funding set-up for secondary mental health care in the Birmingham area, which is replicated nationally.
The ICB commissioned FTB to provide secondary mental health services, both community and in-patient. FTB are able to commission NHS and independent sector acute beds and PICU’s, both in and out of area. However, FTB are not able to commission specialist placement, including PD units. These are commissioned/funded directly by the ICB upon application by the FTB; having found a unit that would accept a patient.
This system, for funding specialist/rehabilitation beds, is inadequate ; particularly in light of the shortage of such specialist/rehabilitation beds. The inquest heard evidence that the process from application to funding approval takes weeks, sometimes months . In this case it took from 13.03.23 to 04.05.23 for a negative outcome.
The shortage of beds/units means that when a bed becomes available there are a number of patients in competition for it. The beds are not kept open for any particular patient and, in essence, allocation becomes a race on funding.
It is surprising that a ‘home team’ (in this case FTB) commissioned by an ICB to provide secondary mental health services is not permitted to make its own funding decisions for specialist units, as it can for acute wards and PICU’s. As can be seen from the evidence Amina was able to be transferred within 24hrs once a PICU accepted her on 01.08.23, albeit it took a wholly unsatisfactory 6 weeks to find a PICU bed.
” 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 Require each Integrated Care Board to develop and publish a three-year plan to localise and realign mental health inpatient care.
Verbatim wording from the response “To support this aim, NHS England published the Commissioning Framework for Mental Health Inpatient Services in early 2024 and introduced a requirement in its Operational Planning Guidance (2024/25) that each Integrated Care Board (ICB) develop and publish a 3 year plan to localise and realign care to the evidence-base summarised in the Framework. Local plans need to cover within them how they will cease the practice of sending people to inpatient services at a distance from their home and/or to outdated or risky models of provision – underpinned by the philosophy that ‘all means all’, and people with acute mental health needs should have access to the evidence-based therapeutic offers they need as close to home as possible and adjusted to their needs. This includes acute and rehabilitation inpatient services.” 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 £42 million recurrent funding to Integrated Care Boards to support delivery of localised and realigned inpatient care.
Verbatim wording from the response “Final ICB plans are due for publication, and £42 million recurrent funding has been provided to ICBs to support delivery.” 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 Run the Mental Health, Learning Disability and Autism Inpatient Quality Transformation Programme to localise and realign inpatient care.
Verbatim wording from the response “In 2022, NHS England launched the Mental Health, Learning Disability and Autism Inpatient Quality Transformation programme. A core aim of the programme is to localise and realign care, harnessing the potential of people and communities. The programme is built upon the cornerstones of good mental healthcare; continuity of care, therapeutic relationships and a relentless commitment to mental health care meeting the needs of all citizens.” 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 Publish the Commissioning Framework for Mental Health Inpatient Services.
Verbatim wording from the response “To support this aim, NHS England published the Commissioning Framework for Mental Health Inpatient Services in early 2024 and introduced a requirement in its Operational Planning Guidance (2024/25) that each Integrated Care Board (ICB) develop and publish a 3 year plan to localise and realign care to the evidence-base summarised in the Framework. Local plans need to cover within them how they will cease the practice of sending people to inpatient services at a distance from their home and/or to outdated or risky models of provision – underpinned by the philosophy that ‘all means all’, and people with acute mental health needs should have access to the evidence-based therapeutic offers they need as close to home as possible and adjusted to their needs. This includes acute and rehabilitation inpatient services.” Source location Response from NHSE
Open published response
13 Jun 2024 Linda MCLAUGHLIN · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Lack of clear guidance on discontinuing nilotinib or similar drugs when patients are in remission View source Lack of awareness and recognition of interstitial lung disease symptoms among oncologists and haematologists View source Delays in referral and treatment for interstitial lung disease View source Failure to include rare complications such as interstitial lung disease in consent discussions for nilotinib 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
Linda MCLAUGHLIN · 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
Linda McLaughlin was treated for chronic myeloid leukaemia with nilotinib and later developed interstitial lung disease, probably as a consequence of the treatment. She was admitted with bronchopneumonia and died at Tameside General Hospital on 27 October 2023. Concerns included limited awareness of this rare complication, consent processes that may not mention it, and a lack of clear guidance on stopping treatment when patients are in remission.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance on discontinuing nilotinib or similar drugs when patients are in remission
Wider context from the report “3. In this case the inquest was told that a decision was taken to continue with nilotinib despite being in remission. The inquest was told that there is growing evidence that some people do not need to stay on these drugs for life if in remission but there is no clear guidance for the approach to take . As a consequence patients may remain on the drug longer than necessary .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 awareness and recognition of interstitial lung disease symptoms among oncologists and haematologists
Wider context from the report “1. The inquest heard evidence that the complication that Mrs McLaughlin developed is rare but recognised internationally. However it is not widely known about and as a consequence of lack of awareness even amongst oncologists/haematologists it may not be recognised that a patient has symptoms of interstitial lung disease and as a consequence referral and treatment that could slow the disease progression may be delayed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 referral and treatment for interstitial lung disease
Wider context from the report “1. The inquest heard evidence that the complication that Mrs McLaughlin developed is rare but recognised internationally. However it is not widely known about and as a consequence of lack of awareness even amongst oncologists/haematologists it may not be recognised that a patient has symptoms of interstitial lung disease and as a consequence referral and treatment that could slow the disease progression may be delayed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 rare complications such as interstitial lung disease in consent discussions for nilotinib
Wider context from the report “2. The inquest was told that the consenting process for starting a patient on a drug such as nilotinib would not ordinarily include mentioning rare complications such as interstitial lung disease . The family gave evidence that in this case this is something that would have been carefully weighed in the decision to proceed with the treatment.
” 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 Nilotinib’s interstitial lung disease risk is identified in product information, the BNF and the patient information leaflet.
Verbatim wording from the response “Your Report raises the concern that it is not widely known by healthcare professionals that interstitial lung disease is a rare side effect of treatment with a tyrosine kinase inhibitor drug called nilotinib, and that the consenting process for such a drug would not usually include mentioning such rare complications.” 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 BNF and MHRA are more appropriate bodies to respond to concerns about nilotinib’s side-effect information and medication regulation.
Verbatim wording from the response “It should be noted that NHS England does not administer the BNF, and that regulation of medication does not sit within our remit. You may wish to revert to the BNF and/or” 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 MHRA is considered more appropriate to comment on guidance concerning continued tyrosine kinase inhibitor treatment after remission.
Verbatim wording from the response “Your Report also raises that there is growing evidence that some people do not need to stay on tyrosine kinase inhibitor drugs for life once in remission, but that there is no clear guidance on this and that consequently patients may remain on the drug longer than necessary. Again, you may wish to direct this concern to the MHRA who would be more appropriate to comment. However, specialist cancer colleagues have advised that this is an issue that currently remains in evolution. A proportion of patients can stop taking the drugs once they achieve a durable molecular remission, and this is normally discussed with patients after a certain length of time, weighing the potential toxicity of ongoing treatment against the risk of recurrence. The British Society for Haematology has an extensive guideline addressing this issue.” Source location Response from NHS England
Open published response
13 Jun 2024 Joseph Lawrence Parker · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Failure to endorse and disseminate PUMA airway management guidance View source Lack of changes following previous Prevention of Future Deaths Reports concerning unrecognised oesophageal intubation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joseph Lawrence Parker · 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
Joseph Lawrence Parker took an overdose of medication on 17 February 2022, collapsed, and was taken to Southmead Hospital for intubation. The breathing tube was accidentally positioned in the oesophagus and the misplacement was not identified promptly, contributing to cardiac arrest, hypoxic encephalopathy, and his death on 16 April 2022. The principal concerns relate to recognising incorrect tube placement, the use and interpretation of capnography, and the dissemination of relevant airway-management guidance.
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 endorse and disseminate PUMA airway management guidance
Wider context from the report “(1) I have been told that capnography is the only reliable test, the gold standard, to confirm that a tracheal tube is in the right place, that no other test should override it.
(2) That the more recent PUMA (Project for Universal Management of Airways) guidelines state, the detection of sustained exhaled carbon dioxide using waveform capnography is the mainstay for excluding oesophageal placement of an intended tracheal tube. The PUMA guidance deserves the widest possible endorsement and dissemination which has not happened yet.
(3) Unrecognised oesophageal intubation was a “Never Event” by NHS England but is no longer.
(4) There have already been a number of Prevention of Futures Deaths Reports written by Coroner’s in relation to this concern but to date, I am told there have been no changes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 changes following previous Prevention of Future Deaths Reports concerning unrecognised oesophageal intubation
Wider context from the report “(1) I have been told that capnography is the only reliable test, the gold standard, to confirm that a tracheal tube is in the right place, that no other test should override it.
(2) That the more recent PUMA (Project for Universal Management of Airways) guidelines state, the detection of sustained exhaled carbon dioxide using waveform capnography is the mainstay for excluding oesophageal placement of an intended tracheal tube. The PUMA guidance deserves the widest possible endorsement and dissemination which has not happened yet.
(3) Unrecognised oesophageal intubation was a “Never Event” by NHS England but is no longer.
(4) There have already been a number of Prevention of Futures Deaths Reports written by Coroner’s in relation to this concern but to date, I am told there have been no changes.
” 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 Make a decision on next steps following the completed consultation, including whether the Never Event definition or list should change.
Verbatim wording from the response “The mitigations used to avoid oesophageal intubation, primarily the use of capnography, which is included in the 2021 AAGBI recommendations referenced above, does not meet the definition of a Never Event. As part of NHS England’s current work to review the Never Events Framework and list of Never Events, we will be clarifying the future direction for the Never Events Framework. Since the completion of a widespread consultation in May 2024, a decision will be made on next steps which will determine if the current definition of a Never Event should change and whether this has implications for including oesophageal intubation on any future list. Further information on the consultation can be found here and NHS England can update the Coroner in due course if this would assist.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Never Events Framework and list to clarify their future direction regarding unrecognised oesophageal intubation.
Verbatim wording from the response “The mitigations used to avoid oesophageal intubation, primarily the use of capnography, which is included in the 2021 AAGBI recommendations referenced above, does not meet the definition of a Never Event. As part of NHS England’s current work to review the Never Events Framework and list of Never Events, we will be clarifying the future direction for the Never Events Framework. Since the completion of a widespread consultation in May 2024, a decision will be made on next steps which will determine if the current definition of a Never Event should change and whether this has implications for including oesophageal intubation on any future list. Further information on the consultation can be found here and NHS England can update the Coroner in due course if this would assist.” 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 PUMA guideline endorsement and dissemination fall outside NHS England’s national policy or programme remit.
Verbatim wording from the response “My response focuses on those areas of concern that fall under the remit of NHS England’s national policy or programmes. NHS England notes that you have also sent your Report to the Royal College of Anaesthetists (RCoA), Faculty of Intensive Care Medicine (FICM), and the Royal College of Emergency Medicine (RCEM), who are better placed to respond to your matters of concern. NHS England will carefully consider their responses to the Coroner in due course.” 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 Royal Colleges are better placed to respond to concerns outside NHS England’s national policy or programme remit.
Verbatim wording from the response “My response focuses on those areas of concern that fall under the remit of NHS England’s national policy or programmes. NHS England notes that you have also sent your Report to the Royal College of Anaesthetists (RCoA), Faculty of Intensive Care Medicine (FICM), and the Royal College of Emergency Medicine (RCEM), who are better placed to respond to your matters of concern. NHS England will carefully consider their responses to the Coroner in due course.” Source location Response from NHS England
Open published response
Concerns raised 4 Insufficient capacity to safely assess and re-prioritise urgent CAMHS waiting-list patients View source Delays in CAMHS treatment View source Delays in CAMHS assessment View source Lack of CAMHS resources keeping pace with increasing demand 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
Sailor (previously known as Sara) COURT · 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
Sailor (previously known as Sara) COURT, aged 14, died by suicide on 17 September 2021 after taking an overdose at home while on the CAMHS waiting list for treatment. The principal concerns were unacceptably long waits for assessment and treatment, which had not improved and were attributed to insufficient resources relative to demand.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient capacity to safely assess and re-prioritise urgent CAMHS waiting-list patients
Wider context from the report “(1) The anticipated waiting times before Sailor’s assessment (approximately one year) was unacceptably long.
(2) The length of time before treatment could be delivered thereafter (approximately 10 months) was unacceptably long.
(3) The Court heard evidence that the waiting times for assessment and treatment have not improved since Sailor’s death, and in fact both have significantly increased. This means that a teenager referred today into the CAMHS could be waiting for around / upwards of two years before they receive treatment. This is an unacceptably long delay.
(4) The Court heard evidence that the Trust is attempting to mitigate the problem by way of a proactive “Keeping in Touch” team with the potential to streamline / re-organise the waiting list. However, due to the number of individuals on the waiting list (estimated to be over 1,000) and the number of staff engaged in the Keeping in Touch team (three) and the scale of the task, I was not re-assured that the Keeping in Touch team could realistically and / or safely assess or re-prioritise those on the waiting list in most urgent need of assessment or treatment .
(5) The Court heard evidence that the long waiting lists were a result of a lack of resources which has not kept pace with significantly increased (and increasing) demand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 CAMHS treatment
Wider context from the report “(1) The anticipated waiting times before Sailor’s assessment (approximately one year) was unacceptably long.
(2) The length of time before treatment could be delivered thereafter (approximately 10 months) was unacceptably long.
(3) The Court heard evidence that the waiting times for assessment and treatment have not improved since Sailor’s death, and in fact both have significantly increased. This means that a teenager referred today into the CAMHS could be waiting for around / upwards of two years before they receive treatment . This is an unacceptably long delay.
(4) The Court heard evidence that the Trust is attempting to mitigate the problem by way of a proactive “Keeping in Touch” team with the potential to streamline / re-organise the waiting list. However, due to the number of individuals on the waiting list (estimated to be over 1,000) and the number of staff engaged in the Keeping in Touch team (three) and the scale of the task, I was not re-assured that the Keeping in Touch team could realistically and / or safely assess or re-prioritise those on the waiting list in most urgent need of assessment or treatment.
(5) The Court heard evidence that the long waiting lists were a result of a lack of resources which has not kept pace with significantly increased (and increasing) demand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 CAMHS assessment
Wider context from the report “(1) The anticipated waiting times before Sailor’s assessment (approximately one year) was unacceptably long.
(2) The length of time before treatment could be delivered thereafter (approximately 10 months) was unacceptably long.
(3) The Court heard evidence that the waiting times for assessment and treatment have not improved since Sailor’s death, and in fact both have significantly increased. This means that a teenager referred today into the CAMHS could be waiting for around / upwards of two years before they receive treatment . This is an unacceptably long delay.
(4) The Court heard evidence that the Trust is attempting to mitigate the problem by way of a proactive “Keeping in Touch” team with the potential to streamline / re-organise the waiting list. However, due to the number of individuals on the waiting list (estimated to be over 1,000) and the number of staff engaged in the Keeping in Touch team (three) and the scale of the task, I was not re-assured that the Keeping in Touch team could realistically and / or safely assess or re-prioritise those on the waiting list in most urgent need of assessment or treatment.
(5) The Court heard evidence that the long waiting lists were a result of a lack of resources which has not kept pace with significantly increased (and increasing) demand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 CAMHS resources keeping pace with increasing demand
Wider context from the report “(1) The anticipated waiting times before Sailor’s assessment (approximately one year) was unacceptably long.
(2) The length of time before treatment could be delivered thereafter (approximately 10 months) was unacceptably long.
(3) The Court heard evidence that the waiting times for assessment and treatment have not improved since Sailor’s death, and in fact both have significantly increased. This means that a teenager referred today into the CAMHS could be waiting for around / upwards of two years before they receive treatment. This is an unacceptably long delay.
(4) The Court heard evidence that the Trust is attempting to mitigate the problem by way of a proactive “Keeping in Touch” team with the potential to streamline / re-organise the waiting list. However, due to the number of individuals on the waiting list (estimated to be over 1,000) and the number of staff engaged in the Keeping in Touch team (three) and the scale of the task, I was not re-assured that the Keeping in Touch team could realistically and / or safely assess or re-prioritise those on the waiting list in most urgent need of assessment or treatment.
(5) The Court heard evidence that the long waiting lists were a result of a lack of resources which has not kept pace with significantly increased (and increasing) demand .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest in the CYPMH workforce and expand NHS mental health support access for children and young people.
Verbatim wording from the response “Improving mental health support for children and young people is a priority for NHS England. The NHS Long Term Plan (LTP) sets an ambitious commitment that access will increase, with 345,000 more children aged 0-25 accessing support in 2023/24 compared to 2019. This commitment came with significant additional funding, rising to over £900 million in 2023/24. We have made significant progress towards this commitment, with 758,000 children and young people receiving support from the NHS in the 12 months to January 2024. This has been achieved through investment in the CYPMH workforce, which has increased by 46% since the start of the LTP in January 2019, and by 70% since 2016.” 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 Delivering expanded children’s mental health access ambitions is subject to future funding settlements, with plans to be clarified later.
Verbatim wording from the response “The NHS Long Term Workforce Plan (June 2023) sets out the importance of continued investment in the mental health workforce and, in 2022, NHS England consulted on potential new access and waiting time standards, including for children and young people’s mental health. Delivering these ambitions will be subject to future funding settlements and we will clarify plans in due course.” Source location Response from NHS England
Open published response
Concerns raised 2 Lack of ambulance carriage of appropriate antidote medication for on-scene administration View source Failure of ambulance triage and prioritisation to provide sufficient time for emergency treatment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Fern Elisabeth Foster · 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
Fern Elisabeth Foster died by suicide on 8 July 2020 after consuming a substance she had procured with the intention of ending her life. The report identified concerns about the absence of independent advocacy and physical professional support when Fern received news concerning the intended adoption of her child, and about ambulance response times and access to antidote medication in suspected poisoning cases.
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 carriage of appropriate antidote medication for on-scene administration
Wider context from the report “(2) The carrying by ambulance services of appropriate antidote medication for on-scene administration (such as Methylene Blue) , whilst trialled elsewhere, is not part of regional or national protocol . Swift access to this in circumstances where ████████ is suspected, and timings mitigate against survival by the time of arrival at the nearest Emergency Department, could prevent future deaths in some cases.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 and prioritisation to provide sufficient time for emergency treatment
Wider context from the report “(1) The process for triaging and prioritising ambulance attendance to an incident involving the suspected ingestion of ████████ (intentionally or otherwise) does not provide sufficient opportunity for travel, attendance, conveyance to hospital for emergency treatment and/or provision of antidote treatment at scene , which may provide the only likely means of prevention of death where sufficient quantity has been ingested.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the national operational procedure for ambulance services managing Category 3 overdose and suicidal-ideation calls.
Verbatim wording from the response “In April 2021, NHS England and Improvement, in conjunction with the Association of Ambulance Chief Executives (AACE), published a new operational procedure for all ambulance services in England entitled, “Category 3/ 999 Overdose and Suicidal Ideation Calls; Initial Assessment of Lethality/Toxicity Principles Document”. This document followed a detailed review that had been undertaken to consider agreed ambulance control room processes, to ensure that suicidal patients receive the correct clinical response. This review had also been the catalyst for NHS England contacting all ambulance and NHS 111 services in early 2019 as described above. In this 2021 document, NHS England set out that, where an overdose is declared, a further clinical intervention should take place within 30 minutes and/or the case will be automatically upgraded if this does not occur within 40 minutes.” Source location 2024-0311 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 Issue overdose-management communications requiring timely clinical assessment or automatic ambulance-response upgrading.
Verbatim wording from the response “NHS England issued communications to ambulance services and NHS 111 providers in 2019 and 2021 in respect of managing overdose cases, and in November 2023 an updated version was issued instructing that any case reaching a Category 3 response should have further clinical assessment within a set timeframe, or else be automatically upgraded to a Category 2 response. Further details are set out below.” Source location 2024-0311 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 Review the overdose and suicidal-ideation operational procedure to ensure it remains fit for purpose.
Verbatim wording from the response “In October 2023, a review of this document was completed by ECPAG and the National Ambulance Service Medical” Source location 2024-0311 Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and deploy the Dx0124 disposition code to identify overdose and suicide-attempt cases for priority clinical assessment.
Verbatim wording from the response “To support NHS England’s 2019 communication and enable services to identify these Category 3 cases to clinicians for priority assessment, NHS Pathways developed a specific disposition code ‘Dx0124 Emergency Ambulance Response for Risk of Suicide (Category 3)’ in April 2019. This code facilitates improved visibility of overdose or suicide attempt cases within the ambulance dispatch queue. These actions, to develop and deploy this disposition code, were ratified by the former NHS Pathways National Clinical Governance Group (NCGG) in February 2019 (this group has been superseded by NCAG). This was also approved by NHS England’s ECPAG on 3rd July 2019. It was deployed to all service users as part of Release 18 in October 2019.” Source location 2024-0311 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 Decisions about ambulance services carrying specific antidotes are operational matters for individual ambulance trusts.
Verbatim wording from the response “Your second concern relates to the fact that it is not regional or national protocol for ambulance services to carry antidote medication for on-scene administration.” Source location 2024-0311 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 current overdose triage process, including urgent clinical assessment and escalation, is considered most suitable.
Verbatim wording from the response “Director’s Group (NASMeD, Association of Ambulance Chief Executives) to ensure it remains fit for purpose. The view from the Ambulance Response Programme Implementation Group at NHS England, supported by NASMeD, was that cases involving suicidal ideation (including overdoses) are often multi-factorial and therefore too complex for Health Advisors to apply a definitive disposition without assessment by a clinician. Instead, they require an urgent remote clinical risk assessment in the absence of priority airway, breathing or circulatory symptoms during triage. This means that for those cases which do not automatically result in a Category 1 or 2 emergency ambulance response, an urgent remote clinical assessment will take place, pending which the case will be dealt with as a Category 3 emergency ambulance response.” Source location 2024-0311 Response from NHS England
Open published response
6 Jun 2024 Robert John Fray · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure of the automated duplicate checker to identify repeat calls when the patient changes location View source Failure to prompt call assessors to consider repeated 999 calls over time when assessing urgency View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Robert John Fray · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Robert John Fray became unwell with suspected sepsis during a dialysis session on 4 April 2022, and ambulance delays and emergency department failures meant he remained untreated for many hours. He developed multi-organ failure after sepsis and a stroke and died on 9 April 2022. The principal concerns were that repeated 999 calls did not trigger consideration of a more urgent response and that the duplicate-call system failed to identify a further call when his location changed.
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 automated duplicate checker to identify repeat calls when the patient changes location
Wider context from the report “1. A volume of 999 calls over a longitudinal period (vs a volume of calls in a short space of time) does not trigger or prompt NHS Pathways to require the call assessor to consider whether a more urgent response is needed. The simple fact of repeated 999 calls over a longitudinal period may be an indicator of a worsening situation. Currently, the call assessor repeats at each call the question ‘has the presentation changed?’ and is reliant on the judgment of the caller who may not have the complete picture (e.g. Mr Fray’s neighbour), rather than also having regard to the number of calls.
2. Linked, the automated ‘duplicate checker’ is based on checking location within a 250-meter radius and not the patient’s name. As Mr Fray had moved more than 250 meters between 999 call no.3 and 999 call no.4, the call at 23:05hrs was not identified as a fourth call. It follows the call assessor was not prompted to ask whether his presentation had worsened and the ambulance was sent to an out-of-date location. This would not have happened had the ‘duplicate checker’ included Mr Fray’s name rather than simply looking for a location within 250-meters.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 prompt call assessors to consider repeated 999 calls over time when assessing urgency
Wider context from the report “1. A volume of 999 calls over a longitudinal period (vs a volume of calls in a short space of time) does not trigger or prompt NHS Pathways to require the call assessor to consider whether a more urgent response is needed. The simple fact of repeated 999 calls over a longitudinal period may be an indicator of a worsening situation. Currently, the call assessor repeats at each call the question ‘has the presentation changed?’ and is reliant on the judgment of the caller who may not have the complete picture (e.g. Mr Fray’s neighbour), rather than also having regard to the number of calls.
2. Linked, the automated ‘duplicate checker’ is based on checking location within a 250-meter radius and not the patient’s name. As Mr Fray had moved more than 250 meters between 999 call no.3 and 999 call no.4, the call at 23:05hrs was not identified as a fourth call. It follows the call assessor was not prompted to ask whether his presentation had worsened and the ambulance was sent to an out-of-date location. This would not have happened had the ‘duplicate checker’ included Mr Fray’s name rather than simply looking for a location within 250-meters.
” 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 National policy on how ambulance services manage duplicate callers is outside NHS England’s remit.
Verbatim wording from the response “NHS England do not set national policy on how ambulance services should manage duplicate callers. Ambulance services adopt good practice and implement their own local procedures to manage this issue. The duplicate checker referred to by the Coroner is good practice across the sector but is not nationally mandated policy.” Source location 2024-0307 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 services are responsible for adopting good practice and implementing local procedures for managing duplicate callers.
Verbatim wording from the response “NHS England do not set national policy on how ambulance services should manage duplicate callers. Ambulance services adopt good practice and implement their own local procedures to manage this issue. The duplicate checker referred to by the Coroner is good practice across the sector but is not nationally mandated policy.” Source location 2024-0307 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 Treating callers with previous contacts differently could delay NHS Pathways assessment, ambulance dispatch, or life-saving advice.
Verbatim wording from the response “NHS Pathways triage assessment assesses symptoms at the time of the call. If all patients who had a previous 999 contact or a previous encounter with a healthcare provider were treated differently when a call reaches the 999 system, this could delay or prevent an NHS Pathways assessment occurring. This could in turn delay ambulance dispatch or life-saving advice.” Source location 2024-0307 Response from NHS England
Open published response
5 Jun 2024 Bernard Compton · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Unavailability of timely ambulance response capacity during periods of demand View source Failure to ensure clinically indicated tests are repeated, directed and monitored View source Failure to ensure urgent blood results are acted upon immediately View source Failure of the emergency call algorithm to identify symptoms consistent with an ongoing myocardial infarction View source Lack of overnight patient oversight and effective patient management in the Emergency View source Delays in assessing and treating patients View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Bernard Compton · 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
Bernard Compton developed symptoms of a myocardial infarction, but delays in ambulance response, ECG interpretation, triage, blood-result review and clinical assessment meant that the optimum window for intervention had passed. He later suffered a left ventricular rupture and died on 19 October 2023. The concerns included inadequate oversight of patients and urgent results, unclear systems for repeating and acting on tests, and demand-related delays in ambulance and emergency care.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unavailability of timely ambulance response capacity during periods of demand
Wider context from the report “Demand on NWAS meant that even though they knew he had been diagnosed as being in the throes of a MI they could not get an ambulance to him in less than 45 minutes due to demand on their services .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure clinically indicated tests are repeated, directed and monitored
Wider context from the report “The ECG told the clinician that there was a likely MI. It was entirely unclear why that was not acted on. The clinician did ask for a repeat within 30 minutes. That did not happen. There was no evidence of a system to ensure tests were repeated and directed and how that was monitored .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure urgent blood results are acted upon immediately
Wider context from the report “It was unclear what system was in place to effectively ensure urgent blood results were acted upon immediately . The inquest was told the lab would telephone through on some occasions. It was unclear what the protocol was and who had oversight of it .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of the emergency call algorithm to identify symptoms consistent with an ongoing myocardial infarction
Wider context from the report “When Mr Compton made his first call to NWAS he was exhibiting symptoms consistent with an ongoing MI. However the questioning via the algorithm did not pick that up . NWAS were unable to clarify why that was the case. A call from someone actively having a MI was therefore categorised as a category 3 despite the time critical nature of the 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 overnight patient oversight and effective patient management in the Emergency
Wider context from the report “The inquest heard evidence that the delays in the Emergency were due to demand and were not unusual. It was recognised that the delays presented a risk and steps had been taken to try to mitigate them but there was no evidence that particularly during the night hours any one person had oversight of patients or that there was a system to ensure effective management of patients . The situation Mr Compton experienced was a direct consequence of the lack of oversight and system.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 assessing and treating patients
Wider context from the report “The consequence of delay in assessing and treating Mr Compton was that an opportunity to treat him effectively was not available to clinicians .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase ambulance capacity through the Urgent and Emergency Care recovery plan.
Verbatim wording from the response “There was significant demand on both NWAS and Tameside and Glossop Integrated Care NHS Foundation Trust in the Autumn of last year, with the Emergency Department (ED) at Tameside under significant pressure and all areas of the ED full. Health systems remain in recovery following the COVID-19 pandemic and pressures arising from it and the societal response. NHS England’s recovery plans include a focus on Urgent and Emergency Care, with one of the plan’s nine workstreams including increasing ambulance capacity. Since October 2023, Tameside’s ED has increased its capacity as part of a planned rebuild of the unit. My regional colleagues have approached the Greater Manchester Integrated Care Board (ICB) for further information regarding your concerns, as the local commissioner of the Trust.” 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 Concerns outside NHS England’s national policy or programme remit are not addressed in this response.
Verbatim wording from the response “My response to you focuses on those concerns raised in your Report that come under the remit of NHS England’s national policy or programme work. It would be more appropriate for the North West Ambulance Service (NWAS) NHS Trust and Tameside and Glossop Integrated Care NHS Foundation Trust to respond to some of the concerns raised, and you may wish to revert to those Trusts for 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 NWAS identified that the initial call was safely and appropriately triaged as Category 3 based on the symptoms provided.
Verbatim wording from the response “My regional colleagues in the North West have also engaged with NWAS on your concerns and are advised that NWAS have identified that the call was safely and appropriately triaged as Category 3 with the symptoms provided by Bernard on the initial call. It was identified by NWAS at the time that the call was potentially suitable to be supported by clinician callback and details were sent to the Greater Manchester Clinical Assessment Service (GMCAS) for clinical assessment, as per agreed” 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 NWAS, Tameside and Glossop Integrated Care NHS Foundation Trust, and the ICB should provide information on concerns assigned to them.
Verbatim wording from the response “My response to you focuses on those concerns raised in your Report that come under the remit of NHS England’s national policy or programme work. It would be more appropriate for the North West Ambulance Service (NWAS) NHS Trust and Tameside and Glossop Integrated Care NHS Foundation Trust to respond to some of the concerns raised, and you may wish to revert to those Trusts for further information.” Source location Response from NHS England
Open published response
3 Jun 2024 Tcherno Bari · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 12 Failure to ensure police access to the written risk assessment View source Failure to provide attending police officers with the written risk rating View source Failure to maintain an accurate and up-to-date missing person policy View source Lack of police officer awareness of the required risk rating View source Failure to communicate the RCRP challenge process to BSMHFT View source Delays in communicating police disagreement with the reported risk category View source Failure to require attending constables to give particular regard to mental health clinicians’ risk expertise View source Lack of formal notification of police disagreement about risk category View source Failure of Clinical Service Managers to coordinate attempts to locate high-risk missing patients View source Failure to inform BSMHFT when missing patient investigations are closed View source Failure to invite police representatives to daily appraisal meetings View source Failure of routine monitoring to ensure completion of the risk rating View source See 9 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
Tcherno Bari · 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
Tcherno Bari, who had been detained under the Mental Health Act and admitted to a psychiatric unit with psychotic depression, left the hospital grounds while assessed as at high risk of suicide. He was found deceased the following day, 26 September 2023, hanging from a tree in parkland outside the police search area. The principal concerns were significant gaps in multi-agency coordination, communication of risk information, use of risk-assessment procedures, and the handling of differing assessments between mental health staff and police.
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 police access to the written risk assessment
Wider context from the report “(7) The BSMHFT Missing Patient Policy and RCRP do not require BSMHFT to hand attending constables a copy of the risk assessment , or require attending constables, or later the Locate team, to request a copy of the risk assessment . In the event of a conflict about risk category, requiring attending constables to take early possession of the written risk assessment may lead to the police identifying they have overlooked key information and revisit their own risk category.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 attending police officers with the written risk rating
Wider context from the report “(1) I am not reassured BSMHFT staff are handing attending police officers ‘appendix C – risk rating’ as required by their missing person policy . I am not reassured WMP officers are aware they should be provided with ‘appendix C – risk rating’. Context: I did not accept the Nurse-in-Charge routinely used ‘appendix C – risk rating’ , and police witnesses - including a Locate Sergeant, and the Head of Locate, a Detective Chief Inspector - indicated they had never seen ‘appendix C – risk rating’.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 an accurate and up-to-date missing person policy
Wider context from the report “(5) The BSMHFT Missing Person Policy purports to append WMP’s missing person process but makes no mention of RCRP . I am not reassured the BSMHFT Missing Person Policy is therefore accurate and up-to-date .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 police officer awareness of the required risk rating
Wider context from the report “(1) I am not reassured BSMHFT staff are handing attending police officers ‘appendix C – risk rating’ as required by their missing person policy. I am not reassured WMP officers are aware they should be provided with ‘appendix C – risk rating’ . Context: I did not accept the Nurse-in-Charge routinely used ‘appendix C – risk rating’, and police witnesses - including a Locate Sergeant, and the Head of Locate, a Detective Chief Inspector - indicated they had never seen ‘appendix C – risk rating’ .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 the RCRP challenge process to BSMHFT
Wider context from the report “(4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT . Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it . However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process . Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later, and WMP often close missing patient investigations without informing BSMHFT.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 communicating police disagreement with the reported risk category
Wider context from the report “(4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT. Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it. However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process. Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later , and WMP often close missing patient investigations without informing BSMHFT.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 require attending constables to give particular regard to mental health clinicians’ risk expertise
Wider context from the report “(8) RCRP and APP do not require attending constables to have particular regard to the expertise of mental health clinicians and hesitate or be extra vigilant before rejecting their opinion on risk category. RCRP and APP appear to regard reports from mental health clinicians no differently to those from members of the public, and family and friends of the missing person . Context: police witnesses agreed that BSMHFT clinicians were the experts on mental health diagnosis, including identifying those conditions that carry an increased risk of suicide, and assessing the risk of suicide generally. However, this case demonstrates how in the heat of the moment an (inexperienced) attending constable can overlook that expertise and quickly dismiss it .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of formal notification of police disagreement about risk category
Wider context from the report “(6) RCRP does not require WMP to formally indicate to BSMHFT (i.e. via a form) when the police have taken a different view about the risk category . BSMHFT will often be unaware of the different view taken by the police rendering the ‘challenge’ process redundant and reducing the chances of the police identifying they have overlooked key information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of Clinical Service Managers to coordinate attempts to locate high-risk missing patients
Wider context from the report “(3) I am not reassured BSMHFT Clinical Service Managers (‘CSMs’) are (a) coordinating the attempts to locate high-risk missing patients , and (b) inviting a representative from WMP to attend ‘daily appraisal’ meetings to discuss the high-risk missing patient’s absence as required by their missing patient policy. I am not reassured WMP officers are aware this is the CSM’s role and of the expectation of being invited to a ‘daily appraisal’. Context: this process did not happen in Mr Bari’s case, and the WMP’s Head of Locate said she was not aware of the police ever being invited by a CSM to attend a ‘daily appraisal’.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to inform BSMHFT when missing patient investigations are closed
Wider context from the report “(4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT. Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it. However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process. Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later, and WMP often close missing patient investigations without informing BSMHFT .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 invite police representatives to daily appraisal meetings
Wider context from the report “(3) I am not reassured BSMHFT Clinical Service Managers (‘CSMs’) are (a) coordinating the attempts to locate high-risk missing patients, and (b) inviting a representative from WMP to attend ‘daily appraisal’ meetings to discuss the high-risk missing patient’s absence as required by their missing patient policy. I am not reassured WMP officers are aware this is the CSM’s role and of the expectation of being invited to a ‘daily appraisal’. Context: this process did not happen in Mr Bari’s case , and the WMP’s Head of Locate said she was not aware of the police ever being invited by a CSM to attend a ‘daily appraisal’ .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 routine monitoring to ensure completion of the risk rating
Wider context from the report “(2) A ‘monitoring tool’ in the BSMHFT Missing Patient Policy requires routine monitoring to ensure nurses are completing ‘appendix A’ and ‘appendix B’, but not ‘appendix C – risk rating’ . Context: I was told this is under review, however I was concerned this is still outstanding 9 months following the 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 Share information with health systems on establishing multi-agency governance, delivery structures, risk management, escalation and communication.
Verbatim wording from the response “To support implementation, NHS England has shared information with health systems about setting up multi-agency governance and delivery structures to oversee delivery, manage risks and escalations and enable open communication between 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 Issue guidance to health systems covering multi-agency governance, delivery structures and real-time and retrospective escalation processes.
Verbatim wording from the response “partners, including to resolve any challenges. Information has also been shared on escalation protocols, including the need for local partners to set up real-time escalation processes (in response to a situation that is currently live) and retrospective escalation processes (to review situations that have occurred, learn lessons and agree changes going forward). This information will be included in guidance that NHS England will issue to health systems shortly.” 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