19 Jul 2023 Evelyn Mary Dutton · Prevention of Future Deaths report Manchester South
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Concerns raised 3 Delays in transfer from ambulance to the Emergency Department View source Delays in ambulance transfer to hospital for elderly frail patients with hip fractures View source Delays in transfer from the Emergency Department to a ward for elderly frail patients with hip fractures View source
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AI-generated summary
Evelyn Mary Dutton · 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
Evelyn Mary Dutton, who had severe systemic sclerosis, was admitted after an accidental fall that caused a fractured neck of femur. Her nutritional status remained compromised, and she developed complications including electrolyte imbalance, vomiting blood and duodenal ulcers before deteriorating and dying in hospital on 13 August 2022. The report raised concerns about prolonged ambulance and hospital transfer delays for elderly frail patients with hip fractures.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in transfer from ambulance to the Emergency Department
Wider context from the report “1. The inquest heard evidence that after her fall, on 28th June 2022, despite her age and frailty there was a prolonged wait for an ambulance to take her to hospital. This was due to the demands on the ambulance service that day.
Once they reached hospital Mrs Dutton had to remain in the ambulance until a space became available for her in the Emergency Department . This was due to the pressure on the Emergency Department and was replicated across Greater Manchester. Once in the Emergency Department she then remained there until transfer to a ward on 29th June when a bed became available;
2. The evidence was that long waits for transfer to hospital and delays in being transferred to wards presented a significant risk to the health and wellbeing of elderly frail patients with hip fractures such as Mrs Dutton. The inquest was told that these delays were not unusual in summer of 2022.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance transfer to hospital for elderly frail patients with hip fractures
Wider context from the report “1. The inquest heard evidence that after her fall, on 28th June 2022, despite her age and frailty there was a prolonged wait for an ambulance to take her to hospital . This was due to the demands on the ambulance service that day.
Once they reached hospital Mrs Dutton had to remain in the ambulance until a space became available for her in the Emergency Department. This was due to the pressure on the Emergency Department and was replicated across Greater Manchester. Once in the Emergency Department she then remained there until transfer to a ward on 29th June when a bed became available;
2. The evidence was that long waits for transfer to hospital and delays in being transferred to wards presented a significant risk to the health and wellbeing of elderly frail patients with hip fractures such as Mrs Dutton. The inquest was told that these delays were not unusual in summer of 2022.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 transfer from the Emergency Department to a ward for elderly frail patients with hip fractures
Wider context from the report “1. The inquest heard evidence that after her fall, on 28th June 2022, despite her age and frailty there was a prolonged wait for an ambulance to take her to hospital. This was due to the demands on the ambulance service that day.
Once they reached hospital Mrs Dutton had to remain in the ambulance until a space became available for her in the Emergency Department. This was due to the pressure on the Emergency Department and was replicated across Greater Manchester. Once in the Emergency Department she then remained there until transfer to a ward on 29th June when a bed became available ;
2. The evidence was that long waits for transfer to hospital and delays in being transferred to wards presented a significant risk to the health and wellbeing of elderly frail patients with hip fractures such as Mrs Dutton. The inquest was told that these delays were not unusual in summer of 2022.
” 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 Speed up hospital discharges.
Verbatim wording from the response “The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care services, including improving ambulance response times, increasing ambulance capacity through growing the workforce, improving flow through hospitals, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.” Source location Response from NHS England
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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 Increase ambulance capacity by growing the workforce.
Verbatim wording from the response “The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care services, including improving ambulance response times, increasing ambulance capacity through growing the workforce, improving flow through hospitals, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.” Source location Response from NHS England
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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 Focus NHS organisations on improving accident-and-emergency and ambulance handover times.
Verbatim wording from the response “In July 2023, we also published a letter to Integrated Care Boards, NHS Trusts and Primary Care Networks titled Delivering operational resilience across the NHS this winter. This also included focusing on improvements around Accident & Emergency handover and ambulance handover times.” 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 Provide community alternatives to hospital admission through urgent response, virtual wards, enhanced care-home support and proactive care services.
Verbatim wording from the response “You also raised a concern over the delays transferring patients to hospital and wards and the risks to health and wellbeing of elderly, frail patients, such as Evelyn, this caused. NHS England’s services such as Urgent Community Response and Virtual” 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 Improve patient flow through hospitals.
Verbatim wording from the response “The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care services, including improving ambulance response times, increasing ambulance capacity through growing the workforce, improving flow through hospitals, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.” Source location Response from NHS England
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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 Improve ambulance response times through the urgent and emergency care recovery plan.
Verbatim wording from the response “NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all ambulance call categories than before the pandemic, as well as issues associated with handing over ambulance patients in a timely way as well as the flow of patients in and out of some NHS Trusts. That is why NHS England are focusing on improving ambulance performance for 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, published in January 2023.” 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 Achieve the Ambulance Response Programme standards in the region.
Verbatim wording from the response “Within the North West, ambulance performance is reviewed regularly via the Strategic Partnership and Transformation Board, a joint committee between NWAS and the Integrated Care Boards in the region. We acknowledge that there remains work to be done to improve NWAS performance but are committed to achieving the Ambulance Response Programme’s standards in the region.” 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 Increase intermediate-care throughput to reduce acute-bed discharge delays and accelerate admissions from emergency departments.
Verbatim wording from the response “Wards, Enhanced Health in Care Homes, and the development of Proactive Care services, are designed to offer support and timely access to alternatives to hospital admission. Whilst Evelyn required acute hospital care for her hip fracture, these improvements aim to reduce delays for those that do require urgent, inpatient care. Measures are also in place to increase throughput in Intermediate Care (IC) to help reduce delays in discharge from acute beds and speed up admission from ED.” Source location Response from NHS England
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17 Jul 2023 Jane Elizabeth Wadsworth · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to ensure administration and escalation of missed antibiotic doses View source Failure to discuss cases with the specialist Liver team View source Lack of clear clinical ownership of specialist consultation actions View source Lack of effective consultant input into inpatient care View source Failure of Critical Care Outreach assessment to address complex non-NEWS2 indicators of ICU need View source Failure to conduct effective doctor-to-doctor discussion of potential ICU involvement View source Unavailability and insufficient capacity of the Critical Care Outreach team View source See 4 more concerns
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AI-generated summary
Jane Elizabeth Wadsworth · 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
Jane Elizabeth Wadsworth became seriously unwell after elective hip surgery, developing a deep vein thrombosis, cellulitis, sepsis, acute kidney injury and liver failure, and died on 31 December 2022 despite intensive care treatment. Concerns included missed antibiotic doses, limited consultant input, unclear escalation and doctor-to-doctor discussion about intensive care, unavailable Critical Care Outreach support, and no evidence that specialist liver advice was obtained.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure administration and escalation of missed antibiotic doses
Wider context from the report “1. Mrs Wadsworth missed three doses of antibiotics prescribed to treat her infection according to the evidence given to the inquest. This did not appear to have been escalated and there was no clear explanation regarding this occurring other than that her cannula may not have been in place and there was a delay in a doctor being available to reinsert one;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss cases with the specialist Liver team
Wider context from the report “6. Following her first admission to ICU there was a note that Mrs Wadsworth’s case should be discussed with a specialist Liver team. There was no evidence available to the inquest that such a discussion had taken place . It was not entirely clear on the evidence precisely which clinician was to take ownership of the action.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 clinical ownership of specialist consultation actions
Wider context from the report “6. Following her first admission to ICU there was a note that Mrs Wadsworth’s case should be discussed with a specialist Liver team. There was no evidence available to the inquest that such a discussion had taken place. It was not entirely clear on the evidence precisely which clinician was to take ownership of the action .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 effective consultant input into inpatient care
Wider context from the report “2. The evidence before the inquest was that on her admission over Christmas/New Year there was no effective consultant input into her care ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of Critical Care Outreach assessment to address complex non-NEWS2 indicators of ICU need
Wider context from the report “4. The alternative support available to ward based staff and possible route into ICU according to the evidence given at inquest was via the Critical Care Outreach team. That team is staffed primarily by nurses and its key focus is on presentation linked to NEWS2 scores according to the evidence given to the inquest. Mrs Wadsworth’s case was a complex one involving issues relating to her liver function and kidney function rather than just her NEWS2 scores and it was unclear if the Critical Care Outreach Team were best placed to assess her need for ICU support ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct effective doctor-to-doctor discussion of potential ICU involvement
Wider context from the report “3. The junior doctor involved in her care felt that ICU involvement/input would be beneficial. The evidence was that there did not seem to be any doctor to doctor discussion of this . The inquest heard evidence that this was one way a patient could be transferred to ICU. It was unclear why there had not been such a discussion and whether in periods such as Christmas/ New Year where there were fewer consultants available the system worked effectively . This was not a situation where there had been a ward based ceiling of care put in place and ultimately Mrs Wadsworth was treated by ICU but was extremely unwell at that point and did not respond to that intervention at that point;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unavailability and insufficient capacity of the Critical Care Outreach team
Wider context from the report “5. The inquest heard that on the date of one referral that team was not in any event available to the ward and the nurse who should have undertaken the role had been redeployed elsewhere in the trust and there was no capacity to fill that role ;
” Open source report
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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 concerns fall under the Trust’s remit rather than NHS England’s functions.
Verbatim wording from the response “The matters of concern raised in your Report come under the remit of Tameside and Glossop Integrated Care NHS Foundation Trust (hereafter “the Trust”), who are therefore the appropriate organisation to respond to the concerns raised. I am however grateful to you for bringing these important patient safety issues to my attention. The concerns have been shared with my relevant regional Quality colleagues in the North West, who are engaging with Greater Manchester Integrated Care Board (the responsible commissioning body for Greater Manchester) about the issues raised.” Source location Response from NHS England
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust is the appropriate organisation to respond, with the Greater Manchester Integrated Care Board responsible for commissioning.
Verbatim wording from the response “The matters of concern raised in your Report come under the remit of Tameside and Glossop Integrated Care NHS Foundation Trust (hereafter “the Trust”), who are therefore the appropriate organisation to respond to the concerns raised. I am however grateful to you for bringing these important patient safety issues to my attention. The concerns have been shared with my relevant regional Quality colleagues in the North West, who are engaging with Greater Manchester Integrated Care Board (the responsible commissioning body for Greater Manchester) about the issues raised.” Source location Response from NHS England
Open published response
Concerns raised 9 Failure of medication-management processes to identify proposed carbamazepine treatment View source Lack of care-coordinators for seriously mentally ill patients View source Lack of GP resources for proactively checking collection of prescribed medication View source Delays in primary care organisations providing important patient updates to GPs View source Unavailability of approved mental health practitioners within 24 hours View source Unavailability of mental health places of safety View source Failure of digital systems used by different health organisations to communicate View source Unavailability of mental health inpatient beds View source Ineffective communication between specialist mental health teams View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
PETER MARTIN AARON FLEMING · 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
Peter Martin Aaron Fleming was found deceased in his flat on 10 November 2022 after taking a deliberate overdose of prescribed medication; his cause of death was confirmed as carbamazepine toxicity and the conclusion was suicide. The report raised concerns about inadequate mental health resources, ineffective communication between specialist teams and health organisations, delays in medication provision, and shortcomings in medication management and monitoring.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of medication-management processes to identify proposed carbamazepine treatment
Wider context from the report “3. Carbamazepine management was proposed in 2012 to manage the deceased’s mental health however this was not picked up by his GP and was only noted by a BSMHFT consultant in August 2022 . Therefore, the deceased went 10 years without this medication. BSMHFT could not explain at the inquest why this omission had not been identified sooner . BSMHFT’s RCA action plan does not have any action to avoid a repeat occurrence. My concern is this RCA indicates a problem with process and systems and further consideration is required to avoid a repeat occurrence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 care-coordinators for seriously mentally ill patients
Wider context from the report “1. There continues to be a chronic lack of resources to treat seriously mentally ill patients in Birmingham and Solihull . In the summer of 2022 Birmingham and Solihull Mental Health Trust (‘BSMHFT’) wanted to admit the deceased to an inpatient psychiatric unit, however, no bed was available, and he remained in the community. Shortly before his death, the deceased had been detained by the police under section 136 of the mental health act. There was no available ‘place of safety’ and he had to be taken to an emergency department. The police, BSMHFT, and hospital Drs agreed the deceased needed to be assessed under the mental health act, however Birmingham City Council could not provide an approved mental health practitioner (‘AMPH’) to attend in a 24-hour period. When the section 136 lapsed the deceased was discharged home after a review by a mental health nurse. At the time of his death the deceased was on BSMHFT’s waiting list for a care-coordinator. The lack of care-coordinators , mental health inpatient beds, ‘place of safety’, and AMHPs, presents a risk seriously mentally ill people are not receiving necessary treatment. The evidence is that these issues are a consequence of a chronic lack of resources at a local and national level. The Birmingham and Solihull coroners have been repeating identical concerns in Prevention of Future Death Reports for many years.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 GP resources for proactively checking collection of prescribed medication
Wider context from the report “5. The deceased’s GP raised concerns that current resources do not allow GPs to pro-actively check patients are collecting prescribed medication due to excessive patient lists . My concern is that this is a consequence of lack of resources at a national level .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 primary care organisations providing important patient updates to GPs
Wider context from the report “4. The deceased’s GP raised concerns that different health organisations use different digital systems that do not communicate with each other. Further, GPs often do not get important patient updates from primary care organisations for many days or weeks . (See examples above: the GP did not pick up the carbamazepine prescription, and could not prescribe the medication in October 2022). My concern is communication between different health organisations is not as effective as it could be and important information is being missed , and consequently a material delay in treatment is occurring .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 approved mental health practitioners within 24 hours
Wider context from the report “1. There continues to be a chronic lack of resources to treat seriously mentally ill patients in Birmingham and Solihull. In the summer of 2022 Birmingham and Solihull Mental Health Trust (‘BSMHFT’) wanted to admit the deceased to an inpatient psychiatric unit, however, no bed was available, and he remained in the community. Shortly before his death, the deceased had been detained by the police under section 136 of the mental health act. There was no available ‘place of safety’ and he had to be taken to an emergency department. The police, BSMHFT, and hospital Drs agreed the deceased needed to be assessed under the mental health act, however Birmingham City Council could not provide an approved mental health practitioner (‘AMPH’) to attend in a 24-hour period . When the section 136 lapsed the deceased was discharged home after a review by a mental health nurse. At the time of his death the deceased was on BSMHFT’s waiting list for a care-coordinator. The lack of care-coordinators, mental health inpatient beds, ‘place of safety’, and AMHPs , presents a risk seriously mentally ill people are not receiving necessary treatment. The evidence is that these issues are a consequence of a chronic lack of resources at a local and national level. The Birmingham and Solihull coroners have been repeating identical concerns in Prevention of Future Death Reports for many years.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 mental health places of safety
Wider context from the report “1. There continues to be a chronic lack of resources to treat seriously mentally ill patients in Birmingham and Solihull. In the summer of 2022 Birmingham and Solihull Mental Health Trust (‘BSMHFT’) wanted to admit the deceased to an inpatient psychiatric unit, however, no bed was available, and he remained in the community. Shortly before his death, the deceased had been detained by the police under section 136 of the mental health act. There was no available ‘place of safety’ and he had to be taken to an emergency department. The police, BSMHFT, and hospital Drs agreed the deceased needed to be assessed under the mental health act, however Birmingham City Council could not provide an approved mental health practitioner (‘AMPH’) to attend in a 24-hour period. When the section 136 lapsed the deceased was discharged home after a review by a mental health nurse. At the time of his death the deceased was on BSMHFT’s waiting list for a care-coordinator. The lack of care-coordinators, mental health inpatient beds, ‘place of safety’ , and AMHPs, presents a risk seriously mentally ill people are not receiving necessary treatment. The evidence is that these issues are a consequence of a chronic lack of resources at a local and national level. The Birmingham and Solihull coroners have been repeating identical concerns in Prevention of Future Death Reports for many years.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 digital systems used by different health organisations to communicate
Wider context from the report “4. The deceased’s GP raised concerns that different health organisations use different digital systems that do not communicate with each other . Further, GPs often do not get important patient updates from primary care organisations for many days or weeks. (See examples above: the GP did not pick up the carbamazepine prescription, and could not prescribe the medication in October 2022). My concern is communication between different health organisations is not as effective as it could be and important information is being missed, and consequently a material delay in treatment is occurring.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 mental health inpatient beds
Wider context from the report “1. There continues to be a chronic lack of resources to treat seriously mentally ill patients in Birmingham and Solihull. In the summer of 2022 Birmingham and Solihull Mental Health Trust (‘BSMHFT’) wanted to admit the deceased to an inpatient psychiatric unit, however, no bed was available , and he remained in the community. Shortly before his death, the deceased had been detained by the police under section 136 of the mental health act. There was no available ‘place of safety’ and he had to be taken to an emergency department. The police, BSMHFT, and hospital Drs agreed the deceased needed to be assessed under the mental health act, however Birmingham City Council could not provide an approved mental health practitioner (‘AMPH’) to attend in a 24-hour period. When the section 136 lapsed the deceased was discharged home after a review by a mental health nurse. At the time of his death the deceased was on BSMHFT’s waiting list for a care-coordinator. The lack of care-coordinators, mental health inpatient beds , ‘place of safety’, and AMHPs, presents a risk seriously mentally ill people are not receiving necessary treatment. The evidence is that these issues are a consequence of a chronic lack of resources at a local and national level. The Birmingham and Solihull coroners have been repeating identical concerns in Prevention of Future Death Reports for many years.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Ineffective communication between specialist mental health teams
Wider context from the report “2. BSMHFT utilizes self-contained specialist teams. The deceased was treated by (a) crisis team/home treatment team, (b) community mental health team, and (b) psychiatric liaison team. The evidence demonstrated communication between the specialist teams was not effective and this caused delays. For example, the psychiatric liaison team nurse that reviewed the deceased updated the community mental health team. However, the GP could not prescribe the deceased’s medication in October 2022 because it had not been approved by the community mental health team consultant via an ESCA and the deceased went without his medication. The deceased’s GP had to contact the community mental health team directly notwithstanding the psychiatric liaison nurse’s involvement. The deceased cited this delay as making his mental health worse shortly before his death. My concern is communication between the specialist teams is not effective enough . BSMHFT’s RCA action plan is to seek assurance from the CCG/ICB that communication between the specialist teams is being strengthened. My concern is that this does not go far enough and there should be consideration of a formal process or policy.
” 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 Develop interoperable shared care records to enable safe and secure information sharing across NHS and social care services.
Verbatim wording from the response “In addition, NHS England is also undertaking a programme of work that will enable the safe and secure sharing of an individual’s health and care information as they move between different parts of the NHS and social care. A shared care record joins up” 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 Establish and operate the Mental Health, Learning Disability and Autism Inpatient Quality Transformation Programme.
Verbatim wording from the response “In 2022, NHS England also established a new Mental Health, Learning Disability and Autism Inpatient Quality Transformation Programme. The programme’s aim is to support cultural change and a reimagined model of care for the future across all NHS-funded mental health, learning disability and autism inpatient settings. It is underpinned by £36 million investment over three years and focuses on the following four themes:” 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 Improve digital capability so relevant information is automatically added to GP patient records.
Verbatim wording from the response “Current GP systems are designed to be interoperable before being allowed to be used for patient care and as such are accredited under the Digital Care Services Catalogue which requires suppliers to meet relevant standards, including interoperability with other systems, which is a pre-requisite of being included on the catalogue. This has enabled almost all GPs (99%) to have the digital capability to share and receive medical information from a variety of care providers within the NHS. This quick and efficient way of relaying and transmitting information between clinicians should address the sharing of important clinical information. The NHS is working to further improve this capability to enable information to be automatically added into the GP Patient record as appropriate.” 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 Accredited interoperable GP systems and widespread digital capability should address the sharing of important clinical information.
Verbatim wording from the response “Current GP systems are designed to be interoperable before being allowed to be used for patient care and as such are accredited under the Digital Care Services Catalogue which requires suppliers to meet relevant standards, including interoperability with other systems, which is a pre-requisite of being included on the catalogue. This has enabled almost all GPs (99%) to have the digital capability to share and receive medical information from a variety of care providers within the NHS. This quick and efficient way of relaying and transmitting information between clinicians should address the sharing of important clinical information. The NHS is working to further improve this capability to enable information to be automatically added into the GP Patient record as 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 Many concerns, particularly those relating to the mental health trust, fall outside the respondent’s remit.
Verbatim wording from the response “This letter responds to the concerns raised in your report relevant to NHS England. It is not within NHS England’s remit to respond to many of the concerns raised, particularly relating to Birmingham and Solihull Mental Health Trust (BSMHFT). NHS England has asked to be sighted on the responses from BSMHFT and Birmingham and Solihull Integrated Care Board (ICB) and will give due consideration to their responses.” Source location Response from NHS England
Open published response
Concerns raised 1 Failure of Mental Health Liaison teams to detain or hold absconding patients in acute hospitals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Rachel Kathleen Garrett · 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
Rachel Kathleen Garrett had been experiencing deteriorating mental health and was found near the cliffs on several occasions. On 29 July 2020, after leaving the Royal Sussex County Hospital for a second time, she returned to the cliffs and ended her life by falling from the cliff top. The report’s principal concern was that mental health liaison staff employed by a separate mental health trust could not themselves use holding powers to prevent a patient leaving an acute hospital, creating a risk when patients with deteriorating mental health attended A&E.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of Mental Health Liaison teams to detain or hold absconding patients in acute hospitals
Wider context from the report “Patients who attend a Hospital Accident and Emergency Department with mental health difficulties are in most hospitals seen by a Mental Health Liaison team (made up of Consultant Psychiatrists and Mental Health nurses) These staff are not employed by the Acute Hospital Trust but are employed by a local Mental Health Trust (in this particular case it was the Sussex Partnership Foundation Trust).
As a result of their employment status the Mental Health Liaison team (who have the best knowledge of the patient having been caring for them) cannot invoke the Doctors or Nurses holding powers under Section 5(2) Mental Health Act (Section 5(4) for nurses). If a patient decides to abscond from the Acute Trust Hospital the Mental Health staff cannot detain/hold the patient. They would have to ask a Doctor within the Acute Hospital to do so. This Doctor may not have any knowledge of the patient and would be unlikely to act immediately in a busy A&E. By that time the patient would have been long gone.
Due to this technical issue around the employment status of the Mental Health Team, those suffering with a deteriorating mental health in an acute setting are at risk in these circumstances.
” 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 Raise the case with the Department for Health and Social Care for consideration of the Mental Health Act issues identified.
Verbatim wording from the response “NHS England will also be raising this case with the Department for Health and Social Education and who have responsibility for Mental Health Act legislation, for their consideration of the issues raised.” 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 Administering or delegating Mental Health Act holding powers within trusts or systems is outside NHS England’s remit.
Verbatim wording from the response “It is not within the remit of NHS England to manage how MHA powers are administered or delegated within Trusts or systems. Some Acute Trusts will provide mental health liaison teams with honorary contracts, to ensure that they can exercise holding powers outside of their substantive Trust. While I note that this arrangement was not in place in Rachel’s case, NHS England has engaged with NHS Sussex Integrated Care Board (ICB) on this matter, who have advised that the following actions are being undertaken:” 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 Sussex Integrated Care Board is undertaking local pathway and safety improvements concerning detention powers in acute emergency departments.
Verbatim wording from the response “It is not within the remit of NHS England to manage how MHA powers are administered or delegated within Trusts or systems. Some Acute Trusts will provide mental health liaison teams with honorary contracts, to ensure that they can exercise holding powers outside of their substantive Trust. While I note that this arrangement was not in place in Rachel’s case, NHS England has engaged with NHS Sussex Integrated Care Board (ICB) on this matter, who have advised that the following actions are being undertaken:” Source location Response from NHS England
Open published response
23 Jun 2023 Stephen Kurt Beadman · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 3 Failure to restrict access to potentially harmful male-grooming equipment for prisoners with an identified history of self-harming View source Insufficient specialist psychiatric care for prisoners View source Failure to withdraw potentially harmful male-grooming equipment from use in the prison View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Stephen Kurt Beadman · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen Kurt Beadman was a 34-year-old serving prisoner at HMP Wakefield who was found unresponsive after applying a ligature to his neck and died in hospital the following day. The Inquest found that he committed suicide having been bullied by other prisoners. The principal concern was that the prison’s limited consultant psychiatrist resource was insufficient for the complex mental health needs of its prisoner population, creating concern that other deaths may occur.
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 restrict access to potentially harmful male-grooming equipment for prisoners with an identified history of self-harming
Wider context from the report “1) Mr Beadman had a history of self-harming ████████. Nonetheless, he was permitted ████████ in his possession when alone in his cell.
2) For the avoidance of doubt, Mr Beadman took his own life later in the afternoon of 7th April 2021 by applying a ligature to his neck, ████████ to take his own life.
3) The issue of ████████ gives rise to a foreseeable risk.
4) Only six weeks before the 7th April 2021 incident, another prisoner, Carl Shaun Langdell had used a similar type of ████████ to inflict a fatal wound to his neck. A Prevention of Future Death Report dated 21.10.22 was made in that case. A copy is attached, along with the response received from ████████ dated 23.12.22.
5) Evidence was taken at the Inquest in which several people working at the prison expressed support for such ████████ to be withdrawn from use in the prison.
6) It is acknowledged that consideration has been given within the prison service nationally to the withdrawal of ████████ of this type and that this work (including various pilot projects) is ongoing. It is further acknowledged that the difficulties in identifying a workable alternative system of male grooming are considerable. This does not, however, obviate the need to remove a clear source of potential harm from those with an identified history of self-harming.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 specialist psychiatric care for prisoners
Wider context from the report “2) Despite this complex cohort of prisoners, the prison only has one day per week of consultant psychiatrist resource . As the professed principle is equivalence of care with the community, this seems not to be achieved , particularly having regard to the psychological make up of the prisoner population.
3) Evidence taken at the Inquest indicated that further senior psychiatric doctor resource would enable the prison to provide better for the needs of the prisoners .
4) For the avoidance of doubt, it is accepted that Mr Beadman himself was able to see the consultant psychiatrist on 19th October 2021 for 1 hour and again on 25th January 2021 (at which time he was discharged). Notwithstanding that his death on 8th April 2021 cannot be attributed to a lack of psychiatric attention, there is a concern that other long-term inmates in the prison are not receiving the specialist care they probably need . This in turn gives rise to a concern that other deaths may occur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 withdraw potentially harmful male-grooming equipment from use in the prison
Wider context from the report “1) Mr Beadman had a history of self-harming ████████. Nonetheless, he was permitted ████████ in his possession when alone in his cell.
2) For the avoidance of doubt, Mr Beadman took his own life later in the afternoon of 7th April 2021 by applying a ligature to his neck, ████████ to take his own life.
3) The issue of ████████ gives rise to a foreseeable risk.
4) Only six weeks before the 7th April 2021 incident, another prisoner, Carl Shaun Langdell had used a similar type of ████████ to inflict a fatal wound to his neck. A Prevention of Future Death Report dated 21.10.22 was made in that case. A copy is attached, along with the response received from ████████ dated 23.12.22.
5) Evidence was taken at the Inquest in which several people working at the prison expressed support for such ████████ to be withdrawn from use in the prison.
6) It is acknowledged that consideration has been given within the prison service nationally to the withdrawal of ████████ of this type and that this work (including various pilot projects) is ongoing. It is further acknowledged that the difficulties in identifying a workable alternative system of male grooming are considerable. This does not, however, obviate the need to remove a clear source of potential harm from those with an identified history of self-harming.
” Open source report
22 Jun 2023 Stephen Norman RICHARDSON · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1 Lack of acute psychiatric beds for immediate inpatient assessment, treatment and care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Stephen Norman RICHARDSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen Norman Richardson died on 28 September 2019 after a self-inflicted ligature incident at the Sid Watkins Unit on 24 September 2019, following extensive brain damage and withdrawal of life support by his family. The report identified concerns including failures to secure an acute mental health bed, missed opportunities relating to treatment and risk assessment, inadequate communication and safeguarding planning, and staff not following the correct emergency response procedure. It also noted an ongoing national shortage of acute psychiatric beds.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of acute psychiatric beds for immediate inpatient assessment, treatment and care
Wider context from the report “It was clear from the investigation that at the time of Stephen ligaturing in May 2019 there was anational shortage of acute psychiatric beds to treat patients in the community suffering with mental disorder of a nature or degree which necessitated immediate assessment treatment and care as an inpatient . The evidence heard has confirmed that that parlous situation has not improved .
” Open source report
Concerns raised 15 Omissions from serious incident investigations View source Failure to communicate the appropriate level of suicide risk to police View source Lack of ward assistance and contingency planning for retrieval of an absconded patient View source Lack of instructions for staff following an absconded patient View source Failure to prepare clinical staff to maintain line of sight when a patient absconds View source Failure to recognise imminent suicide risk after a patient absconds View source Failure to volunteer the trust's risk grading when reporting a patient to police View source Confusion about police contact when a patient is missing View source Lack of training for doctors and nurses in street restraint and patient transport View source Unavailability of police assistance for clinicians responding to an absconded patient View source Failure of police and health-trust partnership working to allocate responsibility for patient retrieval View source Lack of learning culture at ELFT View source Inconsistent terminology and definitions between police and mental-health services View source Failure of police reporting information to align with local policies View source Failure to routinely record all useful risk information in police reports View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Heather FINDLAY · 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
Heather Findlay was detained under section 2 of the Mental Health Act at Mile End Hospital and ran away while on escorted leave on 11 June 2020. She was later found by a member of the public in a nearby park; the inquest concluded that she died by suicide, with a medical cause of death of hypoxic ischaemic encephalopathy and ████████ toxicity. The principal concerns included staff preparedness and procedures when a detained patient absconds, unclear responsibilities between ELFT and the police, communication of suicide risk, and the adequacy of risk grading and organisational learning.
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 Omissions from serious incident investigations
Wider context from the report “6. ELFT staff all told me that, after Ms Findlay had run off, they still graded her as medium rather than high risk. She had had long term suicidal thoughts, had made previous attempts on her life and, prior to being admitted to hospital on 20 May 2020 had purchased ████████ and had planned to take this to kill herself. However, she had appeared to improve in hospital, and had been granted 15 minutes’ escorted leave twice a day since 1 June without incident.
At one point in her evidence it appeared to me that the matron, taking the point that by running away Ms Findlay had acted in a manner that was wholly unexpected by the trust, was of the view that Ms Findlay should then have been re-categorised as high risk. However, following re-examination by counsel for ELFT the matron appeared to retract this and to return to her former position that, even after she had run away Ms Findlay was only of medium risk to herself.
It is of course a matter of clinical opinion what risk grading a patient should be given, and no person can see into the future.
However,
• the jury found a failure by ELFT to recognise that, by 11 June 2020, Ms Findlay was at imminent risk of suicide by ████████; and
• any investigation following a death like Heather Findlay’s presents an opportunity for sober and searching reflection.
So I am concerned that an element of positional bias may have influenced the thinking of ELFT staff.
I am concerned about this particularly because, when giving evidence at inquest, the ELFT serious incident investigation author was adamant that it was only appropriate for the HCA who called the police on 11 June 2020 after Ms Findlay had run away, to tell the police of a risk of self harm not of a risk of suicide. Her rationale for this was that the last time Ms Findlay had articulated a plan to kill herself, was when she was found in hospital with a ligature round her neck on 28 May 2020.
This position seems lacking the necessary reflection.
I draw your attention to earlier prevention of future deaths reports (PFDs) as follows:
• Sent to ELFT on 8 June 2023 by Assistant Coroner Buckett following the inquest touching the death of Hilary (Billy) Guedalla, including concern regarding the failure of ELFT to inform the police of the serious suicide risk that the deceased posed to themselves; and the confusion among staff about who should be contacted and in what manner, once a patient was found to be missing.
• Sent to ELFT on 25 January 2023 by me following the inquest touching the death of Andrew Largin, including concern about omissions from a serious incident investigation .
• Sent to ELFT on 20 October 2021 by me following the inquest touching the death of Freeda Glausiusz, including concern about a lack of learning culture at ELFT.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 appropriate level of suicide risk to police
Wider context from the report “6. ELFT staff all told me that, after Ms Findlay had run off, they still graded her as medium rather than high risk. She had had long term suicidal thoughts, had made previous attempts on her life and, prior to being admitted to hospital on 20 May 2020 had purchased ████████ and had planned to take this to kill herself. However, she had appeared to improve in hospital, and had been granted 15 minutes’ escorted leave twice a day since 1 June without incident.
At one point in her evidence it appeared to me that the matron, taking the point that by running away Ms Findlay had acted in a manner that was wholly unexpected by the trust, was of the view that Ms Findlay should then have been re-categorised as high risk. However, following re-examination by counsel for ELFT the matron appeared to retract this and to return to her former position that, even after she had run away Ms Findlay was only of medium risk to herself.
It is of course a matter of clinical opinion what risk grading a patient should be given, and no person can see into the future.
However,
• the jury found a failure by ELFT to recognise that, by 11 June 2020, Ms Findlay was at imminent risk of suicide by ████████; and
• any investigation following a death like Heather Findlay’s presents an opportunity for sober and searching reflection.
So I am concerned that an element of positional bias may have influenced the thinking of ELFT staff.
I am concerned about this particularly because, when giving evidence at inquest, the ELFT serious incident investigation author was adamant that it was only appropriate for the HCA who called the police on 11 June 2020 after Ms Findlay had run away, to tell the police of a risk of self harm not of a risk of suicide . Her rationale for this was that the last time Ms Findlay had articulated a plan to kill herself, was when she was found in hospital with a ligature round her neck on 28 May 2020.
This position seems lacking the necessary reflection .
I draw your attention to earlier prevention of future deaths reports (PFDs) as follows:
• Sent to ELFT on 8 June 2023 by Assistant Coroner Buckett following the inquest touching the death of Hilary (Billy) Guedalla, including concern regarding the failure of ELFT to inform the police of the serious suicide risk that the deceased posed to themselves; and the confusion among staff about who should be contacted and in what manner, once a patient was found to be missing.
• Sent to ELFT on 25 January 2023 by me following the inquest touching the death of Andrew Largin, including concern about omissions from a serious incident investigation.
• Sent to ELFT on 20 October 2021 by me following the inquest touching the death of Freeda Glausiusz, including concern about a lack of learning culture at ELFT.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of ward assistance and contingency planning for retrieval of an absconded patient
Wider context from the report “4. I heard that Right Care, Right Person is an operational model developed by Humberside Police that changes the way the emergency services respond to calls involving concerns about mental health. I understand that it is in the process of being rolled out across the UK as part of ongoing work between police forces, health providers and government.
I heard that the MPS has already created a similar model under the resource and demand team. The protocol is called Affinity. It attempts to target preventable demand from the mental health trusts.
I was told that ELFT and the MPS work in partnership, so I asked the MPS what is meant to happen if an escort is following a patient who has run away and about whom the escort is worried.
I was told that this is primarily a health problem. It was pointed out that doctors, nurses and other hospital staff have the same powers as the police under section 18 of the Mental Health Act. Hospital employees have the legal authority to take a sectioned patient into custody and return them to hospital.
However, I heard nothing of an ELFT protocol that would advise staff on the ward to come out to assist an escort who already following a patient. I heard nothing of a trust contingency plan that would allow a ward to function without the doctors and nurses needed to undertake such a task . I heard nothing of any training given to doctors and nurses in how to restrain a patient in the middle of the street and to transport them back to the ward.
From the evidence I heard, the police / health trust partnership working allows each agency to regard such a situation as the other’s responsibility, whilst nobody is on the ground attempting to retrieve a seriously ill patient who is meant to be inside a locked ward for their own safety.
Whether this is a matter of policy or practice, the result is the same. If partner agency working is to be effective in caring for this extremely vulnerable cohort of patients, there needs to be crystal clear understanding by all those involved, from the highest policy maker to the most junior member of a team at the sharp end, of how to tackle these difficult situations and exactly who is meant to be doing what.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of instructions for staff following an absconded patient
Wider context from the report “2. By the time the HCA rang the duty senior nurse for advice Ms Findlay was out of sight, and so the HCA was instructed to return to the ward.
I heard evidence that an email is to be sent out shortly to explain that a new ELFT absent without leave policy will be in place by the end of June 2023. The new policy will confirm that, if it is safe to do so an escort may follow a patient who has absconded, keeping them in line of sight whilst ringing the duty senior nurse for instructions.
However, there is no ELFT policy for what those instructions should be or even what they could include . No member of ELFT gave evidence of any organisational thought having gone into how then to progress such a situation, other than the ward calling the police to report a missing person. No member of ELFT giving evidence was able to set out what the staff member following should do .
This appears to be a significant omission.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 prepare clinical staff to maintain line of sight when a patient absconds
Wider context from the report “1. When Ms Findlay ran off, the HCA escorting her was so panicked that she did not even think of following. Ms Findlay had run across a road and so chasing her at speed did present safety considerations. However, the ELFT policy, training, culture and expectation was such, that there the HCA did not at any point consider attempting to walk after her to keep her in sight . Clinical staff must be adequately prepared for such an eventuality .
That means more than simply a change in policy wording.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 imminent suicide risk after a patient absconds
Wider context from the report “6. ELFT staff all told me that, after Ms Findlay had run off, they still graded her as medium rather than high risk. She had had long term suicidal thoughts, had made previous attempts on her life and, prior to being admitted to hospital on 20 May 2020 had purchased ████████ and had planned to take this to kill herself. However, she had appeared to improve in hospital, and had been granted 15 minutes’ escorted leave twice a day since 1 June without incident.
At one point in her evidence it appeared to me that the matron, taking the point that by running away Ms Findlay had acted in a manner that was wholly unexpected by the trust, was of the view that Ms Findlay should then have been re-categorised as high risk. However, following re-examination by counsel for ELFT the matron appeared to retract this and to return to her former position that, even after she had run away Ms Findlay was only of medium risk to herself.
It is of course a matter of clinical opinion what risk grading a patient should be given, and no person can see into the future.
However,
• the jury found a failure by ELFT to recognise that, by 11 June 2020, Ms Findlay was at imminent risk of suicide by ████████; and
• any investigation following a death like Heather Findlay’s presents an opportunity for sober and searching reflection.
So I am concerned that an element of positional bias may have influenced the thinking of ELFT staff .
I am concerned about this particularly because, when giving evidence at inquest, the ELFT serious incident investigation author was adamant that it was only appropriate for the HCA who called the police on 11 June 2020 after Ms Findlay had run away, to tell the police of a risk of self harm not of a risk of suicide. Her rationale for this was that the last time Ms Findlay had articulated a plan to kill herself, was when she was found in hospital with a ligature round her neck on 28 May 2020.
This position seems lacking the necessary reflection.
I draw your attention to earlier prevention of future deaths reports (PFDs) as follows:
• Sent to ELFT on 8 June 2023 by Assistant Coroner Buckett following the inquest touching the death of Hilary (Billy) Guedalla, including concern regarding the failure of ELFT to inform the police of the serious suicide risk that the deceased posed to themselves; and the confusion among staff about who should be contacted and in what manner, once a patient was found to be missing.
• Sent to ELFT on 25 January 2023 by me following the inquest touching the death of Andrew Largin, including concern about omissions from a serious incident investigation.
• Sent to ELFT on 20 October 2021 by me following the inquest touching the death of Freeda Glausiusz, including concern about a lack of learning culture at ELFT.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 volunteer the trust's risk grading when reporting a patient to police
Wider context from the report “5. Evidence was given that the police classify a person at high risk as: the risk is immediate and there are substantial grounds for believing immediate risk of self harm.
I was told by the MPS that, at the time of reporting to the MPS, trusts should volunteer their own grading of the patient’s risk. The police said that they will not necessarily following the trust grading, but they regard it as a significant factor and it should form part of the MPS thinking. ELFT witnesses told me that if the police did not ask for the trust’s grading then the trust would not offer it .
I was told that, until April 2022 the grab pack prepared by ELFT for the MPS in such a situation was printed out and handed to police if & when the police attended the ward. It is now filled out on a portal as part of the reporting procedure. However, it is not clear to me how far the grab pack aligns with local policies, whether all useful information (including the trust’s grading of risk) is recorded as a matter of routine, and how far the police and the trust are using the same terminology with the same definitions.
It seems that this would benefit from consideration.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Confusion about police contact when a patient is missing
Wider context from the report “6. ELFT staff all told me that, after Ms Findlay had run off, they still graded her as medium rather than high risk. She had had long term suicidal thoughts, had made previous attempts on her life and, prior to being admitted to hospital on 20 May 2020 had purchased ████████ and had planned to take this to kill herself. However, she had appeared to improve in hospital, and had been granted 15 minutes’ escorted leave twice a day since 1 June without incident.
At one point in her evidence it appeared to me that the matron, taking the point that by running away Ms Findlay had acted in a manner that was wholly unexpected by the trust, was of the view that Ms Findlay should then have been re-categorised as high risk. However, following re-examination by counsel for ELFT the matron appeared to retract this and to return to her former position that, even after she had run away Ms Findlay was only of medium risk to herself.
It is of course a matter of clinical opinion what risk grading a patient should be given, and no person can see into the future.
However,
• the jury found a failure by ELFT to recognise that, by 11 June 2020, Ms Findlay was at imminent risk of suicide by ████████; and
• any investigation following a death like Heather Findlay’s presents an opportunity for sober and searching reflection.
So I am concerned that an element of positional bias may have influenced the thinking of ELFT staff.
I am concerned about this particularly because, when giving evidence at inquest, the ELFT serious incident investigation author was adamant that it was only appropriate for the HCA who called the police on 11 June 2020 after Ms Findlay had run away, to tell the police of a risk of self harm not of a risk of suicide. Her rationale for this was that the last time Ms Findlay had articulated a plan to kill herself, was when she was found in hospital with a ligature round her neck on 28 May 2020.
This position seems lacking the necessary reflection.
I draw your attention to earlier prevention of future deaths reports (PFDs) as follows:
• Sent to ELFT on 8 June 2023 by Assistant Coroner Buckett following the inquest touching the death of Hilary (Billy) Guedalla, including concern regarding the failure of ELFT to inform the police of the serious suicide risk that the deceased posed to themselves ; and the confusion among staff about who should be contacted and in what manner, once a patient was found to be missing .
• Sent to ELFT on 25 January 2023 by me following the inquest touching the death of Andrew Largin, including concern about omissions from a serious incident investigation.
• Sent to ELFT on 20 October 2021 by me following the inquest touching the death of Freeda Glausiusz, including concern about a lack of learning culture at ELFT.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of training for doctors and nurses in street restraint and patient transport
Wider context from the report “4. I heard that Right Care, Right Person is an operational model developed by Humberside Police that changes the way the emergency services respond to calls involving concerns about mental health. I understand that it is in the process of being rolled out across the UK as part of ongoing work between police forces, health providers and government.
I heard that the MPS has already created a similar model under the resource and demand team. The protocol is called Affinity. It attempts to target preventable demand from the mental health trusts.
I was told that ELFT and the MPS work in partnership, so I asked the MPS what is meant to happen if an escort is following a patient who has run away and about whom the escort is worried.
I was told that this is primarily a health problem. It was pointed out that doctors, nurses and other hospital staff have the same powers as the police under section 18 of the Mental Health Act. Hospital employees have the legal authority to take a sectioned patient into custody and return them to hospital.
However, I heard nothing of an ELFT protocol that would advise staff on the ward to come out to assist an escort who already following a patient. I heard nothing of a trust contingency plan that would allow a ward to function without the doctors and nurses needed to undertake such a task. I heard nothing of any training given to doctors and nurses in how to restrain a patient in the middle of the street and to transport them back to the ward .
From the evidence I heard, the police / health trust partnership working allows each agency to regard such a situation as the other’s responsibility, whilst nobody is on the ground attempting to retrieve a seriously ill patient who is meant to be inside a locked ward for their own safety.
Whether this is a matter of policy or practice, the result is the same. If partner agency working is to be effective in caring for this extremely vulnerable cohort of patients, there needs to be crystal clear understanding by all those involved, from the highest policy maker to the most junior member of a team at the sharp end, of how to tackle these difficult situations and exactly who is meant to be doing what.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 police assistance for clinicians responding to an absconded patient
Wider context from the report “3. Moreover, one of the MPS policy leads in this area gave evidence that in such a situation the police would not necessarily attend , even if called direct by a hospital staff member in the street following a patient about whom they are worried.
I spent some time examining the police regarding this point, and I was left with the impression that a clinician calling the police in what the clinician perceived to be an emergency situation might not be assisted by the police .
That concerned me.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of police and health-trust partnership working to allocate responsibility for patient retrieval
Wider context from the report “4. I heard that Right Care, Right Person is an operational model developed by Humberside Police that changes the way the emergency services respond to calls involving concerns about mental health. I understand that it is in the process of being rolled out across the UK as part of ongoing work between police forces, health providers and government.
I heard that the MPS has already created a similar model under the resource and demand team. The protocol is called Affinity. It attempts to target preventable demand from the mental health trusts.
I was told that ELFT and the MPS work in partnership, so I asked the MPS what is meant to happen if an escort is following a patient who has run away and about whom the escort is worried.
I was told that this is primarily a health problem. It was pointed out that doctors, nurses and other hospital staff have the same powers as the police under section 18 of the Mental Health Act. Hospital employees have the legal authority to take a sectioned patient into custody and return them to hospital.
However, I heard nothing of an ELFT protocol that would advise staff on the ward to come out to assist an escort who already following a patient. I heard nothing of a trust contingency plan that would allow a ward to function without the doctors and nurses needed to undertake such a task. I heard nothing of any training given to doctors and nurses in how to restrain a patient in the middle of the street and to transport them back to the ward.
From the evidence I heard, the police / health trust partnership working allows each agency to regard such a situation as the other’s responsibility , whilst nobody is on the ground attempting to retrieve a seriously ill patient who is meant to be inside a locked ward for their own safety.
Whether this is a matter of policy or practice, the result is the same. If partner agency working is to be effective in caring for this extremely vulnerable cohort of patients, there needs to be crystal clear understanding by all those involved, from the highest policy maker to the most junior member of a team at the sharp end, of how to tackle these difficult situations and exactly who is meant to be doing what.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 learning culture at ELFT
Wider context from the report “6. ELFT staff all told me that, after Ms Findlay had run off, they still graded her as medium rather than high risk. She had had long term suicidal thoughts, had made previous attempts on her life and, prior to being admitted to hospital on 20 May 2020 had purchased ████████ and had planned to take this to kill herself. However, she had appeared to improve in hospital, and had been granted 15 minutes’ escorted leave twice a day since 1 June without incident.
At one point in her evidence it appeared to me that the matron, taking the point that by running away Ms Findlay had acted in a manner that was wholly unexpected by the trust, was of the view that Ms Findlay should then have been re-categorised as high risk. However, following re-examination by counsel for ELFT the matron appeared to retract this and to return to her former position that, even after she had run away Ms Findlay was only of medium risk to herself.
It is of course a matter of clinical opinion what risk grading a patient should be given, and no person can see into the future.
However,
• the jury found a failure by ELFT to recognise that, by 11 June 2020, Ms Findlay was at imminent risk of suicide by ████████; and
• any investigation following a death like Heather Findlay’s presents an opportunity for sober and searching reflection.
So I am concerned that an element of positional bias may have influenced the thinking of ELFT staff.
I am concerned about this particularly because, when giving evidence at inquest, the ELFT serious incident investigation author was adamant that it was only appropriate for the HCA who called the police on 11 June 2020 after Ms Findlay had run away, to tell the police of a risk of self harm not of a risk of suicide. Her rationale for this was that the last time Ms Findlay had articulated a plan to kill herself, was when she was found in hospital with a ligature round her neck on 28 May 2020.
This position seems lacking the necessary reflection.
I draw your attention to earlier prevention of future deaths reports (PFDs) as follows:
• Sent to ELFT on 8 June 2023 by Assistant Coroner Buckett following the inquest touching the death of Hilary (Billy) Guedalla, including concern regarding the failure of ELFT to inform the police of the serious suicide risk that the deceased posed to themselves; and the confusion among staff about who should be contacted and in what manner, once a patient was found to be missing.
• Sent to ELFT on 25 January 2023 by me following the inquest touching the death of Andrew Largin, including concern about omissions from a serious incident investigation.
• Sent to ELFT on 20 October 2021 by me following the inquest touching the death of Freeda Glausiusz, including concern about a lack of learning culture at ELFT .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inconsistent terminology and definitions between police and mental-health services
Wider context from the report “5. Evidence was given that the police classify a person at high risk as: the risk is immediate and there are substantial grounds for believing immediate risk of self harm.
I was told by the MPS that, at the time of reporting to the MPS, trusts should volunteer their own grading of the patient’s risk. The police said that they will not necessarily following the trust grading, but they regard it as a significant factor and it should form part of the MPS thinking. ELFT witnesses told me that if the police did not ask for the trust’s grading then the trust would not offer it.
I was told that, until April 2022 the grab pack prepared by ELFT for the MPS in such a situation was printed out and handed to police if & when the police attended the ward. It is now filled out on a portal as part of the reporting procedure. However, it is not clear to me how far the grab pack aligns with local policies, whether all useful information (including the trust’s grading of risk) is recorded as a matter of routine, and how far the police and the trust are using the same terminology with the same definitions .
It seems that this would benefit from consideration.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 police reporting information to align with local policies
Wider context from the report “5. Evidence was given that the police classify a person at high risk as: the risk is immediate and there are substantial grounds for believing immediate risk of self harm.
I was told by the MPS that, at the time of reporting to the MPS, trusts should volunteer their own grading of the patient’s risk. The police said that they will not necessarily following the trust grading, but they regard it as a significant factor and it should form part of the MPS thinking. ELFT witnesses told me that if the police did not ask for the trust’s grading then the trust would not offer it.
I was told that, until April 2022 the grab pack prepared by ELFT for the MPS in such a situation was printed out and handed to police if & when the police attended the ward. It is now filled out on a portal as part of the reporting procedure. However, it is not clear to me how far the grab pack aligns with local policies , whether all useful information (including the trust’s grading of risk) is recorded as a matter of routine, and how far the police and the trust are using the same terminology with the same definitions.
It seems that this would benefit from consideration.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely record all useful risk information in police reports
Wider context from the report “5. Evidence was given that the police classify a person at high risk as: the risk is immediate and there are substantial grounds for believing immediate risk of self harm.
I was told by the MPS that, at the time of reporting to the MPS, trusts should volunteer their own grading of the patient’s risk. The police said that they will not necessarily following the trust grading, but they regard it as a significant factor and it should form part of the MPS thinking. ELFT witnesses told me that if the police did not ask for the trust’s grading then the trust would not offer it.
I was told that, until April 2022 the grab pack prepared by ELFT for the MPS in such a situation was printed out and handed to police if & when the police attended the ward. It is now filled out on a portal as part of the reporting procedure. However, it is not clear to me how far the grab pack aligns with local policies, whether all useful information (including the trust’s grading of risk) is recorded as a matter of routine , and how far the police and the trust are using the same terminology with the same definitions.
It seems that this would benefit from consideration.
” 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 Discuss received Regulation 28 reports through the national Regulation 28 Working Group.
Verbatim wording from the response “I would also like to provide further assurances on national NHSE work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Trust’s responses and related reports to determine whether further action is needed.
Verbatim wording from the response “I do however take the concerns raised seriously, and I thank you for bringing them to my attention, together with the other Reports to Prevent Future Deaths you highlight concerning the care of other patients at the Trust. I have asked that NHS England is sighted on the Trust’s response to your Report, as well as the responses to the other cases and we will consider these carefully, to include whether any further action needs to be taken. I have already been sighted on the Trust’s Patient Safety Serious Incident Review Report on this matter and note that they have taken a learning to ensure that the police are provided with a direct dial number whenever reporting a patient absconding, which did not happen in this case.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning and insights from received Regulation 28 reports across the NHS nationally and regionally.
Verbatim wording from the response “I would also like to provide further assurances on national NHSE work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Many concerns concern East London Foundation Trust and Metropolitan Police policy, making NHS England inappropriate to respond to them.
Verbatim wording from the response “The concerns in your Report relate to organisational policy at East London Foundation Trust as well as policy within the Metropolitan Police Service. NHS England is not therefore the appropriate organisation to respond to many of the concerns raised.” Source location Response from NHS England
Open published response
Concerns raised 5 Insufficient guidance for custody sergeants assessing detainee risk View source Lack of shared knowledge and understanding of terminology, processes and communication among emergency and search and rescue services View source Inaccessibility of post-release detainee information due to language or literacy barriers View source Insufficient identification, collation and recording of factors increasing detainee risk on the Niche system View source Lack of guidance for releasing detainees without an address to reside at View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ivan Rumenov Ignatov · 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
Ivan Rumenov Ignatov entered the English Channel on 19 July 2020 and did not resurface; he was found deceased in the water on 31 July 2020. The report raises concerns about police risk assessment and recording, support for detainees released without accommodation or with language and literacy barriers, and communication between emergency and search-and-rescue services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient guidance for custody sergeants assessing detainee risk
Wider context from the report “ii. There is not sufficient guidance given to custody sergeants on a national basis of how to assess a person’s risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of shared knowledge and understanding of terminology, processes and communication among emergency and search and rescue services
Wider context from the report “iv. There is a lack of knowledge and/or understanding amongst emergency services and search and rescue services, especially around terminology, process and communication for them to be able to work together when an incident arises without confusion or misunderstanding arising . I would request that consideration is given to further national and local training or guidance across emergency and search and rescue services to ensure communication can be facilitated without delay, and ensure terms and processes are understood to avoid any doubt of what action is being taken when an incident is ongoing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inaccessibility of post-release detainee information due to language or literacy barriers
Wider context from the report “v. Leaflets given to detainees when released from police custody are not always accessible due to language or literacy barriers and I would request that consideration is given nationally by NHS England and all Police Forces to ensure that any documentation detainees, especially any providing help and assistance, is accessible to them.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 identification, collation and recording of factors increasing detainee risk on the Niche system
Wider context from the report “i. There is not sufficient clarity in the identifying, collating and recording of factors which may increase a person’s risk on the Niche system that Dorset Police, and other forces nationally, use and as a result information could be missed which is vital to a person’s risk assessment and their risk to themselves or others .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for releasing detainees without an address to reside at
Wider context from the report “iii. There is no guidance, that I am aware of, which addresses what should be done by police forces, and particularly custody sergeants, when a person is to be released without an address to reside at and I would request consideration is given to such guidance being provided.
” 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 Dorset Police are better placed to respond to many concerns addressed to multiple parties involved in the case.
Verbatim wording from the response “It should be noted that many of the concerns raised in your Report do not fall under NHS England’s remit and I am only able to provide comment on those concerns relevant to NHS England. I note that you have addressed your Report to several parties involved in Ivan’s case, to include Dorset Police, who are better placed to respond to many of the concerns raised.” 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 Translation and interpreting services are commissioned locally to reflect local population needs.
Verbatim wording from the response “Regarding your concern over accessibility of resources, NHS England encourages local systems to consider how to best meet the needs of their population and address any inequalities in access and support. That includes providing information in languages and formats to meet the needs of the population. Any translation and interpreting service are commissioned at a local level, to reflect the local and population needs.” 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 Many concerns in the report fall outside NHS England’s remit, so it can comment only on matters relevant to its functions.
Verbatim wording from the response “It should be noted that many of the concerns raised in your Report do not fall under NHS England’s remit and I am only able to provide comment on those concerns relevant to NHS England. I note that you have addressed your Report to several parties involved in Ivan’s case, to include Dorset Police, who are better placed to respond to many of the concerns raised.” 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 Search and rescue services are tasked through the Police and do not fall under NHS England’s remit.
Verbatim wording from the response “Search and rescue services such as Coastguard and Mountain Rescue are tasked through the Police and do not fall under NHS remit. Any multi-agency working such as that which took place during the search for Ivan should be governed by the Joint Emergency Services Interoperability Principles: Home - JESIP Website.” 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, rather than Liaison and Diversion, are responsible for custody physical healthcare and pre-release assessments.
Verbatim wording from the response “You also raised a concern over custody release practices and guidance. In Ivan’s case, while the Police did identify the need for referral to a mental health practitioner, it is not clear from your Report that a referral was made to the relevant Liaison & Diversion (L&D) Team or to the Police and Crime Commissioner (PCC) commissioned Police Custody Healthcare Services (PCHS) Team, who are commissioned by the Police directly, and who all advise the police on ‘Fitness to Release’ decisions. The L&D Team are a vulnerability service, not a local mental health crisis service. They are not responsible for providing any physical healthcare within a police custody setting or to undertake pre-release assessments, which falls under the remit of the PCHS.” Source location Response from NHS England
Open published response
Concerns raised 5 Lack of training for stepdown service teams on BDD diagnosis and associated risks View source Failure to share BDD diagnoses with clinics providing aesthetic dermatology treatment View source Failure to inform patients with BDD of the risks of seeking aesthetic dermatology treatment View source Failure to share risk information and coordinate risk management planning between specialist and stepdown services at discharge View source Lack of national specialist resources for BDD View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Conrad Richard James Colson · 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
Conrad Colson, who had severe body dysmorphic disorder and a previous serious suicide attempt, was found deceased at home on 2 March 2022 after friends became concerned for his welfare. The inquest concluded that he took his own life while accessing aesthetic dermatology treatment, without therapeutic medication or professional mental health support, and after discharge without a robust risk assessment or relapse risk-management plan. Concerns included insufficient liaison and information sharing between mental health services, inadequate consideration of risks associated with aesthetic dermatology treatment, and training and resource gaps relating to body dysmorphic disorder.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of training for stepdown service teams on BDD diagnosis and associated risks
Wider context from the report “3. The Inquest heard that there is a need for training to be provided to step-down service teams in relation to the diagnosis of BDD and the risks associated with 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 to share BDD diagnoses with clinics providing aesthetic dermatology treatment
Wider context from the report “2. Both mental health services were aware that Conrad was accessing aesthetic dermatology treatment. There was a concern that neither service adequately highlighted the risks of accessing such treatment to Conrad or attempted to share information with the skin clinic. The inquest heard that patients with BDD should be fully informed of the risks of seeking aesthetic dermatology treatment and wherever possible, clinics who are providing treatment should be made aware of the BDD diagnosis .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to inform patients with BDD of the risks of seeking aesthetic dermatology treatment
Wider context from the report “2. Both mental health services were aware that Conrad was accessing aesthetic dermatology treatment. There was a concern that neither service adequately highlighted the risks of accessing such treatment to Conrad or attempted to share information with the skin clinic. The inquest heard that patients with BDD should be fully informed of the risks of seeking aesthetic dermatology treatment and wherever possible, clinics who are providing treatment should be made aware of the BDD diagnosis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to share risk information and coordinate risk management planning between specialist and stepdown services at discharge
Wider context from the report “1. A concern arose at the Inquest hearing in relation to the absence of liaison between the highly specialist services of the CADAT team and the stepdown services provided by NELFT . There was a lack of full information sharing around risk and risk assessment/risk management planning on discharge .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of national specialist resources for BDD
Wider context from the report “4. The inquest heard that there is a lack of national resources for BDD . The highly specialised service at South London and Maudsley has a very long waiting list (several months) . This is on a background of concerns of a likely increase in BDD. In light of this concern, I am also providing this report to the Royal College of Psychiatrists, to the Department for Health & Social Care and to NHSE.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue monitoring referral trends and the need for greater BDD treatment capacity in primary and secondary mental healthcare.
Verbatim wording from the response “While there has recently been a perceived increase in the overall number of referrals to the NHS England Highly Specialised Severe OCD/BDD Service for children and adolescents at SLAM, a similar pattern of increased BDD referrals has not so far been seen in the adult Service, but it may simply be a matter of time before the perceived increased occurrence in younger people filters through to adult mental health services, highlighting a probable need to consider building greater capacity for treating BDD at primary and secondary mental healthcare levels, which we will continue to monitor.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide education and training on BDD to relevant healthcare professionals through the national specialist service.
Verbatim wording from the response “The clinicians in the NHS England Highly Specialised Severe OCD/BDD Service consider this issue highly important because BDD is common, estimated at 0.5-3.2% in the general population, 1.3-5.8% in student cohorts, 4.9- 21.1% in general dermatology cohorts, and 2.9-57% in cosmetic surgery cohorts. It is also a dangerous condition with a markedly high suicide rate; 0.3% per annum prospectively end their life and about 25% have made a past attempt on their life, and it can be very difficult to treat. The Service therefore engages in education and training activities for relevant healthcare professionals and aspires to expand these education and training activities as well as the future development of regional specialist centres, to disseminate best practice more widely, conditional on additional resourcing.” 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 Consent barriers may prevent mental health professionals and private providers from disclosing BDD information to each other.
Verbatim wording from the response “There can however be barriers to implementation of the NICE guidance, where patients do not consent for private providers and their mental health professionals to disclose information to each other.” 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 SLAM and NELFT are responsible for addressing liaison, communication, information sharing and staff training concerning Conrad’s care.
Verbatim wording from the response “In terms of the matters of concern specific to Conrad, NHS England are unable to comment on the absence of liaison between the Centre for Anxiety Disorders and Trauma (CADAT) team at SLAM and the stepdown services provided by North East London NHS Foundation Trust (NELFT), nor the adequacy of communication, information sharing between the two Trusts or the training of staff employed by NELFT, who are the appropriate organisations to respond to your concerns. NHS England has however been sighted on NELFT’s Serious Incident Report into the matters surrounding Conrad’s death and note that there have been learnings and recommendations made, including improvements to information sharing. We have also asked to be sighted on the response to you Report from both NELFT and SLAM and will consider these carefully.” Source location Response from NHS England
Open published response
15 May 2023 Raymond Lee · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Limited evidence on the risks of stenting oesophageal strictures View source Lack of national guidance and evidence-based best practice for treating oesophageal strictures View source Lack of evidence on the optimum number of dilatations and when to stop dilatation and consider stenting View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Raymond Lee · 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
Raymond Douglas Lee had oesophageal cancer treated with radiotherapy, developed an oesophageal stricture, and later had a stent inserted. He was admitted with bleeding and died at Stepping Hill Hospital on 14 September 2021 from complications including an aorta-oesophageal fistula. The report raised concerns about limited national guidance and evidence on treating oesophageal strictures, including uncertainty about when to stop dilatation and consider stenting, and the risks of perforation associated with both procedures.
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 Limited evidence on the risks of stenting oesophageal strictures
Wider context from the report “The inquest heard evidence that oesophageal strictures are a recognised complication of radiotherapy for oesophageal cancers. The implications of them are significant for patients as they can lead to aspiration and as well as significantly impact quality of life. At this time there is only very limited national guidance on how to best treat patients with strictures and limited evidence on which to develop best practice. The evidence given was that careful dilatation by an experienced practitioner was the best approach initially. However, dilatation particularly repeated dilatation carried risk of perforation and needed to be seen as something that could not be continued indefinitely. However, there was limited evidence on what the optimum number of dilatations were and/or when to stop and move to consider stenting.
The inquest heard that stenting of patients in these circumstances has a limited body of evidence regarding the risk . The inquest highlighted that perforation may be a risk in some cases where a stent is used and that needed to be factored into any decision to use a stent.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance and evidence-based best practice for treating oesophageal strictures
Wider context from the report “The inquest heard evidence that oesophageal strictures are a recognised complication of radiotherapy for oesophageal cancers. The implications of them are significant for patients as they can lead to aspiration and as well as significantly impact quality of life. At this time there is only very limited national guidance on how to best treat patients with strictures and limited evidence on which to develop best practice . The evidence given was that careful dilatation by an experienced practitioner was the best approach initially. However, dilatation particularly repeated dilatation carried risk of perforation and needed to be seen as something that could not be continued indefinitely. However, there was limited evidence on what the optimum number of dilatations were and/or when to stop and move to consider stenting.
The inquest heard that stenting of patients in these circumstances has a limited body of evidence regarding the risk. The inquest highlighted that perforation may be a risk in some cases where a stent is used and that needed to be factored into any decision to use a stent.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 evidence on the optimum number of dilatations and when to stop dilatation and consider stenting
Wider context from the report “The inquest heard evidence that oesophageal strictures are a recognised complication of radiotherapy for oesophageal cancers. The implications of them are significant for patients as they can lead to aspiration and as well as significantly impact quality of life. At this time there is only very limited national guidance on how to best treat patients with strictures and limited evidence on which to develop best practice. The evidence given was that careful dilatation by an experienced practitioner was the best approach initially. However, dilatation particularly repeated dilatation carried risk of perforation and needed to be seen as something that could not be continued indefinitely. However, there was limited evidence on what the optimum number of dilatations were and/or when to stop and move to consider stenting .
The inquest heard that stenting of patients in these circumstances has a limited body of evidence regarding the risk. The inquest highlighted that perforation may be a risk in some cases where a stent is used and that needed to be factored into any decision to use a stent.
” 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 national, evidence-based advice or guidance for managing post-radiotherapy oesophageal stenting cases with AUGIS and NICE.
Verbatim wording from the response “To support a response, I sought the opinion from our clinical advisor within the Cancer Programme of Care at NHS England and they have also spoken to the relevant professional association lead from the Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS). In terms of learning from this case, and from other stenting cases previously reviewed, it is clear that these types of cases are clinically difficult to manage; the NICE guidance is not comprehensive and there does not appear to be a guidelines in place covering these sorts of circumstances (i.e., post radiotherapy). We acknowledge this is something that needs to be addressed and we are actively discussing how best to do this in partnership with AUGIS and NICE.” 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 GM Cancer Alliance, through its Oesophago-Gastric Pathway Board, is responsible for developing the stenting pathway and completing MDT Reform actions.
Verbatim wording from the response “I have also received an update from Greater Manchester Integrated Care Board (ICB) regarding this matter. They have advised that the Greater Manchester (GM) Cancer Alliance will be tasking the Oesophago-Gastric (OG) Pathway Board with developing a clear pathway for the management of oesophageal stenting. The Alliance will also be ensuring that outstanding elements of the Multi-Disciplinary Team (MDT) Reform” Source location Response from NHS England
Open published response
15 May 2023 Rebekah Juliet Mills · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Lack of clinician recognition of the potentially fatal DVT risk in immobilised surgical patients View source Lack of clear guidance for clinicians on reducing DVT risk in immobilised surgical patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Rebekah Juliet Mills · 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
Rebekah Juliet Mills suffered a knee injury in an accidental skiing fall, underwent surgery, collapsed at home several days later, and died from a pulmonary embolism. The inquest identified unclear clinical guidance about reducing the risk of DVT in young, immobile patients taking oral contraception who require surgery, with differing approaches and insufficient recognition of the potential fatal risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of clinician recognition of the potentially fatal DVT risk in immobilised surgical patients
Wider context from the report “During the course of the inquest evidence was given that the guidance for clinicians in relation to reducing the risk of DVT when dealing with patients such as Ms Mills who are young and on oral contraception but are immobile following an accident and require surgery is unclear. That lack of clarity can give rise to a differing approach and a lack of recognition of the potential fatal risk that patients such as Ms Mills can face in such a situation .
The evidence was that greater clarity and greater understanding of the risks could prevent future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance for clinicians on reducing DVT risk in immobilised surgical patients
Wider context from the report “During the course of the inquest evidence was given that the guidance for clinicians in relation to reducing the risk of DVT when dealing with patients such as Ms Mills who are young and on oral contraception but are immobile following an accident and require surgery is unclear . That lack of clarity can give rise to a differing approach and a lack of recognition of the potential fatal risk that patients such as Ms Mills can face in such a situation.
The evidence was that greater clarity and greater understanding of the risks could prevent future deaths.
” Open source report
Concerns raised 3 Long-term vacancy of a substantive neurology consultant post View source Delays in neurology outpatient appointments View source Gaps in neurology service provision View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nicholas John PENNICOTT · 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
Nicholas John PENNICOTT’s health deteriorated from March 2021, and he suffered a cardiac arrest at home on 19 August 2021 while awaiting an urgent neurology appointment. The report identified persistent neurology capacity problems, including a long-term consultant vacancy and long waiting times, which led to a missed opportunity for earlier specialist assessment.
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 Long-term vacancy of a substantive neurology consultant post
Wider context from the report “During the course of the evidence the Hospital explained that long waiting times for neurology outpatient appointments was a persistent challenge for the Trust due to capacity issues within the neurology service.
There had been a long-term vacancy, of three years, within the neurology service for a substantive neurology consultant at the hospital . The Inquest was told that there was a national shortage of neurologists. The Trust had relied on long term locum consultants, leading to some short-term gaps in provision.
The shortage of Neurologists nationally and the capacity issues within the neurology service at the Hospital led to a missed opportunity for Mr PENNICOTT to receive earlier specialist assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in neurology outpatient appointments
Wider context from the report “During the course of the evidence the Hospital explained that long waiting times for neurology outpatient appointments was a persistent challenge for the Trust due to capacity issues within the neurology service .
There had been a long-term vacancy, of three years, within the neurology service for a substantive neurology consultant at the hospital. The Inquest was told that there was a national shortage of neurologists. The Trust had relied on long term locum consultants, leading to some short-term gaps in provision.
The shortage of Neurologists nationally and the capacity issues within the neurology service at the Hospital led to a missed opportunity for Mr PENNICOTT to receive earlier specialist assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Gaps in neurology service provision
Wider context from the report “During the course of the evidence the Hospital explained that long waiting times for neurology outpatient appointments was a persistent challenge for the Trust due to capacity issues within the neurology service.
There had been a long-term vacancy, of three years, within the neurology service for a substantive neurology consultant at the hospital. The Inquest was told that there was a national shortage of neurologists. The Trust had relied on long term locum consultants, leading to some short-term gaps in provision .
The shortage of Neurologists nationally and the capacity issues within the neurology service at the Hospital led to a missed opportunity for Mr PENNICOTT to receive earlier specialist assessment.
” 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 Publish the NHS Long Term Workforce Plan to grow, retain and reform the NHS workforce.
Verbatim wording from the response “Last month, NHS England published the NHS Long Term Workforce Plan, setting out our plans to grow, retain and reform our workforce across the next fifteen years. This plan looks to reduce the national shortages we see across the NHS, helping to provide safe and timely access to urgent care that will reduce the delays currently being faced by patients such as Nicholas.” 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 Implementing recommended acute neurology outpatient clinics is constrained by workforce shortages.
Verbatim wording from the response “Your Report also raises a concern that there is a shortage of neurologists at a national level. This is a well-recognised issue within the NHS and there is currently significant variation in neurologist numbers across England. The Getting It Right First Time (GIRFT) programme for neurology (GIRFT is a national NHS England programme designed to improve the treatment and care of patients through clinically led reviews) recommends that all acute hospitals have acute neurology liaison services in place, and, ideally, acute neurology outpatient clinics to urgently see rapidly deteriorating patients. However, this is dependent on workforce constraints.” Source location Response from NHS England
Open published response
9 May 2023 Sandra Dianne Finch · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 3 Lack of a prioritisation system for category 3 ambulance call assessments View source Lack of time limits for category 3 ambulance call assessments View source Failure of ambulance categorisation pathways to allow movement away from rigid categories View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Sandra Dianne Finch · 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
Sandra Dianne Finch, a 44-year-old woman with Type 1 diabetes who used an insulin pump, developed rising glucose levels, sleepiness and vomiting after a recent dental procedure and antibiotic treatment. An ambulance response was delayed following categorisation of her call as category 3 and a clinical review process without a time limit; she was later found to have died from ketoacidosis. The principal concerns were rigid ambulance categorisation pathways and the absence of a time limit or prioritisation system for assessing category 3 calls.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a prioritisation system for category 3 ambulance call assessments
Wider context from the report “2. That the use of an assessment team, to asses a category 3 ambulance call, with no time limit for assessments to take place, and no prioritisation system , will lead to further deaths resulting from delays.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 time limits for category 3 ambulance call assessments
Wider context from the report “2. That the use of an assessment team, to asses a category 3 ambulance call, with no time limit for assessments to take place , and no prioritisation system, will lead to further deaths resulting from delays.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 categorisation pathways to allow movement away from rigid categories
Wider context from the report “1. That the pathways used by the service to categorise the level of ambulance and ridged and have no capacity for movement away from the path . This led to a type 1 diabetic patient, who was feeling sleepy and with deranged glucose levels, not being classed as a potentially serious situation requiring rapid intervention. Clinical opinion in agreement that this was, but the rigidly of the pathway meant it was categorised incorrectly .
” Open source report
27 Apr 2023 Ben Alan SHIPLEY · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 2 Reliance on untrained A&E staff and family for mental health support while detention is pending View source Delays in completing Mental Health Act detention when no bed is available overnight View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ben Alan SHIPLEY · 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
Ben Alan Shipley, aged 22, died on 29 August 2019 after absconding from hospital and being struck by a train. The report raises concern about delays in securing a mental health bed, during which a section 2 detention could not be completed and Ben was reliant on the goodwill of A&E staff and his family for safety.
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 Reliance on untrained A&E staff and family for mental health support while detention is pending
Wider context from the report “Ben was assessed at 22.00 on 28th August 2019. It seems to me that there are about 12 hours of delay following a 22.00 assessment Health Act assessment built into the system if there is no bed. Presumably this would be longer if Ben had been assessed earlier in the night shift. I am told beds do not become available over night. This means Ben cannot be legally detained as the section 2 is not complete until there is a bed. He is therefore subject to the goodwill of the A&E (who are not trained in mental health) and the goodwill of the family (who are similarly not trained in mental health) . ████████
████████
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 completing Mental Health Act detention when no bed is available overnight
Wider context from the report “Ben was assessed at 22.00 on 28th August 2019. It seems to me that there are about 12 hours of delay following a 22.00 assessment Health Act assessment built into the system if there is no bed . Presumably this would be longer if Ben had been assessed earlier in the night shift. I am told beds do not become available over night . This means Ben cannot be legally detained as the section 2 is not complete until there is a bed . He is therefore subject to the goodwill of the A&E (who are not trained in mental health) and the goodwill of the family (who are similarly not trained in mental health). ████████
████████
” Open source report
24 Apr 2023 Samuel Thomas Howes · Prevention of Future Deaths report South London
View report summary
Concerns raised 6 Inadequate mental health and social care responses to alcohol dependency View source Lack of a complex service providing adolescents with treatment for both substance misuse and mental health issues View source Inadequate provision of care to adolescents with mental health vulnerabilities and substance use difficulties View source Failure of Child & Adolescent Mental Health Service teams to work together effectively View source Failure to provide a rehabilitative placement View source Delays in Adult Complex Additions Service responses to referrals 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
Samuel Thomas Howes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Samuel Thomas Howes died from fatal injuries after jumping in front of a train on 2 September 2020. The inquest found that his ongoing mental health issues, drug use and alcohol dependency probably contributed to his death. Substantive concerns included inadequate mental health and social care responses, failures to share risk information between agencies, inadequate custody safeguarding and failures in the missing-person investigation.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequate mental health and social care responses to alcohol dependency
Wider context from the report “(4) The inadequate response of mental health and social care services in relation to Samuel’s dependency on alcohol and the provision of a rehabilitative placement.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 complex service providing adolescents with treatment for both substance misuse and mental health issues
Wider context from the report “(3) The lack of a complex service providing, to adolescents, treatment for both substance misuse and mental health issues models, in terms of willingness to engage, being problematic for some young people.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 provision of care to adolescents with mental health vulnerabilities and substance use difficulties
Wider context from the report “(2) The delayed response of the Adult Complex Additions Service to referral and issues related to provision of care to adolescents presenting with mental health vulnerabilities and substance use difficulties .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 Child & Adolescent Mental Health Service teams to work together effectively
Wider context from the report “(1) Samuel’s case should be a stimulus for some level of Child & Adolescent Mental Health Service reflection on how different Child and Adolescent Mental Health Service teams are organised and work together.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a rehabilitative placement
Wider context from the report “(4) The inadequate response of mental health and social care services in relation to Samuel’s dependency on alcohol and the provision of a rehabilitative placement .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 Adult Complex Additions Service responses to referrals
Wider context from the report “(2) The delayed response of the Adult Complex Additions Service to referral and issues related to provision of care to adolescents presenting with mental health vulnerabilities and substance use difficulties.
” 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 children and young people’s mental health workforce to increase service capacity.
Verbatim wording from the response “Improving mental health support for children and young people is a priority for NHS England. The NHS Long Term Plan (LTP) sets an ambitious commitment that access will increase, with 345,000 more children aged 0-25 accessing support in 2023/24 compared to 2019. We have made significant progress towards this commitment with a record of 720,817 children and young people receiving support from the NHS in the 12 months to February 2023. This has been achieved through investment in the children and young people’s mental health workforce, which has increased by 46% since the start of the LTP, and by 70% since 2016. However, the prevalence of mental health need has also increased following the pandemic in 6-16 year olds from 1 in 9” 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 Commission a review of care models for young adults aged 16–25, including integration for co-existing mental health and substance-use needs.
Verbatim wording from the response “While local commissioners are responsible for ensuring services are integrated, NHS England has a role to support this at national and regional levels. We have established Clinical Networks and regional delivery groups for mental health across NHS regions to support commissioning of effective services. We have ensured the leadership in these networks and groups are aware of the findings of this Report. NHS England commissioned the National Collaborating Centre for Mental Health to review models of care for young adults aged16 - 25. Their report published in 2022 highlighted examples of positive practice in terms of integration including and set out principles and considerations to inform the development of support, care and treatment for young people. This includes considerations where young people have co-existing mental health and substance abuse needs.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish the Framework for Integrated Care (Community) and select 12 vanguard sites to deliver it for children with complex needs.
Verbatim wording from the response “The Framework for Integrated Care (Community) (“Framework”) is the evidence-based response to the NHS LTP commitment to invest in additional support for the most vulnerable children who have complex needs. These are young people who could be described as presenting with high-risk, high-harm behaviours and high vulnerability.” 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 Office for Health Improvement and Disparities oversees drug and alcohol service policy.
Verbatim wording from the response “We also accept that alongside increasing capacity across services, there is a need to ensure Children and Young People’s services are integrated with support across the whole system – including mental health support as part of the transition from child to adult services for adults, physical health needs, social care, education and health and justice. This includes integration with drug and alcohol services, which are largely commissioned by Local Authorities. Oversight of drug and alcohol service policy rests with the Office for Health Improvement and Disparities within the Department for Health and Social Care, who are copied into the Report.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local commissioners and providers are responsible for addressing local support provision and service integration concerns.
Verbatim wording from the response “This response focuses on the national NHS policy and programmes relevant to the matters of concern you have identified in your Report. Most of the matters of concern raised in your Report are in respect of the provision of local support and the actions taken in providing that support to Mr. Howes and his family. These local concerns would need to be addressed by the relevant local commissioners and providers.” Source location Response from NHS England
Open published response
21 Apr 2023 Amy Henderson · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Lack of clarity about responsibility for identifying and removing banned and restricted items at admission View source Lack of rapid access to NHS records on admission to a private hospital View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Amy Henderson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Amy Henderson, who had been diagnosed with post-partum depression and admitted to Priory Hospital, Woking after expressing suicidal thoughts and plans, died there on 21 March 2022 after taking her own life by suspension in a disabled toilet. Concerns included risk assessments and observations not being completed in line with policy, therapy notes indicating deterioration not being acted upon, incomplete information about her suicide risk, and ineffective management of the disabled toilet as a high-risk area.
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 about responsibility for identifying and removing banned and restricted items at admission
Wider context from the report “2. The Priory Woking has a policy in relation to the removal of banned and restricted items but there was a lack of clarity and confusion among the clinicians as to who was responsible for ensuring that such items are identified and removed from the patient at admission .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 rapid access to NHS records on admission to a private hospital
Wider context from the report “1. The information that Miss Henderson had practised tying a ligature was divulged by her at Kingston Hospital but not repeated on admission to the Priory Woking. The evidence given at the inquest was that there is no quick method to obtain NHS records on admission to a private hospital . A request could have been made but the records would have taken over a week to be released . The records were not sought. An ability to obtain the NHS records quickly would have been of assistance to the Priory clinicians .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review national guidance on risk assessments.
Verbatim wording from the response “NHS England has, however, been sighted on Priory Group’s Serious Incident Report regarding this matter and the resulting Action Plan and recommendations. I would like to provide some additional assurance that national guidance around risk assessments is currently being reviewed. I have also asked my regional colleagues to confirm whether Priory Woking now has access to GP records. NHS England is happy to provide further updates 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 Priory Group is identified as the appropriate organisation to address responsibility for removing banned or restricted items at admission.
Verbatim wording from the response “Regarding your second concern that at The Priory Woking there was a lack of clarity and confusion among clinicians as to who was responsible for ensuring that banned and restricted items are identified and removed from a patient at admission, this is outside of NHS England’s remit and I note that you have also addressed your Report to Priory Group who are the appropriate organisation to respond to this concern.” 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 Implementation and operation of shared care records is assigned to Integrated Care Boards.
Verbatim wording from the response “Implementation and operation of shared care records is the responsibility of Integrated Care Boards (ICBs). Initially, public sector connectivity is being prioritised but the forward programme plan for the Shared Care Record programme for 2023/25 acknowledges the important role that independent sector providers of care play. NHS England are aware that some ICBs are already engaging with Voluntary, Community and Social Enterprise organisations, recognising the important role that they play in the provision of care to their population. The Shared Care Record programme is also” 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 Clarifying responsibility for identifying and removing banned or restricted items at admission is outside NHS England’s remit.
Verbatim wording from the response “Regarding your second concern that at The Priory Woking there was a lack of clarity and confusion among clinicians as to who was responsible for ensuring that banned and restricted items are identified and removed from a patient at admission, this is outside of NHS England’s remit and I note that you have also addressed your Report to Priory Group who are the appropriate organisation to respond to this concern.” Source location Response from NHS England
Open published response
20 Apr 2023 Joseph Willy Maunick · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 3 Failure to promptly transfer patients to an available ward bed or appropriate alternative place View source Insufficient hospital resources and staffing to provide required care and supervision View source Insufficient provision of suitable care, including residential care placements View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joseph Willy Maunick · 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 Willy Maunick died on 15 March 2022 from a severe head injury sustained in a fall in the Emergency Department of West Suffolk Hospital, where he had been admitted as a social admission while his wife underwent emergency surgery. The report identified concerns about a national shortage of suitable care, and severe hospital pressures including insufficient staffing and resources, which prevented the constant supervision he needed and delayed transfer to a more appropriate environment.
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 promptly transfer patients to an available ward bed or appropriate alternative place
Wider context from the report “2) The severe pressures on the hospital, including the Emergency Department, were such that they were experiencing scarcity of resource relative to demand and a severe deficiency of staff. In these circumstances, it was both not possible to provide the care and supervision that Will needed in the Emergency Department, and the scarcity of resource contributed to Will not being transferred sooner to a ward or other more appropriate environment , where Will could receive the constant supervision that would probably have prevented the fall that led to his death. The evidence was that the scarcity of resource experienced was a challenge on the national level, rather than just a particular local issue. If hospitals, including Emergency Departments, do not receive sufficient resource, then circumstances creating a risk of future deaths, due to an inability to provide the required care and / or prompt transfer to an available ward bed or appropriate alternative place , will occur or continue to exist in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 hospital resources and staffing to provide required care and supervision
Wider context from the report “2) The severe pressures on the hospital, including the Emergency Department, were such that they were experiencing scarcity of resource relative to demand and a severe deficiency of staff . In these circumstances, it was both not possible to provide the care and supervision that Will needed in the Emergency Department , and the scarcity of resource contributed to Will not being transferred sooner to a ward or other more appropriate environment, where Will could receive the constant supervision that would probably have prevented the fall that led to his death. The evidence was that the scarcity of resource experienced was a challenge on the national level, rather than just a particular local issue. If hospitals, including Emergency Departments, do not receive sufficient resource , then circumstances creating a risk of future deaths, due to an inability to provide the required care and / or prompt transfer to an available ward bed or appropriate alternative place, will occur or continue to exist in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 provision of suitable care, including residential care placements
Wider context from the report “1) A national care shortage contributed to a situation where a gentleman who was not experiencing a medical emergency, but who required constant supervision for his own safety in view of his cognitive impairment and very high falls risk, could not be cared for anywhere other than in a hospital Emergency Department. If there is not sufficient provision of care, including residential care placements , such that those in similar need do not receive suitable care , then circumstances creating a risk of future deaths will occur or continue to exist in the future, when they are placed in an environment that is not realistically able to provide the constant supervision needed, as occurred in this case.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with Integrated Care Systems to provide streamlined pathways for older adults, including people with dementia.
Verbatim wording from the response “In January 2023, the Delivery plan for recovering urgent and emergency care services was published by NHS England, which sets out the steps that the NHS are taking to respond to the demand being placed on urgent and emergency care (UEC) services at a national level. The plan also includes details for the expansion of community services including more joined-up care for older people living with frailty, including scaling up urgent community response, frailty and falls services across the whole country – meaning the right people delivering the right care and avoiding admission to hospital where it’s not necessary. We will also work with Integrated Care Systems (ICSs) to provide streamlined pathways for older adults, including people with dementia.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a national delivery plan setting out steps to recover urgent and emergency care services, including expanded community services for older people with frailty.
Verbatim wording from the response “In January 2023, the Delivery plan for recovering urgent and emergency care services was published by NHS England, which sets out the steps that the NHS are taking to respond to the demand being placed on urgent and emergency care (UEC) services at a national level. The plan also includes details for the expansion of community services including more joined-up care for older people living with frailty, including scaling up urgent community response, frailty and falls services across the whole country – meaning the right people delivering the right care and avoiding admission to hospital where it’s not necessary. We will also work with Integrated Care Systems (ICSs) to provide streamlined pathways for older adults, including people with dementia.” 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 DHSC is responsible for addressing the national social care shortage and is best placed to comment on it.
Verbatim wording from the response “The first concern you raised related to a national social care shortage, and the impact this has had on the quality of care provided to Will. The Department of Health and Social Care (DHSC) are best placed to comment on this issue as they hold responsibility for social care provision. The DHSC have committed to adult social care reform and have recommitted £700 million to transform and improve the adult social care system in England, to include around access to support and joining up of services as part of their ‘People at the Heart of Care’ plan.” Source location Response from NHS England
Open published response
Concerns raised 8 Call-handler pathway failing to consider adrenal crisis risk after trauma View source National treatment guidance failing to emphasise replacement steroid therapy after trauma or physiological stress View source Failure of acute hospital clinicians to recognise the need for replacement steroid therapy after trauma or physiological stress View source Absence of adrenal insufficiency prompts in emergency department and clerking documentation View source Guideline failing to emphasise replacement steroid therapy after trauma or physiological stress View source Unclear NHS England monitoring of compliance with National Patient Safety Alerts View source Insufficient clinician knowledge of adrenal insufficiency and replacement steroid therapy View source Failure of internal investigation coordination and learning from patient-safety incidents View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
DAVID ERNEST MASON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Ernest Mason, aged 82, fell at home on 5 March 2022, fractured his hip and was taken to hospital after an ambulance delay. He had Addison’s disease and died in the early hours of 7 March 2022 after developing an acute adrenal crisis. The principal concerns were that clinicians and ambulance staff did not recognise the need for additional steroid replacement after trauma and physiological stress, and that relevant clinical guidance, call-handler pathways and documentation prompts did not sufficiently address this risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Call-handler pathway failing to consider adrenal crisis risk after trauma
Wider context from the report “2) Evidence heard at the inquest demonstrated that when information is given to an EOC (emergency operations centre) call-handler at WMAS that a patient has a diagnosis of Addison’s disease and has suffered trauma, the call-handler question pathway (which, the inquest heard, is based on a computer-programmed logarithm (designed by NHS Digital, now part of NHS England)) does not go on to consider the risk of adrenal insufficiency and the requirement for replacement steroid therapy to commence immediately . This appears to be potentially relevant both in respect of whether time-critical steroid treatment may be required (and thus for a holistic consideration of call categorisation) and safety-netting advice that should be given (for additional doses of steroid medication to be taken by the patient, prior to any ambulance arrival). Safety-netting advice takes on even greater significance in the current climate, where healthcare demand and pressures on capacity are often causing severe delays in ambulance attendance. Evidence heard at the inquest confirmed that the position is different if information is given that the patient is medically unwell, particularly if concerns of a cardiac nature are present or adrenal insufficiency may be the direct cause of current illness, with the call-handler question pathway then going on to consider the risk of adrenal insufficiency. Currently there is a cohort of patients (which included Mr Mason) whose risk of developing an adrenal crisis is not being considered by call-handlers at WMAS .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 treatment guidance failing to emphasise replacement steroid therapy after trauma or physiological stress
Wider context from the report “1) The relevant treatment guideline disclosed by WAHT (‘Guideline for the management of adrenal insufficiency in adults’) very much focuses on presentations of acute adrenal crisis and procedure-based/perioperative situations, and (save for a small section containing ‘sick day’ rules) does not emphasise that replacement steroid therapy must be given to patients with adrenal insufficiency who have suffered trauma or physiological stress . Evidence heard at the inquest suggested that this internal Trust guideline (and, one assumes, other such guidelines in other acute trusts in the country) is based upon various pieces of national guidance. It is my understanding that a new guideline in respect of managing the treatment of adrenal insufficiency is currently being developed by NICE. Consideration of these matters should be included as part of guideline development.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 acute hospital clinicians to recognise the need for replacement steroid therapy after trauma or physiological stress
Wider context from the report “1) Evidence heard at the inquest demonstrated that no clinician involved in providing care to Mr Mason (in both the emergency department and the surgical trauma department) appreciated that , as someone who had Addison’s disease and who had suffered the trauma of a fall, long lie and a fractured hip, Mr Mason required additional replacement steroid therapy , to prevent the development of an acute adrenal 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 Absence of adrenal insufficiency prompts in emergency department and clerking documentation
Wider context from the report “4) Evidence heard at the inquest confirmed that no prompts exist on emergency department/clerking documentation at WAHT for clinicians to check whether a patient suffers from adrenal insufficiency . Although the inquest was informed that changes have been made in this regard by WAHT to some peri-operative patient documentation, the National Patient Safety Alert (NatPSA/2020/005/NHSPS) requires acute trusts to review admission/assessment/clerking documentation to ensure such prompts are included.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Guideline failing to emphasise replacement steroid therapy after trauma or physiological stress
Wider context from the report “2) The relevant internal Trust guideline disclosed by WAHT (‘Guideline for the management of adrenal insufficiency in adults’) very much focuses on presentations of acute adrenal crisis and procedure-based/perioperative situations, and (save for a small section containing ‘sick day’ rules, which are on the same page as advice to patients and families for long-term condition management) does not emphasise that replacement steroid therapy must be given to patients with adrenal insufficiency who have suffered trauma or physiological stress .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 NHS England monitoring of compliance with National Patient Safety Alerts
Wider context from the report “2) Evidence heard at the inquest confirmed that no prompts exist on emergency department/clerking documentation at WAHT for clinicians to check whether a patient suffers from adrenal insufficiency. Although the inquest was informed that changes have been made in this regard by WAHT to some peri-operative patient documentation, the National Patient Safety Alert (NatPSA/2020/005/NHSPS) requires acute trusts to review admission/assessment/clerking documentation to ensure such prompts are included. It is not clear what follow-up action is taken by NHS England in relation to monitoring of compliance by NHS Trusts following National Patient Safety Alerts being issued.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 clinician knowledge of adrenal insufficiency and replacement steroid therapy
Wider context from the report “3) Evidence heard at the inquest (relating to the trauma/surgical department at WAHT) suggested that it is likely that many clinicians (including at consultant level) do not have a well-developed understanding of adrenal insufficiency and the crucial importance of administering replacement steroid therapy to patients who, although not presenting as acutely unwell, are at risk of suffering an adrenal 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 internal investigation coordination and learning from patient-safety incidents
Wider context from the report “4) Evidence heard at the inquest confirmed that the investigation lead at WMAS had not been shown the inquest disclosure bundle , which had been disclosed to the legal department at WMAS a number of months prior to the inquest. This bundle contained relevant evidence from a different internal investigation (by WAHT), suggesting that the likely cause of Mr Mason’s deterioration and death was an acute adrenal crisis and not, as had been considered when a coronial referral had initially been made, hyperkalaemia and rhabdomyolysis (following a fall and long lie). This lack of internal co-ordination within WMAS prevented full internal investigation and learning in respect of the care given to Mr Mason by WMAS.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop the NHS Steroid Emergency Card for patients at risk of adrenal crisis.
Verbatim wording from the response “NHS England has worked closely with the Society for Endocrinology and the Royal College of Physicians on the issue of under-recognition and treatment of adrenal insufficiency or crisis. This culminated in the publication of ‘Guidance for the prevention and emergency management of adult patients with adrenal insufficiency’ in July 2020, which outlines the causes of adrenal insufficiency, groups at risk of an adrenal crisis, emergency management and management for surgical procedures. As a result of work in this area, a new NHS Steroid Emergency Card was developed, to be carried by patients at risk of adrenal crisis and ensure the prompt delivery of steroids to those patients presenting with adrenal insufficiency or acute medicine setting.” 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 Engage stakeholders and monitor emerging evidence and guidelines on emergency steroid replacement in pre-hospital care.
Verbatim wording from the response “However, having learned of this case, NHS Pathways will engage with its stakeholders and monitor emerging evidence and guidelines with respect to emergency steroid replacement therapy in the pre-hospital setting, with a view to making system changes where appropriate in accordance with the governance framework. If it is established that system-wide changes are required, NHS Pathways will work closely with colleagues in the ambulance sector to ensure safety-netting advice is appropriate.” 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 Ask regional colleagues to engage relevant Integrated Care Boards about trusts that remain non-compliant with the patient safety alert.
Verbatim wording from the response “In this case, Worcestershire Acute Hospitals NHS Trust declared compliance in March 2022. There are currently three Trusts who remain non-compliant. The national team at NHS England has asked regional colleagues to engage with the relevant ICBs regarding these Trusts. It is ultimately the role of the Care Quality Commission (CQC) to ensure the implementation of actions set out in alerts, which is made clear in all NatPSAs, through the following statement; ‘Failure to take the actions required under this National Patient Safety Alert may lead to CQC taking regulatory action’.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish guidance for preventing and managing adult adrenal insufficiency emergencies.
Verbatim wording from the response “NHS England has worked closely with the Society for Endocrinology and the Royal College of Physicians on the issue of under-recognition and treatment of adrenal insufficiency or crisis. This culminated in the publication of ‘Guidance for the prevention and emergency management of adult patients with adrenal insufficiency’ in July 2020, which outlines the causes of adrenal insufficiency, groups at risk of an adrenal crisis, emergency management and management for surgical procedures. As a result of work in this area, a new NHS Steroid Emergency Card was developed, to be carried by patients at risk of adrenal crisis and ensure the prompt delivery of steroids to those patients presenting with adrenal insufficiency or acute medicine setting.” 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 Engage Medical Priority Dispatch System suppliers to review their processes for assessing adrenal insufficiency.
Verbatim wording from the response “NHS England will also engage with Medical Priority Dispatch System, the suppliers of the alternative telephone and digital triage system used by ambulance services in England, to review their processes for assessing adrenal insufficiency.” 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 Issue the National Patient Safety Alert requiring providers to prompt checks for adrenal-crisis risk and Steroid Emergency Cards.
Verbatim wording from the response “The work above also resulted in the publication of the National Patient Safety Alert (NatPSA), mentioned in your report, which includes the specific action that ‘Providers that treat patients with acute physical illness or trauma, or who may require emergency or elective surgical or other invasive procedures, including day patients, should review their admission/assessment/examination/clerking documentation to ensure it includes prompts to check for risk of adrenal crisis and to establish if the patient has a Steroid Emergency Card.’ Trusts were expected to implement actions around this specific alert by 13 May 2021.” 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 NHS Pathways design is considered sufficient because extra adrenal-insufficiency questioning could delay care or create confusion.
Verbatim wording from the response “The majority of calls taken using NHS Pathways are handled by a highly trained but non-clinical Health Advisor. Health Advisors (as per the NHS Pathways Provider Licence) should have access to support from clinicians to support safe call-handling. Even though thorough training is provided, it is not within the remit of the Health Advisor to be trained in, or understand more complex medical elements, such as in this case. Indeed, such enquiry and added confusion delays the management of the case and triaging process. It is for these reasons that questions on past medical history or pharmacology are utilised sparingly across the system, and only where it is deemed that a clear understanding can be sought.” 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 ICBs are responsible for local compliance mechanisms, while the CQC is responsible for regulatory enforcement of alert implementation.
Verbatim wording from the response “Alert compliance data for NatPSAs is published monthly on the Central Alerting System website. Guidance issued to NHS staff in August 2022, outlines the separate roles and responsibilities of the national Patient Safety Team, the region, the Integrated Care Board (ICB) and the providers regarding issuing and complying with alerts. The national team at NHS England has statutory responsibilities for identifying new or under-recognised issues and issuing NatPSAs when required but are not responsible for overseeing compliance. It is the role of ICBs to have local mechanisms in place to support compliance with any actions required in NatPSAs, in line with NHS Standard Contract requirements and the national Patient Safety Strategy. Regions and ICBs are expected to have sight of providers who do not complete actions by the required dates and provide support and assurance where this occurs.” 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’s national team is not responsible for overseeing NHS Trust compliance with National Patient Safety Alerts.
Verbatim wording from the response “Alert compliance data for NatPSAs is published monthly on the Central Alerting System website. Guidance issued to NHS staff in August 2022, outlines the separate roles and responsibilities of the national Patient Safety Team, the region, the Integrated Care Board (ICB) and the providers regarding issuing and complying with alerts. The national team at NHS England has statutory responsibilities for identifying new or under-recognised issues and issuing NatPSAs when required but are not responsible for overseeing compliance. It is the role of ICBs to have local mechanisms in place to support compliance with any actions required in NatPSAs, in line with NHS Standard Contract requirements and the national Patient Safety Strategy. Regions and ICBs are expected to have sight of providers who do not complete actions by the required dates and provide support and assurance where this occurs.” Source location Response from NHS England
Open published response
Concerns raised 4 Failure to share or provide access to critical self-harm risk information for directly involved NHS Trusts View source Lack of a single effective global focus for consolidating and retrieving cross-agency risk information View source Unavailability of GP-held clinical history to accident and emergency departments outside surgery hours or across geographic areas View source Lack of a national risk-flagging system for previous self-harm attendances View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Patrick Soames · 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
Patrick Soames died by suicide on 21 June 2021 after a final month involving repeated serious self-harm, including cutting, medication overdose and excessive alcohol misuse, with multiple hospital attendances. The principal concerns were that information about his risk was fragmented across NHS Trusts, police forces, local authorities and geographical areas, with no effective system to consolidate or flag his recent self-harm history nationally.
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 share or provide access to critical self-harm risk information for directly involved NHS Trusts
Wider context from the report “1. 5 NHS Trusts and 3 police forces in different geographic areas had contact with Patrick in the final month of his life and each thereby gained some information about the risk to him. However, that information was by reason of the agencies falling into different geographic areas. There was no single effective global focus for the information being acquired piecemeal about Patrick’s pattern of serious self-harming behaviour. The various agencies were significantly impeded in forming a single clear picture of Patrick’s pattern of behaviour (which was particularly necessary in circumstances where he was not engaging and therefore not assisting in providing a complete history himself).
2. GPs act as a repository for information about contact with other clinical agencies (such as attendances at accident and emergency departments) and therefore serve as a point of contact for information about past history. However, I heard evidence at inquest from accident and emergency consultants that it is either not possible to access information held by a GP outside of GP surgery hours or where it is possible to do so that is only available if the GP is in the same geographic area as the accident and emergency department. Several of Patrick’s attendances at accident and emergency departments were out of GP surgery hours.
3. I was informed at inquest that one local authority (in whose area Patrick resided) had been made aware by police of the risk to Patrick following one of his self-harm incidents (in respect of a particularly important piece of information) and had relayed that information to a 6th NHS Trust (not one of the 5 from which I heard evidence at inquest) but Patrick did not reside in that Trust area. Those Trusts which did have direct contact with Patrick were never made aware of that piece of information nor had any means of accessing it.
4. I heard evidence that there is no national ‘risk flagging’ system: for example, when a person attends an accident and emergency department having self-harmed, the fact of a previous self-harm attendance at a different accident and emergency department is not systematically flagged up.
5. In summary, there was no single effective global focus consolidating the information which was flowing into the various agencies about Patrick; no global focus to which those agencies could in turn refer in emergency to obtain the totality of information about Patrick’s recent pattern of behaviour; no national ‘risk flagging’ system to alert those agencies to his significant recent history.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a single effective global focus for consolidating and retrieving cross-agency risk information
Wider context from the report “1. 5 NHS Trusts and 3 police forces in different geographic areas had contact with Patrick in the final month of his life and each thereby gained some information about the risk to him. However, that information was by reason of the agencies falling into different geographic areas. There was no single effective global focus for the information being acquired piecemeal about Patrick’s pattern of serious self-harming behaviour. The various agencies were significantly impeded in forming a single clear picture of Patrick’s pattern of behaviour (which was particularly necessary in circumstances where he was not engaging and therefore not assisting in providing a complete history himself).
2. GPs act as a repository for information about contact with other clinical agencies (such as attendances at accident and emergency departments) and therefore serve as a point of contact for information about past history. However, I heard evidence at inquest from accident and emergency consultants that it is either not possible to access information held by a GP outside of GP surgery hours or where it is possible to do so that is only available if the GP is in the same geographic area as the accident and emergency department. Several of Patrick’s attendances at accident and emergency departments were out of GP surgery hours.
3. I was informed at inquest that one local authority (in whose area Patrick resided) had been made aware by police of the risk to Patrick following one of his self-harm incidents (in respect of a particularly important piece of information) and had relayed that information to a 6th NHS Trust (not one of the 5 from which I heard evidence at inquest) but Patrick did not reside in that Trust area. Those Trusts which did have direct contact with Patrick were never made aware of that piece of information nor had any means of accessing it.
4. I heard evidence that there is no national ‘risk flagging’ system: for example, when a person attends an accident and emergency department having self-harmed, the fact of a previous self-harm attendance at a different accident and emergency department is not systematically flagged up.
5. In summary, there was no single effective global focus consolidating the information which was flowing into the various agencies about Patrick ; no global focus to which those agencies could in turn refer in emergency to obtain the totality of information about Patrick’s recent pattern of behaviour ; no national ‘risk flagging’ system to alert those agencies to his significant recent history.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unavailability of GP-held clinical history to accident and emergency departments outside surgery hours or across geographic areas
Wider context from the report “1. 5 NHS Trusts and 3 police forces in different geographic areas had contact with Patrick in the final month of his life and each thereby gained some information about the risk to him. However, that information was by reason of the agencies falling into different geographic areas. There was no single effective global focus for the information being acquired piecemeal about Patrick’s pattern of serious self-harming behaviour. The various agencies were significantly impeded in forming a single clear picture of Patrick’s pattern of behaviour (which was particularly necessary in circumstances where he was not engaging and therefore not assisting in providing a complete history himself).
2. GPs act as a repository for information about contact with other clinical agencies (such as attendances at accident and emergency departments) and therefore serve as a point of contact for information about past history. However, I heard evidence at inquest from accident and emergency consultants that it is either not possible to access information held by a GP outside of GP surgery hours or where it is possible to do so that is only available if the GP is in the same geographic area as the accident and emergency department . Several of Patrick’s attendances at accident and emergency departments were out of GP surgery hours.
3. I was informed at inquest that one local authority (in whose area Patrick resided) had been made aware by police of the risk to Patrick following one of his self-harm incidents (in respect of a particularly important piece of information) and had relayed that information to a 6th NHS Trust (not one of the 5 from which I heard evidence at inquest) but Patrick did not reside in that Trust area. Those Trusts which did have direct contact with Patrick were never made aware of that piece of information nor had any means of accessing it.
4. I heard evidence that there is no national ‘risk flagging’ system: for example, when a person attends an accident and emergency department having self-harmed, the fact of a previous self-harm attendance at a different accident and emergency department is not systematically flagged up.
5. In summary, there was no single effective global focus consolidating the information which was flowing into the various agencies about Patrick; no global focus to which those agencies could in turn refer in emergency to obtain the totality of information about Patrick’s recent pattern of behaviour; no national ‘risk flagging’ system to alert those agencies to his significant recent history.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a national risk-flagging system for previous self-harm attendances
Wider context from the report “1. 5 NHS Trusts and 3 police forces in different geographic areas had contact with Patrick in the final month of his life and each thereby gained some information about the risk to him. However, that information was by reason of the agencies falling into different geographic areas. There was no single effective global focus for the information being acquired piecemeal about Patrick’s pattern of serious self-harming behaviour. The various agencies were significantly impeded in forming a single clear picture of Patrick’s pattern of behaviour (which was particularly necessary in circumstances where he was not engaging and therefore not assisting in providing a complete history himself).
2. GPs act as a repository for information about contact with other clinical agencies (such as attendances at accident and emergency departments) and therefore serve as a point of contact for information about past history. However, I heard evidence at inquest from accident and emergency consultants that it is either not possible to access information held by a GP outside of GP surgery hours or where it is possible to do so that is only available if the GP is in the same geographic area as the accident and emergency department. Several of Patrick’s attendances at accident and emergency departments were out of GP surgery hours.
3. I was informed at inquest that one local authority (in whose area Patrick resided) had been made aware by police of the risk to Patrick following one of his self-harm incidents (in respect of a particularly important piece of information) and had relayed that information to a 6th NHS Trust (not one of the 5 from which I heard evidence at inquest) but Patrick did not reside in that Trust area. Those Trusts which did have direct contact with Patrick were never made aware of that piece of information nor had any means of accessing it.
4. I heard evidence that there is no national ‘risk flagging’ system : for example, when a person attends an accident and emergency department having self-harmed, the fact of a previous self-harm attendance at a different accident and emergency department is not systematically flagged up .
5. In summary, there was no single effective global focus consolidating the information which was flowing into the various agencies about Patrick; no global focus to which those agencies could in turn refer in emergency to obtain the totality of information about Patrick’s recent pattern of behaviour; no national ‘risk flagging’ system to alert those agencies to his significant recent history .
” Open source report
28 Mar 2023 Louis James Rogers · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 10 Failure to document general practice assessment of febrile seizures View source Failure to make timely referrals from general practice to secondary medical services for febrile seizures View source Sudden unexpected death in childhood following febrile seizures View source Failure to make paramedic information available to all clinicians View source Lack of coordinated response across clinicians to febrile seizure presentations View source Delays in referral for assessment and investigation of febrile seizures View source Failure to ensure febrile seizure diagnoses are supported by the child’s presentation View source Failure to undertake a detailed history and full neurological examination in general practice View source Failure to follow escalation guidance for complex febrile seizures View source Insufficient information for parents and guardians after a child’s febrile seizure 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
Louis James Rogers · 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
Louis James Rogers died after being found unresponsive at home following a period of clinical illness and was pronounced dead on 18 June 2021 despite resuscitation attempts. Autopsy identified a viral infection, and genetic studies confirmed Dravet’s Syndrome. The report raised concerns about the management and investigation of febrile seizures, information provided to parents, paramedic and general practice guidance, and the lack of a coordinated febrile seizure pathway.
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 general practice assessment of febrile seizures
Wider context from the report “4. General Practice -
At his mother’s request after the possibility of a further seizure, Louis was reviewed by his general practitioner on the 13th May 2021 following which Louis’s mother was reassured without a detailed history from Louis’s mother or a full neurological examination and in the absence of documentation in circumstances whereby it was acknowledged there was sufficient information at that time to refer Louis to secondary services for the management of children with febrile seizures. It would therefore be appropriate to consider providing robust national guidance and education to general practitioners to ensure appropriate history, examination, investigation are undertaken to allow timely referrals to secondary medical services to be undertaken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to make timely referrals from general practice to secondary medical services for febrile seizures
Wider context from the report “4. General Practice -
At his mother’s request after the possibility of a further seizure, Louis was reviewed by his general practitioner on the 13th May 2021 following which Louis’s mother was reassured without a detailed history from Louis’s mother or a full neurological examination and in the absence of documentation in circumstances whereby it was acknowledged there was sufficient information at that time to refer Louis to secondary services for the management of children with febrile seizures. It would therefore be appropriate to consider providing robust national guidance and education to general practitioners to ensure appropriate history, examination, investigation are undertaken to allow timely referrals to secondary medical services to be undertaken .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Sudden unexpected death in childhood following febrile seizures
Wider context from the report “1. Management and investigation of Febrile Seizures
Evidence was heard that a number of children who have ‘febrile’ seizures subsequently die from ‘sudden unexpected death in childhood’ . Evidence was provided that there should be greater emphasis on medical education, research and public information for sudden unexpected deaths associated with febrile seizures. Further evidence was heard that referrals for assessment and investigation of febrile seizures should be undertaken earlier to exclude a more severe underlying illness.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to make paramedic information available to all clinicians
Wider context from the report “5. Febrile Seizure Pathway
Evidence was heard that Louis was seen by a number of clinicians without a co-ordinated response to his presentation and that consideration should be given for all hospitals emergency departments and GP’s to be provided with a febrile seizure pathway as a checklist to ensure children are not given a diagnosis of a ‘febrile seizure when this is not supported by their presentation and for all consultations – including GP appointment and information from the paramedics is available for all clinicians to view to provide a holistic picture and to assist further management.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 coordinated response across clinicians to febrile seizure presentations
Wider context from the report “5. Febrile Seizure Pathway
Evidence was heard that Louis was seen by a number of clinicians without a co-ordinated response to his presentation and that consideration should be given for all hospitals emergency departments and GP’s to be provided with a febrile seizure pathway as a checklist to ensure children are not given a diagnosis of a ‘febrile seizure when this is not supported by their presentation and for all consultations – including GP appointment and information from the paramedics is available for all clinicians to view to provide a holistic picture and to assist further management.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 for assessment and investigation of febrile seizures
Wider context from the report “1. Management and investigation of Febrile Seizures
Evidence was heard that a number of children who have ‘febrile’ seizures subsequently die from ‘sudden unexpected death in childhood’. Evidence was provided that there should be greater emphasis on medical education, research and public information for sudden unexpected deaths associated with febrile seizures. Further evidence was heard that referrals for assessment and investigation of febrile seizures should be undertaken earlier to exclude a more severe underlying illness.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 febrile seizure diagnoses are supported by the child’s presentation
Wider context from the report “5. Febrile Seizure Pathway
Evidence was heard that Louis was seen by a number of clinicians without a co-ordinated response to his presentation and that consideration should be given for all hospitals emergency departments and GP’s to be provided with a febrile seizure pathway as a checklist to ensure children are not given a diagnosis of a ‘febrile seizure when this is not supported by their presentation and for all consultations – including GP appointment and information from the paramedics is available for all clinicians to view to provide a holistic picture and to assist further management.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake a detailed history and full neurological examination in general practice
Wider context from the report “4. General Practice -
At his mother’s request after the possibility of a further seizure, Louis was reviewed by his general practitioner on the 13th May 2021 following which Louis’s mother was reassured without a detailed history from Louis’s mother or a full neurological examination and in the absence of documentation in circumstances whereby it was acknowledged there was sufficient information at that time to refer Louis to secondary services for the management of children with febrile seizures. It would therefore be appropriate to consider providing robust national guidance and education to general practitioners to ensure appropriate history, examination, investigation are undertaken to allow timely referrals to secondary medical services to be undertaken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 follow escalation guidance for complex febrile seizures
Wider context from the report “3. Improvement to and highlighting of the JRCALC guidelines for paramedic management of seizures in children
JRCALC guidelines indicated paramedics should have conveyed Louis to hospital or contacted the GP and/or Out of Hours GP service following Louis’s second seizure on 11th February 2020, as the close proximity of two seizures indicated it was a ‘complex febrile seizure’ rather than a febrile seizure. This led to a lost opportunity to expeditiously trigger further investigation and/or a referral to either the ‘first seizure’ service or to a specialist paediatrician for further assessment and management. Evidence was heard that improving and highlighting JRCALC guidelines with additional teaching would prevent this happening again.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 information for parents and guardians after a child’s febrile seizure
Wider context from the report “2. Information provided to parents/guardians after their child had a Febrile Seizure
Evidence was heard that the NHS website and pamphlet provided to parents/guardians following a child’s febrile seizure is insufficiently informative to provide parents with sufficiently detailed information to assist them in picking up potential early indicators of a more severe illness e.g. issues with gait, co-ordination, definition of complex seizures, developmental regression etc.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review related actions, including support for families and improving the evidence base on SIDS, safer sleep, SUDC and febrile seizures.
Verbatim wording from the response “I would also like to highlight the National Child Mortality Database Thematic Report (published December 2022) which includes a recommendation for action by the Department of Health and Social Care (DHSC), NHS England and National Child Mortality Database (NCMD) to ‘Ensure there is robust and consistent national training available on the child death review statutory process, Sudden Infant Death Syndrome (SIDS), Sudden Unexplained Death in Childhood (SUDC) and available resources’. Work is underway to review this and other related actions, to include providing high-quality support for families on these issues as well as to improve the evidence base for research on SIDS and safer sleep, and on SUDC and association with febrile seizures. We will also look to engage with the Royal College of Paediatrics and Child Health (RCPCH) on this matter.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ask colleagues from seven NHS regions to share learning and available guidance with Integrated Care Boards for cascading to relevant healthcare professionals.
Verbatim wording from the response “As a result of your Report, we will also be asking colleagues from each of the seven NHS regions to share the learnings from this matter and the guidance available with their Integrated Care Boards for cascading to relevant healthcare professionals.” 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 responsible for producing clinical guidance on the diagnosis, treatment and management of febrile seizures.
Verbatim wording from the response “The National Institute for Health and Care Excellence (NICE) are responsible for producing clinical guidance for health and care practitioners on the issue of febrile seizures. Their guidance on Epilepsies in children, young people and adults (NG127) covers the diagnosis, treatment and management, referral recommendations and information and support for the management of epilepsy and seizures in children:” 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 AACE is the appropriate organisation to decide whether JRCALC guidelines for paramedic seizure management require updates.
Verbatim wording from the response “Regarding any updates to be made to JRCALC guidelines for paramedic management of seizures in children, I have been sighted on the response to your Report from the” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing national guidance is considered sufficient for managing febrile seizures.
Verbatim wording from the response “NHS England has been sighted on the response to your Report from NICE, who have advised that there is sufficient national guidance regarding the management of febrile seizures.” 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 increased risks after febrile seizures, including epilepsy, neurodevelopmental delay and SUDC, are considered very low.
Verbatim wording from the response “The increased risk of children who have experienced febrile seizures of developing epilepsy, having neurodevelopmental delays, or suffering SUDC is very low. Febrile seizures are very common in childhood and there is a balance to be met to avoid disproportionately concerning parents and carers. We have heard from Paediatric Neurology specialists that the advice within the leaflet on febrile seizures should be tailored to safety-netting during seizure, management of infection and who to contact if further seizures occur.” Source location Response from NHS England
Open published response
15 Mar 2023 Jai SINGH · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 11 Failure to meaningfully engage with families and consider family concerns View source Poor record keeping within and between teams View source Failure to recognise the significance of reported psychotic symptoms and provide adequate assessment and treatment View source Absence of a rolling risk assessment facility in SystemOne View source Absence of ongoing risk assessment documentation for patients with mental illness in SystemOne View source Failings in use of the ACCT system View source Failure to identify the need for inpatient admission and assessment for secure transfer View source Delays in taking patients onto the mental health caseload and providing allocated CPN and MDT oversight View source Failure to use interpreters View source Absence of a psychiatrist from the mental health MDT View source Poor communication within and between teams View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jai SINGH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jai Singh died at City Hospital on 28 January 2022 after being found in cardiac arrest in his cell at HMP Birmingham, having asphyxiated after placing a bag over his head. The report identifies repeated failures to communicate and record family and clinical concerns, use interpreters, assess risk, operate the ACCT process, and provide appropriate mental-health admission and transfer. It also identifies ongoing risks from the absence of a psychiatrist in the prison mental-health MDT and the lack of ongoing risk-assessment documentation in SystemOne.
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 meaningfully engage with families and consider family concerns
Wider context from the report “1. A multitude of factors contributed to Mr. Singh's death across the custodial and healthcare teams within HMP Birmingham. Many steps have been taken by all organisations with responsibility for Mr. Singh's safety and health during his time at HMP Birmingham to rectify failings that have been identified such as the consistent failure to use interpreters, poor communication and record keeping within and between teams, the absence of meaningful engagement with Mr. Singh's family , insufficient consideration of family concerns and failings in the use of the ACCT 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 Poor record keeping within and between teams
Wider context from the report “1. A multitude of factors contributed to Mr. Singh's death across the custodial and healthcare teams within HMP Birmingham. Many steps have been taken by all organisations with responsibility for Mr. Singh's safety and health during his time at HMP Birmingham to rectify failings that have been identified such as the consistent failure to use interpreters, poor communication and record keeping within and between teams , the absence of meaningful engagement with Mr. Singh's family, insufficient consideration of family concerns and failings in the use of the ACCT 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 Failure to recognise the significance of reported psychotic symptoms and provide adequate assessment and treatment
Wider context from the report “4. In Mr. Singh's case it is my conclusion that it is likely that if a psychiatrist had been at a mental health MDT meeting held on the 19th January 2022 they would have identified that he needed to be admitted to ward 2 without further delay. At the very least the need for urgent review by a psychiatrist and CPN would have been recognised and facilitated which would in turn have lead to admission. CPNs in Mr. Singh's case continually failed to identify the significance of repeatedly and consistently reported psychotic symptoms and consequently he did not receive adequate assessment and treatment which increased his risk of self harm and suicide which in turn was not sufficiently identified. The absence of a psychiatrist at the MDT creates a risk that the significance of some symptoms and presentations will not be recognised and further deaths could occur due to lack of appropriate assessment and 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 Absence of a rolling risk assessment facility in SystemOne
Wider context from the report “5. Other electronic health care records systems used in mental health settings have a rolling risk assessment document that clinicians are required to review and update at certain points in a patient's management. The risk assessment document provides a prompt to clinicians to formally consider risk and come to a reasoned, documented conclusion that then feeds into decision making. The record also provides a reliable, easily accessible source of risk history. No such facility is in use on SystemOne at HMP Birmingham . Further, the evidence given was that once a system is not being used routinely across mental health care within the prison estate and is not provided as standard on SystemOne. This creates an ongoing risk to life arising from under-estimation of risk as a result of clinicians not formally considering and assessing current risk levels, and salient risk history not being easily accessible . It is understood by Birmingham and Solihull Mental Health Trust that it should be possible to create a specific risk assessment record within SystemOne and this is being considered locally. However, the evidence given was that this issue should be highlighted nationally and that the developers and distributors of SystemOne should be involved so as to ensure the best available solution is identified.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Absence of ongoing risk assessment documentation for patients with mental illness in SystemOne
Wider context from the report “3. However, there are two features of the mental health care provided to Mr. Singh that create a risk to the lives of others that have not yet been rectified:
i. the fact that the mental health team multi-disciplinary team (MDT) does not include a psychiatrist; and
ii. the absence of any ongoing risk assessment documentation for patients with mental illness within the SystemOne records at HMP Birmingham .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failings in use of the ACCT system
Wider context from the report “1. A multitude of factors contributed to Mr. Singh's death across the custodial and healthcare teams within HMP Birmingham. Many steps have been taken by all organisations with responsibility for Mr. Singh's safety and health during his time at HMP Birmingham to rectify failings that have been identified such as the consistent failure to use interpreters, poor communication and record keeping within and between teams, the absence of meaningful engagement with Mr. Singh's family, insufficient consideration of family concerns and failings in the use of the ACCT 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 Failure to identify the need for inpatient admission and assessment for secure transfer
Wider context from the report “2. Much of the evidence at the inquest focused on the central issue of repeated missed opportunities to identify that Mr. Singh required admission to the prison's inpatient ward, ward 2, and assessment for section 48 transfer to a medium secure unit (which would have been likely to result in transfer to a medium secure unit). The consequences of the failure to transfer Mr. Singh to an inpatient setting were compounded by the fact that he was not taken onto the mental health team's caseload promptly and therefore did not have the benefit of an allocated CPN and the oversight and input of a mental health multi-disciplinary team. Many steps have been undertaken by Birmingham and Solihull Mental Health Trust (who provide mental health services within the prison) to minimise the risk of such a situation occurring again.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 taking patients onto the mental health caseload and providing allocated CPN and MDT oversight
Wider context from the report “2. Much of the evidence at the inquest focused on the central issue of repeated missed opportunities to identify that Mr. Singh required admission to the prison's inpatient ward, ward 2, and assessment for section 48 transfer to a medium secure unit (which would have been likely to result in transfer to a medium secure unit). The consequences of the failure to transfer Mr. Singh to an inpatient setting were compounded by the fact that he was not taken onto the mental health team's caseload promptly and therefore did not have the benefit of an allocated CPN and the oversight and input of a mental health multi-disciplinary team . Many steps have been undertaken by Birmingham and Solihull Mental Health Trust (who provide mental health services within the prison) to minimise the risk of such a situation occurring again.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to use interpreters
Wider context from the report “1. A multitude of factors contributed to Mr. Singh's death across the custodial and healthcare teams within HMP Birmingham. Many steps have been taken by all organisations with responsibility for Mr. Singh's safety and health during his time at HMP Birmingham to rectify failings that have been identified such as the consistent failure to use interpreters , poor communication and record keeping within and between teams, the absence of meaningful engagement with Mr. Singh's family, insufficient consideration of family concerns and failings in the use of the ACCT 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 Absence of a psychiatrist from the mental health MDT
Wider context from the report “3. However, there are two features of the mental health care provided to Mr. Singh that create a risk to the lives of others that have not yet been rectified:
i. the fact that the mental health team multi-disciplinary team (MDT) does not include a psychiatrist ; and
ii. the absence of any ongoing risk assessment documentation for patients with mental illness within the SystemOne records at HMP Birmingham.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Poor communication within and between teams
Wider context from the report “1. A multitude of factors contributed to Mr. Singh's death across the custodial and healthcare teams within HMP Birmingham. Many steps have been taken by all organisations with responsibility for Mr. Singh's safety and health during his time at HMP Birmingham to rectify failings that have been identified such as the consistent failure to use interpreters, poor communication and record keeping within and between teams, the absence of meaningful engagement with Mr. Singh's family, insufficient consideration of family concerns and failings in the use of the ACCT system.
” 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 Booking interpreters, communication and family engagement are matters for local organisations to address.
Verbatim wording from the response “NHS England is unable to comment on the matters of concern highlighted that relate to booking of interpreters, communication, and engagement with Mr Singh’s family as these are matters for response locally. I have considered the concern raised in your report regarding the absence of any ongoing risk assessment documentation for patients with mental illness, within the SystmOne records at HMP Birmingham and my response is as follows:” 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 A psychiatrist need not be included in every mental health MDT; membership depends on the patient's history and presentation.
Verbatim wording from the response “MDT members can include a variety of practitioners, specialists and care-givers from a wide range of different services, including Psychiatrists. NHS England would not however prescribe to have a psychiatrist included in every MDT.” 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 NICE-aligned risk assessments, SystmOne templates and staff training provide sufficient arrangements for mental health assessment documentation.
Verbatim wording from the response “Risk assessments are carried out in line with relevant National Institute for Health and Care Excellence (NICE) guidance for the mental health assessment of people in prison. There are templates available within SystmOne for this purpose. Any concern relating to record keeping within SystmOne, is for Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) to respond to locally as a separate matter.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Concerns about SystmOne record keeping are for Birmingham and Solihull Mental Health Foundation Trust to address locally.
Verbatim wording from the response “Risk assessments are carried out in line with relevant National Institute for Health and Care Excellence (NICE) guidance for the mental health assessment of people in prison. There are templates available within SystmOne for this purpose. Any concern relating to record keeping within SystmOne, is for Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) to respond to locally as a separate matter.” Source location Response from NHS England
Open published response
27 Feb 2023 Sophie Gwen Williams · Prevention of Future Deaths report North London
View report summary
Concerns raised 11 Lack of mental health care for patients on waiting lists View source Lack of a single, named point of contact available to patients when needed View source Failure of assessment protocols to require consideration of dissociation and psychosis risks and effects View source Failure to provide initial and annual training for staff caring for trans persons View source Lack of quality assurance scrutiny of staff training delivery and implementation View source Failure to set and implement criteria for treatment prioritisation View source Failure to direct patients to specialist carers View source Failure of assessment protocols to require consideration of previous diagnoses, treatment and available care information View source Failure of liaison among clinicians involved in patient care and treatment View source Lack of a helpline available to patients when needed View source Failure of assessment protocols to require obtaining and considering the views of people close to patients View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sophie Gwen 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
Sophie Gwen Williams died at home in the early hours of 20 May 2021 after taking a fatal overdose of prescription medications while in a psychotic or dissociative state. The report identifies concerns about the lack of assessment and management of her overdose and self-harm risk, continuity of care and crisis support, staff training and gender-affirming care, and coordination between mental health and gender-identity services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of mental health care for patients on waiting lists
Wider context from the report “for trans persons on a Personality Disorder Pathway, arise out of the lack of provision of the following:
(A) by local NHS Trusts:
(1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient;
(2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:
(a) the needs of trans persons
(b) gender-affirming care
(c) dissociation and psychosis
(3) Scrutiny of the delivery and implementation of such training, by way of quality assurance.
(4) The absence from the assessment protocol of a provision to ensure that the full account is taken of:
(a) any previous diagnosis and treatment
(b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team
(c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life
(d) the views of those who are close to the patient, including the patient’s carers, family and advocates (both formal and informal), who should be contacted, for that purpose
(B) By clinics providing gender-identity treatment (and in relation to both current and prospective patients):
(1) a help-line, available when needed by patients
(2) the direction of patients to specialist carers
(3) provision of mental health care for those patients on waiting-lists
(4) liaison (at both local and national levels) among all clinicians concerned (or expected to be concerned) in the care and treatment of such patients
(5) the setting and implementation (where practicable) of criteria for deciding whether (and, if so, which) patients (other than those terminally ill) should be given priority for receiving 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 Lack of a single, named point of contact available to patients when needed
Wider context from the report “for trans persons on a Personality Disorder Pathway, arise out of the lack of provision of the following:
(A) by local NHS Trusts:
(1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient ;
(2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:
(a) the needs of trans persons
(b) gender-affirming care
(c) dissociation and psychosis
(3) Scrutiny of the delivery and implementation of such training, by way of quality assurance.
(4) The absence from the assessment protocol of a provision to ensure that the full account is taken of:
(a) any previous diagnosis and treatment
(b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team
(c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life
(d) the views of those who are close to the patient, including the patient’s carers, family and advocates (both formal and informal), who should be contacted, for that purpose
(B) By clinics providing gender-identity treatment (and in relation to both current and prospective patients):
(1) a help-line, available when needed by patients
(2) the direction of patients to specialist carers
(3) provision of mental health care for those patients on waiting-lists
(4) liaison (at both local and national levels) among all clinicians concerned (or expected to be concerned) in the care and treatment of such patients
(5) the setting and implementation (where practicable) of criteria for deciding whether (and, if so, which) patients (other than those terminally ill) should be given priority for receiving 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 of assessment protocols to require consideration of dissociation and psychosis risks and effects
Wider context from the report “for trans persons on a Personality Disorder Pathway, arise out of the lack of provision of the following:
(A) by local NHS Trusts:
(1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient;
(2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:
(a) the needs of trans persons
(b) gender-affirming care
(c) dissociation and psychosis
(3) Scrutiny of the delivery and implementation of such training, by way of quality assurance.
(4) The absence from the assessment protocol of a provision to ensure that the full account is taken of:
(a) any previous diagnosis and treatment
(b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team
(c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life
(d) the views of those who are close to the patient, including the patient’s carers, family and advocates (both formal and informal), who should be contacted, for that purpose
(B) By clinics providing gender-identity treatment (and in relation to both current and prospective patients):
(1) a help-line, available when needed by patients
(2) the direction of patients to specialist carers
(3) provision of mental health care for those patients on waiting-lists
(4) liaison (at both local and national levels) among all clinicians concerned (or expected to be concerned) in the care and treatment of such patients
(5) the setting and implementation (where practicable) of criteria for deciding whether (and, if so, which) patients (other than those terminally ill) should be given priority for receiving 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 provide initial and annual training for staff caring for trans persons
Wider context from the report “for trans persons on a Personality Disorder Pathway, arise out of the lack of provision of the following:
(A) by local NHS Trusts:
(1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient;
(2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:
(a) the needs of trans persons
(b) gender-affirming care
(c) dissociation and psychosis
(3) Scrutiny of the delivery and implementation of such training, by way of quality assurance.
(4) The absence from the assessment protocol of a provision to ensure that the full account is taken of:
(a) any previous diagnosis and treatment
(b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team
(c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life
(d) the views of those who are close to the patient, including the patient’s carers, family and advocates (both formal and informal), who should be contacted, for that purpose
(B) By clinics providing gender-identity treatment (and in relation to both current and prospective patients):
(1) a help-line, available when needed by patients
(2) the direction of patients to specialist carers
(3) provision of mental health care for those patients on waiting-lists
(4) liaison (at both local and national levels) among all clinicians concerned (or expected to be concerned) in the care and treatment of such patients
(5) the setting and implementation (where practicable) of criteria for deciding whether (and, if so, which) patients (other than those terminally ill) should be given priority for receiving 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 Lack of quality assurance scrutiny of staff training delivery and implementation
Wider context from the report “for trans persons on a Personality Disorder Pathway, arise out of the lack of provision of the following:
(A) by local NHS Trusts:
(1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient;
(2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:
(a) the needs of trans persons
(b) gender-affirming care
(c) dissociation and psychosis
(3) Scrutiny of the delivery and implementation of such training, by way of quality assurance .
(4) The absence from the assessment protocol of a provision to ensure that the full account is taken of:
(a) any previous diagnosis and treatment
(b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team
(c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life
(d) the views of those who are close to the patient, including the patient’s carers, family and advocates (both formal and informal), who should be contacted, for that purpose
(B) By clinics providing gender-identity treatment (and in relation to both current and prospective patients):
(1) a help-line, available when needed by patients
(2) the direction of patients to specialist carers
(3) provision of mental health care for those patients on waiting-lists
(4) liaison (at both local and national levels) among all clinicians concerned (or expected to be concerned) in the care and treatment of such patients
(5) the setting and implementation (where practicable) of criteria for deciding whether (and, if so, which) patients (other than those terminally ill) should be given priority for receiving 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 set and implement criteria for treatment prioritisation
Wider context from the report “for trans persons on a Personality Disorder Pathway, arise out of the lack of provision of the following:
(A) by local NHS Trusts:
(1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient;
(2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:
(a) the needs of trans persons
(b) gender-affirming care
(c) dissociation and psychosis
(3) Scrutiny of the delivery and implementation of such training, by way of quality assurance.
(4) The absence from the assessment protocol of a provision to ensure that the full account is taken of:
(a) any previous diagnosis and treatment
(b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team
(c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life
(d) the views of those who are close to the patient, including the patient’s carers, family and advocates (both formal and informal), who should be contacted, for that purpose
(B) By clinics providing gender-identity treatment (and in relation to both current and prospective patients):
(1) a help-line, available when needed by patients
(2) the direction of patients to specialist carers
(3) provision of mental health care for those patients on waiting-lists
(4) liaison (at both local and national levels) among all clinicians concerned (or expected to be concerned) in the care and treatment of such patients
(5) the setting and implementation (where practicable) of criteria for deciding whether (and, if so, which) patients (other than those terminally ill) should be given priority for receiving 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 direct patients to specialist carers
Wider context from the report “for trans persons on a Personality Disorder Pathway, arise out of the lack of provision of the following:
(A) by local NHS Trusts:
(1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient;
(2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:
(a) the needs of trans persons
(b) gender-affirming care
(c) dissociation and psychosis
(3) Scrutiny of the delivery and implementation of such training, by way of quality assurance.
(4) The absence from the assessment protocol of a provision to ensure that the full account is taken of:
(a) any previous diagnosis and treatment
(b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team
(c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life
(d) the views of those who are close to the patient, including the patient’s carers, family and advocates (both formal and informal), who should be contacted, for that purpose
(B) By clinics providing gender-identity treatment (and in relation to both current and prospective patients):
(1) a help-line, available when needed by patients
(2) the direction of patients to specialist carers
(3) provision of mental health care for those patients on waiting-lists
(4) liaison (at both local and national levels) among all clinicians concerned (or expected to be concerned) in the care and treatment of such patients
(5) the setting and implementation (where practicable) of criteria for deciding whether (and, if so, which) patients (other than those terminally ill) should be given priority for receiving 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 of assessment protocols to require consideration of previous diagnoses, treatment and available care information
Wider context from the report “for trans persons on a Personality Disorder Pathway, arise out of the lack of provision of the following:
(A) by local NHS Trusts:
(1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient;
(2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:
(a) the needs of trans persons
(b) gender-affirming care
(c) dissociation and psychosis
(3) Scrutiny of the delivery and implementation of such training, by way of quality assurance.
(4) The absence from the assessment protocol of a provision to ensure that the full account is taken of:
(a) any previous diagnosis and treatment
(b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team
(c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life
(d) the views of those who are close to the patient, including the patient’s carers, family and advocates (both formal and informal), who should be contacted, for that purpose
(B) By clinics providing gender-identity treatment (and in relation to both current and prospective patients):
(1) a help-line, available when needed by patients
(2) the direction of patients to specialist carers
(3) provision of mental health care for those patients on waiting-lists
(4) liaison (at both local and national levels) among all clinicians concerned (or expected to be concerned) in the care and treatment of such patients
(5) the setting and implementation (where practicable) of criteria for deciding whether (and, if so, which) patients (other than those terminally ill) should be given priority for receiving 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 of liaison among clinicians involved in patient care and treatment
Wider context from the report “for trans persons on a Personality Disorder Pathway, arise out of the lack of provision of the following:
(A) by local NHS Trusts:
(1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient;
(2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:
(a) the needs of trans persons
(b) gender-affirming care
(c) dissociation and psychosis
(3) Scrutiny of the delivery and implementation of such training, by way of quality assurance.
(4) The absence from the assessment protocol of a provision to ensure that the full account is taken of:
(a) any previous diagnosis and treatment
(b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team
(c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life
(d) the views of those who are close to the patient, including the patient’s carers, family and advocates (both formal and informal), who should be contacted, for that purpose
(B) By clinics providing gender-identity treatment (and in relation to both current and prospective patients):
(1) a help-line, available when needed by patients
(2) the direction of patients to specialist carers
(3) provision of mental health care for those patients on waiting-lists
(4) liaison (at both local and national levels) among all clinicians concerned (or expected to be concerned) in the care and treatment of such patients
(5) the setting and implementation (where practicable) of criteria for deciding whether (and, if so, which) patients (other than those terminally ill) should be given priority for receiving 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 Lack of a helpline available to patients when needed
Wider context from the report “for trans persons on a Personality Disorder Pathway, arise out of the lack of provision of the following:
(A) by local NHS Trusts:
(1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient;
(2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:
(a) the needs of trans persons
(b) gender-affirming care
(c) dissociation and psychosis
(3) Scrutiny of the delivery and implementation of such training, by way of quality assurance.
(4) The absence from the assessment protocol of a provision to ensure that the full account is taken of:
(a) any previous diagnosis and treatment
(b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team
(c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life
(d) the views of those who are close to the patient, including the patient’s carers, family and advocates (both formal and informal), who should be contacted, for that purpose
(B) By clinics providing gender-identity treatment (and in relation to both current and prospective patients):
(1) a help-line, available when needed by patients
(2) the direction of patients to specialist carers
(3) provision of mental health care for those patients on waiting-lists
(4) liaison (at both local and national levels) among all clinicians concerned (or expected to be concerned) in the care and treatment of such patients
(5) the setting and implementation (where practicable) of criteria for deciding whether (and, if so, which) patients (other than those terminally ill) should be given priority for receiving 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 of assessment protocols to require obtaining and considering the views of people close to patients
Wider context from the report “for trans persons on a Personality Disorder Pathway, arise out of the lack of provision of the following:
(A) by local NHS Trusts:
(1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient;
(2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:
(a) the needs of trans persons
(b) gender-affirming care
(c) dissociation and psychosis
(3) Scrutiny of the delivery and implementation of such training, by way of quality assurance.
(4) The absence from the assessment protocol of a provision to ensure that the full account is taken of:
(a) any previous diagnosis and treatment
(b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team
(c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life
(d) the views of those who are close to the patient, including the patient’s carers, family and advocates (both formal and informal), who should be contacted, for that purpose
(B) By clinics providing gender-identity treatment (and in relation to both current and prospective patients):
(1) a help-line, available when needed by patients
(2) the direction of patients to specialist carers
(3) provision of mental health care for those patients on waiting-lists
(4) liaison (at both local and national levels) among all clinicians concerned (or expected to be concerned) in the care and treatment of such patients
(5) the setting and implementation (where practicable) of criteria for deciding whether (and, if so, which) patients (other than those terminally ill) should be given priority for receiving treatment
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase financial investment in Gender Dysphoria Clinics to support recruitment of additional clinicians where possible.
Verbatim wording from the response “the Royal College of Physicians to design and fund the UK’s first Gender Identity Healthcare Credential, which since 2020 has provided a route for clinicians to train in the specialty of gender dysphoria healthcare. In addition, NHS England has significantly increased financial investment in the Gender Dysphoria Clinics in recent years, to recruit additional clinicians where possible.” 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 Design and fund the Gender Identity Healthcare Credential to provide clinicians with a specialist gender dysphoria healthcare training route.
Verbatim wording from the response “the Royal College of Physicians to design and fund the UK’s first Gender Identity Healthcare Credential, which since 2020 has provided a route for clinicians to train in the specialty of gender dysphoria healthcare. In addition, NHS England has significantly increased financial investment in the Gender Dysphoria Clinics in recent years, to recruit additional clinicians where possible.” 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 Disseminate descriptions of existing helplines and NHS-commissioned patient support to all commissioned Gender Dysphoria Clinics for best-practice assessment.
Verbatim wording from the response “By November 2023, NHS England will have disseminated amongst all NHS commissioned Gender Dysphoria Clinics a description of existing helplines used by Gender Dysphoria Services – and a description of other forms of support commissioned by NHS England - so that an assessment of ‘best practice’ may be made by Gender Dysphoria Clinics in forming their response to HM Coroner’s finding of concern about the lack of this support for the benefit of patients on their waiting lists.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish and commission waiting-list support for gender dysphoria patients, including screening, outreach, peer support, advice lines and pre-assessment workshops.
Verbatim wording from the response “NHS England has directly supported NHS Gender Dysphoria Clinics in developing and establishing forms of support for patients while they remain on the waiting list. In a recent discretionary investment exercise, NHS England sought proposals from Gender Dysphoria Clinics that would either increase the number of clinical staff in their service or, in recognition of the workforce constraints, would improve the patient experience in other ways, such as support while on the waiting list. While not certain it would have changed the outcome in this case, there is clinical opinion that telephone” 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 Integrated Care Boards, rather than NHS England, are responsible for commissioning local mental health services.
Verbatim wording from the response “Commissioning responsibility for local mental health services rests with Integrated Care Boards (ICB), rather than NHS England. The make-up of local services will therefore differ according to each ICB’s commissioning strategy. Also, an individual’s GP plays an important role in supporting patients who have physical and mental health support needs, including referral to local NHS services (being mindful that evidence shows that transgender and non-binary people are more likely to experience poor mental health than the general population). The NHS Long Term Plan for Mental Health describes an expansion of local mental health care so that more people can access treatment by increasing funding at a faster rate than the overall NHS budget – and by at least £2.3bn a year by 2023/24.” 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 Specialist workforce expansion could not keep pace with demand because clinicians were difficult to attract, train and retain.
Verbatim wording from the response “The number of referrals into NHS gender dysphoria services has increased significantly, and it has not been possible to grow the specialist workforce at the required rate to keep pace with demand. In 2019, NHS England ran a national procurement exercise for both surgical and non-surgical services, in an effort to attract additional providers to start offering gender dysphoria services. Unfortunately, no new providers came forward, which reflects the difficulty in attracting, training, and retaining clinicians to work in this area of healthcare. For that reason, NHS England worked with” 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 Referral-date ordering is considered appropriate because risk-based triage could disadvantage patients who have waited longest.
Verbatim wording from the response “Currently, based on recent clinical opinion, patients are seen based on the referral date to a Gender Dysphoria Clinic. This is considered an appropriate process in that if patients are triaged based on risk, this could negatively impact patients who do not exhibit significant risk and who have been waiting longest. In the absence of firm evidence, the solution is likely to be improving access to more timely healthcare for individuals with gender dysphoria.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Trusts directly involved in care are better placed to address many concerns raised in the report.
Verbatim wording from the response “The Trusts directly involved in Sophie’s care are better placed to answer many of the concerns raised in your Report, and NHS England have been sighted on the response from The Tavistock and Portman NHS Foundation Trust. NHS England are the commissioner for specialised gender dysphoria services, and we have therefore focused on the Matters of Concern relating to clinics providing gender identity treatment, where we are in a position to address the concerns raised.” Source location Response from NHS England
Open published response
22 Feb 2023 Jacqueline Sharman CAMPBELL · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 2 Failure to actively identify patients taking high-risk medication combinations and rationalize or reduce their medications View source Severe risk of cumulative and synergistic central nervous system depression from gabapentinoid and opioid polypharmacy View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jacqueline Sharman CAMPBELL · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jacqueline Sharman CAMPBELL was found collapsed at home after living with chronic back pain for more than 20 years and taking multiple prescribed medicines. The inquest concluded that she likely inadvertently overdosed on tramadol, which in combination with other medicines had a synergistic effect causing respiratory depression and death. The principal concern was the safety risk of polypharmacy involving gabapentinoids and opioids, particularly their cumulative and synergistic effects on the central nervous system.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to actively identify patients taking high-risk medication combinations and rationalize or reduce their medications
Wider context from the report “Her GP, ████████, gave clear and candid evidence. I accept the management of patients who describe intractable debilitating pain is challenging and difficult and that requests for other or increasing doses of medication can be difficult to resist. ████████ agreed that the prescribing of the various drugs identified had potential to be dangerous. He told me that after a certain point the benefits of increasing or adding doses or medications in terms of pain relief were minimal. This scenario seems to be an on individuals one for GP’s and patients alike.
████████ told me that subsequent to Ms Campbell’s death the practice had convened and discussed the circumstances and agreed on regular reviews for patients taking these sorts of medication. There were no plans identified to actively look for these patients and to work to rationalize and / or reduce their medications.
I am of the view that polypharmacy including gabapentinoids and opiates represents a severe safety risk in patients with a iatrogenic drug dependency. I consider that the risk in individuals like Ms Campbell of an inadvertent overdose of medications which have a cumulative and synergistic effect to depress the central nervous system can easily become extreme and lead to death. There have been a number of deaths in the Milton Keynes, Bedfordshire and Luton areas related to concomitant use of high dose and combination gabapentinoids and opioids.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Severe risk of cumulative and synergistic central nervous system depression from gabapentinoid and opioid polypharmacy
Wider context from the report “Her GP, ████████, gave clear and candid evidence. I accept the management of patients who describe intractable debilitating pain is challenging and difficult and that requests for other or increasing doses of medication can be difficult to resist. ████████ agreed that the prescribing of the various drugs identified had potential to be dangerous . He told me that after a certain point the benefits of increasing or adding doses or medications in terms of pain relief were minimal . This scenario seems to be an on individuals one for GP’s and patients alike.
████████ told me that subsequent to Ms Campbell’s death the practice had convened and discussed the circumstances and agreed on regular reviews for patients taking these sorts of medication. There were no plans identified to actively look for these patients and to work to rationalize and / or reduce their medications.
I am of the view that polypharmacy including gabapentinoids and opiates represents a severe safety risk in patients with a iatrogenic drug dependency . I consider that the risk in individuals like Ms Campbell of an inadvertent overdose of medications which have a cumulative and synergistic effect to depress the central nervous system can easily become extreme and lead to death . There have been a number of deaths in the Milton Keynes, Bedfordshire and Luton areas related to concomitant use of high dose and combination gabapentinoids and opioids.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a national programme to reduce harm from high-dose opioids prescribed for non-cancer pain.
Verbatim wording from the response “The NHS Medicines Safety Improvement Programme (which forms a key part of the NHS Patient Safety Strategy) has launched a focussed programme of work to improve the care of people with chronic pain and a reduction in the use of prescribed opioids by aiming to reduce harm from opioid medicines by reducing high dose prescribing” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a national framework to help systems improve personalised care for adults prescribed dependence- or withdrawal-associated medicines.
Verbatim wording from the response “In March 2023, NHS England published ‘Optimising personalised care for adults prescribed medicines associated with dependence or withdrawal symptoms: Framework for action for ICBs and primary care’. The framework includes five actions, resources, and case studies to help systems develop plans that can support people who are taking medicines associated with dependence and withdrawal symptoms by:” 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 Integrated Care Systems to develop, implement, adapt and share effective improvements in chronic pain and opioid prescribing care.
Verbatim wording from the response “(>120mg oral Morphine equivalent), for non-cancer pain by 50%, by March 2024. The programme has been in place since January 2021. The national programme is supporting Integrated Care Systems to learn from, adapt and adopt effective practice using a whole-system improvement approach.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop national resources supporting consistent repeat-prescribing processes and structured medication reviews for patients at risk from multiple medicines.
Verbatim wording from the response “The National overprescribing review report commissioned by DHSC in 2018 evaluated the extent, causes and consequences of overprescribing and made 20 recommendations to address it. NHS England aims to make long term sustainable reductions to overprescribing and is working on several outputs to help implement the review’s recommendations. Outputs include national resources to help practices improve the consistency of repeat prescribing processes, supported by appropriate training; and resources to enhance structured medication reviews for patients who may experience harm from taking multiple medicines.” 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 ICBs are responsible for commissioning chronic pain and opioid-withdrawal support services for their geographically covered populations.
Verbatim wording from the response “Commissioning of services to support people with chronic pain (including services to support people to safely withdraw from opioid use) now lies with the ICBs. NHS England expects ICBs to commission appropriate services to meet the needs of the population that the ICB geographically covers.” Source location Response from NHS England
Open published response
Concerns raised 1 Lack of automatic GP-record alerts for smear-test non-responders View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rachelle Naomi Ross · 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
Rachelle Naomi Ross, aged 34, had not undergone a smear test before being diagnosed with squamous cell carcinoma in November 2020. Despite treatment, the cancer metastasised and she died at home on 20 April 2022. The report raised concerns that GP systems did not automatically flag patients who failed to attend smear tests, potentially requiring manual recording of warnings.
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 automatic GP-record alerts for smear-test non-responders
Wider context from the report “1. During the course of the inquest I heard evidence from ████████, GP Partner at the Collingwood Health Group who informed me that GP practice records do not include an alert from EMIS or System 1 IT systems to provide an automatic flag on a patient's GP medical records if they are classed as a non-responder for a smear test by the National Screening Service.
2. The alert system is only triggered after a patient attends a smear test. For a non-responder, they go back into the three or five year waiting list for a National Screening invitation for a smear test.
3. An automatic flag or alert when a patient fails to attend for a smear test as part of the National Screening Service, would mean that a GP surgery would not have to manually add a warning as an entry onto an individual’s GP records. It would standardise the approach across all GP surgeries and could increase patient safety.
” 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 GP IT systems automatically display overdue cervical-screening alerts, including for non-responders, so the concern that records lack an alert is incorrect.
Verbatim wording from the response “GP IT software systems typically have inbuilt alerts to notify users when a person’s cervical screening is overdue. Such alerts appear automatically in the person’s record without any further manual input, when they reach their 25th birthday. Once a person has had a cervical screening test done, the alert next appears if that person is overdue their next test. This alert stays present even if the national service has recorded the person as a non-responder and has set their recall to the next screening cycle date. These alerts appear to the user when in a patient’s records in an alert tab. This is visible in EMIS (bottom right-hand side of the screen) and in TPP (top right-hand side of the screen) along with other alerts pertinent to that person’s health status.” Source location Response NHS England
Open published response
10 Feb 2023 Celia Sanderson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Lack of DGH Emergency Department protocols and staff awareness for recognising potential silver trauma cases at arrival View source Delays in Emergency Department senior clinician review due to insufficient senior medical staffing View source Delays in Emergency Department clinician review due to patient volume and insufficient staff availability View source Delays in carrying out and reporting CT scans due to insufficient suitably qualified radiology staff 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
Celia Sanderson · 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
Celia Sanderson was involved in a road traffic collision and died at Wythenshawe Hospital after developing severe injuries, neurological damage and an acute myocardial infarction while awaiting transfer to a major trauma centre. The concerns included delays in triage and clinician review, shortages of senior emergency department and radiology staff, delays in CT scanning and reporting, and insufficient recognition of potential “silver trauma” cases in district general hospitals.
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 DGH Emergency Department protocols and staff awareness for recognising potential silver trauma cases at arrival
Wider context from the report “4. The inquest heard evidence from a trauma specialist about the importance of recognising “silver trauma”. There was recognition amongst trauma specialists of the high risk of significant trauma amongst elderly patients such as Mrs Sanderson even from what could appear to be relatively minor incidents. As a consequence major trauma centres generally had developed protocols that assisted staff at triage to pick up such cases and prioritise them and set a low threshold for an early CT scan . Such protocols were not generally in force in DGH settings . The evidence was that there needed to be steps taken to increase awareness amongst DGH ED staff to pick up these potential silver trauma cases on arrival in order to expedite discussion with and transfer to a trauma centre and increase the chances of survival.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 Emergency Department senior clinician review due to insufficient senior medical staffing
Wider context from the report “2. The inquest heard that amongst the challenges faced was a shortage of ED consultants and ED middle grade doctors . Mrs Sanderson’s time at the hospital included late evening and the early hours of the morning. The inquest heard that across the NHS during these hours the number of staff at these grades in an ED is significantly reduced . Historically that had been a quieter period however demands on ED meant that was no longer the case . As a consequence senior reviews of patients were further delayed . An earlier review by a senior clinician was likely to have identified her as a potential silver trauma case and ensured she was moved to a trauma centre for appropriate treatment before she began to deteriorate;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 Emergency Department clinician review due to patient volume and insufficient staff availability
Wider context from the report “1. Demands on the Emergency Department due to the volume of people waiting to be seen meant that Mrs Sanderson had a long wait for a clinician review far outside the expected target time . The inquest heard evidence that delays such as hers were common throughout that period and were due to the volume of people attending and staff available to deal with them ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 carrying out and reporting CT scans due to insufficient suitably qualified radiology staff
Wider context from the report “3. Evidence given to the inquest indicated that the ability to carry out and report promptly on CT scans was essential if trauma cases were to be identified with sufficient speed to ensure a timely transfer to a trauma unit. The inquest heard that timely transfer to a trauma unit was likely to significantly improve the outcome for a trauma patient. The inquest was told that once CT scans were requested there were often delays due to a shortage of suitably qualified staff to carry them out and then to report on them . As an example of this the inquest was told that overnight 1 radiology registrar was responsible for reporting on CT scans for 3 hospitals (Wythenshawe, the MRI and RMCH) In Mrs Sanderson’s case this meant that the ED clinician had to wait for it to be carried out and then assess the CT scan without the report ;
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Greater Manchester Integrated Care provides the relevant services, while its Integrated Care Board decides commissioned health services.
Verbatim wording from the response “In order to be able to respond to your Report, NHS England has engaged with Greater Manchester Integrated Care (NHS GM) who is the provider of the healthcare services in question, and the Integrated Care Board (ICB) who is responsible for making decisions about commissioned health services across Greater Manchester NHS England’s response to your Report is based on our informed discussions with these two organisations.” 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