10 Feb 2023 Sandra Adina Lomax · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to ensure regular participation of all Trusts in the GM Upper GI MDT View source Absence of a commissioned pan-Greater Manchester specialist service for complex oesophageal stricture cases View source Lack of detailed national guidance on management of oesophageal strictures and when and how to approach stenting View source Failure of the MDT to effectively communicate agreed actions and recommendations for individual patients View source See 1 more concern
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AI-generated summary
Sandra Adina Lomax · 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 Adina Lomax died at Stepping Hill Hospital on 25 June 2022 after complications developed from an oesophageal stent that was not removed within the required six-week period. The concerns included inadequate communication and case ownership, delayed escalation, lack of detailed national guidance, absence of a commissioned specialist service, staffing gaps in the regional MDT, and ineffective communication of MDT recommendations.
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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 regular participation of all Trusts in the GM Upper GI MDT
Wider context from the report “3. The inquest also heard evidence that to support management of cases such as Mrs Lomax there was a regular GM Upper GI MDT led by Salford Royal Hospital. However staffing issues meant that there was not a regular presence for all Trusts at the meeting . This impacted effective communication and impacted patient 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 Absence of a commissioned pan-Greater Manchester specialist service for complex oesophageal stricture cases
Wider context from the report “2. Within Greater Manchester the inquest was told that the Christie were seeking to develop a specialist service for these complex cases but funding of a commissioned pan GM service was fundamental to a successful roll out that would benefit such patients as Mrs Lomax. The absence of such a service meant that cases such as Mrs Lomax’s could arise going forward given that in most hospitals even experienced radiologists/gastroenterologists would have limited experience on how to manage such cases;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of detailed national guidance on management of oesophageal strictures and when and how to approach stenting
Wider context from the report “1. The inquest heard evidence that the development of oesophageal strictures such as Mrs Lomax’s was a relatively new development as a consequence of advances in chemo/radiotherapy that meant that surgery was not the only option for oesophageal cancer. However the management of these strictures was complicated and there was no detailed national guidance on management of them and in particular when and how stenting should be approached . The development and implementation of detailed National Guidance was the inquest was told key to improving outcomes for patients such as Mrs Lomax across England;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of the MDT to effectively communicate agreed actions and recommendations for individual patients
Wider context from the report “4. This was compounded by the fact that the inquest heard evidence that the MDT did not have a system of effective communication of agreed actions and recommendations for individual patients discussed at the MDT . As a consequence local clinicians were unsighted as to the recommended way forward . The inquest was told that an effective and consistent pan GM approach to sharing the outcomes of MDTs would improve patient outcomes.
” 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 the Report and updated NICE guidance with the Cancer Clinical Advisory Group before publication to consider immediate actions.
Verbatim wording from the response “NICE are currently consulting on a partial update to their guidance on Oesophago-gastric cancer, with publication expected on/or around 4 July 2023. This includes consideration of treatments offered to patients who have had stents inserted. In response to your Report and the concerns raised, NHS England plans to discuss your Report and the NICE guidance with the Cancer Clinical Advisory Group, in advance of the publication of updated NICE guidance relating to oesophago-gastric cancer, to consider whether any further immediate actions need to be taken. NHS England would be happy to write to the Coroner again in due course to provide an update if she so wishes.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and consider any proposal from The Christie supporting service-specification requirements for chemo-radiotherapy and stenting.
Verbatim wording from the response “NHS England’s Regional Specialised Commissioning Team for the North West will review and consider any proposal from The Christie to support the delivery of the service specification requirements relating to chemo-radiotherapy and stenting.” 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 Share the Report and concerns through System Quality Groups with relevant NHS England trusts and clinicians to support learning, including effective frequent MDT meetings.
Verbatim wording from the response “In addition, the national Regulation 28 Working Group will ensure that your Report and the concerns raised are shared with System Quality Groups for onward sharing to relevant Trusts and clinicians across NHS England, so that they may take learnings from this case.” 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 Greater Manchester is the appropriate organisation to address local staffing and ineffective communication between the multidisciplinary team.
Verbatim wording from the response “GM are the appropriate organisation to respond to your concerns around GM staffing issues and ineffective communication between the MDT. I have been sighted on their response and welcome the Greater Manchester Cancer Alliance improvement programme for MDT reform. I also note that they will be sharing learning from Sandra’s death across the Greater Manchester System.” 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 Complex oesophageal cancer cases require individual multidisciplinary team management, so national guidance does not cover every aspect of care.
Verbatim wording from the response “NHS England does not provide guidance covering every aspect of care. This is particularly pertinent for management of complex cases and cancers, such as Sandra’s, which require management on an individual basis with input from a multi-disciplinary team (MDT) within the relevant Trust and NICE does make clear that MDT decision-making is important in these complex cases.” Source location Response from NHS England
Open published response
Concerns raised 4 Failure to issue Governor notices in response to increased psychoactive substance risks View source Lack of specific and dedicated guidance for defining and caring for vulnerable prisoners View source Inadequate quantity and quality of prison staff record keeping on NOMIS View source Failure of the keyworker programme to operate as planned View source See 1 more concern
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jason Anthony 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
Jason Anthony Williams was found unresponsive in his cell at HMP Guys Marsh on 31 July 2020, and his death was confirmed by paramedics. The report states that synthetic cannabinoid intoxication was the medical cause of death and that he had deliberately taken drugs without intending fatal consequences. Concerns included inadequate guidance on vulnerable prisoners, shortcomings in the keyworker programme and NOMIS record keeping, and the absence of a Governor notice about increased psychoactive-substance risks.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to issue Governor notices in response to increased psychoactive substance risks
Wider context from the report “iv. A Governor notice was not issued in the time leading up to Jason’s death to prisoners or staff around the concerns regarding access to, and the impact of using, psychoactive substances . I request that consideration is given to a review being undertaken by HMP Guys Marsh as to when such notices should be issued, particularly in relation to increased risks to prisoners around drug use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 specific and dedicated guidance for defining and caring for vulnerable prisoners
Wider context from the report “i. There is a lack of specific and dedicated national guidance to prison and healthcare staff on how to define and care for vulnerable prisoners. I would request that consideration is given to producing national guidance on this, to also include guidance on addressing self-neglect .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 quantity and quality of prison staff record keeping on NOMIS
Wider context from the report “iii. The quantity and quality of record keeping by prison staff at HMP Guys Marsh on NOMIS . I request that consideration is given to providing refresher training to prison staff on record keeping to cover the importance of records and their contents, and the required regularity of recording.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of the keyworker programme to operate as planned
Wider context from the report “ii. The current keyworker programme is not working as planned at HMP Guys Marsh and there was reference to this also being reflected nationally . I would request that consideration is given to a review being undertaken of the keyworker programme within the whole prison estate, and also specifically at HMP Guys Marsh.
” 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 Include information about self-neglect in the Safeguarding Adults Pocket Guide.
Verbatim wording from the response “Locally, adult safeguarding Boards and teams record indicators of self-neglect and NHS England includes information about self-neglect in a Safeguarding Adults Pocket Guide.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing safeguarding guidance, training and planned partnership work support identification and protection of vulnerable prisoners.
Verbatim wording from the response “Locally, adult safeguarding Boards and teams record indicators of self-neglect and NHS England includes information about self-neglect in a Safeguarding Adults Pocket Guide.” 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 HMPPS and HMP Guys Marsh are better placed to address many concerns raised about prison care and safeguarding.
Verbatim wording from the response “I note that you have also sent your Report to His Majesty’s Prison and Probation Service and (HMPPS) and HMP Guys Marsh, who are better placed to comment on many of the concerns raised in your Report. All prisoners have the potential to be vulnerable, requiring a case-by-case assessment and careful management and in my response, I have considered the concerns raised in your Report regarding the apparent lack of national guidance on how to define vulnerability and care for and safeguard vulnerable prisoners.” Source location Response from NHS England
Open published response
Concerns raised 3 Failure to share primary care complaint review information back to practices for learning View source Failure to ensure that primary care complaint clinical reviews are fully informed by relevant information View source Failure to cascade relevant primary care complaint review information to the primary care network View source
Responses linked to these concerns
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AI-generated summary
David John Nash · 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 John Nash developed a fatal cerebellar abscess caused by mastoiditis and died at Leeds General Infirmary on 4 November 2020. The inquest identified a missed opportunity during his GP appointment on 2 November 2020 to direct him to face-to-face or urgent care. A further concern was how clinical complaint reviews were informed by, and communicated to, the GP practice and wider primary care network.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to share primary care complaint review information back to practices for learning
Wider context from the report “I heard evidence that David's father made a complaint to NHSE about the primary care service, namely the GP Practice, that David had had contact with. This resulted in a clinical review of that complaint by Dr D'Souza which was initially highly critical of the 4 occasions of care which David had at his GP Practice (listed above)
It appears that this complaint was handled without a clinical rationale from the GP Practice being provided which resulted in ████████ reviewing his opinion once that information was provided in the anticipation of inquest proceedings. I heard evidence from the GP Practice that they were not made aware of the concerns raised by ████████ ████████ until the inquest process had disclosed these concerns.
I am unclear how the primary care complaints team ensure that the details from their clinical reviews are fully informed taking account of information provided from complainants and those involved in the clinical management of a patient and how that information is then shared back to the practice to ensure appropriate learning can be undertaken. I am also not clear of the process of cascading this information to the primary care network in general where that is appropriate to raise awareness of an issue or condition for example.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that primary care complaint clinical reviews are fully informed by relevant information
Wider context from the report “I heard evidence that David's father made a complaint to NHSE about the primary care service, namely the GP Practice, that David had had contact with. This resulted in a clinical review of that complaint by Dr D'Souza which was initially highly critical of the 4 occasions of care which David had at his GP Practice (listed above)
It appears that this complaint was handled without a clinical rationale from the GP Practice being provided which resulted in ████████ reviewing his opinion once that information was provided in the anticipation of inquest proceedings. I heard evidence from the GP Practice that they were not made aware of the concerns raised by ████████ ████████ until the inquest process had disclosed these concerns.
I am unclear how the primary care complaints team ensure that the details from their clinical reviews are fully informed taking account of information provided from complainants and those involved in the clinical management of a patient and how that information is then shared back to the practice to ensure appropriate learning can be undertaken. I am also not clear of the process of cascading this information to the primary care network in general where that is appropriate to raise awareness of an issue or condition for example.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 cascade relevant primary care complaint review information to the primary care network
Wider context from the report “I heard evidence that David's father made a complaint to NHSE about the primary care service, namely the GP Practice, that David had had contact with. This resulted in a clinical review of that complaint by Dr D'Souza which was initially highly critical of the 4 occasions of care which David had at his GP Practice (listed above)
It appears that this complaint was handled without a clinical rationale from the GP Practice being provided which resulted in ████████ reviewing his opinion once that information was provided in the anticipation of inquest proceedings. I heard evidence from the GP Practice that they were not made aware of the concerns raised by ████████ ████████ until the inquest process had disclosed these concerns.
I am unclear how the primary care complaints team ensure that the details from their clinical reviews are fully informed taking account of information provided from complainants and those involved in the clinical management of a patient and how that information is then shared back to the practice to ensure appropriate learning can be undertaken. I am also not clear of the process of cascading this information to the primary care network in general where that is appropriate to raise awareness of an issue or condition for example.
” 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 Remind all regional complaints teams to share final responses with concerned providers under the complaints policy.
Verbatim wording from the response “1. NHS England will ensure that all regional complaints teams are reminded of the requirement to share a copy of its final response with the provider(s) concerned, in line with NHS England policy.” 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 Update the complaints policy to require sharing final responses with concerned providers.
Verbatim wording from the response “Our review has shown it appears that copies of the complaint responses were not shared with the GP practice. NHS England apologises for this and for any distress caused to the family. NHS England updated its complaints policy in October 2021, to state that all responses must be shared with the provider and this change should have been acknowledged and acted upon. We will ensure all regions are reminded of the complaints policy and the need to be compliant with the policy.” 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 Routine information sharing with Primary Care Networks is not required because established locality, ICB and national processes support appropriate complaint learning.
Verbatim wording from the response “It is not NHS England policy to routinely share information with Primary Care Networks, however, agreed ways of working and processes are in place to ensure sharing and learning from complaints.” Source location Response from NHS England
Open published response
30 Jan 2023 Mr Nathan Forrester · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 5 Unavailability of airways in emergency bags View source Inadequate handover during resuscitation emergencies View source Failure of nurses to provide effective resuscitation View source Lack of nurse training in insertion of iGel or oropharyngeal airways View source Lack of prison officer training for assessment, removal and immediate CPR of prisoners on top bunks 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
Mr Nathan Forrester · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Nathan Forrester died in a shared prison cell after consuming illicit drugs, and the jury concluded that he died of a drug-related death. Concerns included delays and insufficient training in removing an unresponsive prisoner from a top bunk for CPR, and gaps in nurses’ CPR, airway-management and handover training in detention settings.
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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 Unavailability of airways in emergency bags
Wider context from the report “2. Training of nurses in CPR (NHS England)
Nurses attending the Code Blue had no training insertion of an IGel or oropharyngeal tube, nor was an airway available in the emergency bags . Paramedics reported that resuscitation being provided by nurses was ineffective (too low and too fast) and that they had an inadequate handover. These deficiencies have been addressed locally and all nurses in Oxleas NHS Trust are trained annually to ILS level and airways are available. The concern is that this standard of training of nurses working in detention settings nationally may not be universal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 handover during resuscitation emergencies
Wider context from the report “2. Training of nurses in CPR (NHS England)
Nurses attending the Code Blue had no training insertion of an IGel or oropharyngeal tube, nor was an airway available in the emergency bags. Paramedics reported that resuscitation being provided by nurses was ineffective (too low and too fast) and that they had an inadequate handover . These deficiencies have been addressed locally and all nurses in Oxleas NHS Trust are trained annually to ILS level and airways are available. The concern is that this standard of training of nurses working in detention settings nationally may not be universal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 nurses to provide effective resuscitation
Wider context from the report “2. Training of nurses in CPR (NHS England)
Nurses attending the Code Blue had no training insertion of an IGel or oropharyngeal tube, nor was an airway available in the emergency bags. Paramedics reported that resuscitation being provided by nurses was ineffective (too low and too fast) and that they had an inadequate handover. These deficiencies have been addressed locally and all nurses in Oxleas NHS Trust are trained annually to ILS level and airways are available. The concern is that this standard of training of nurses working in detention settings nationally may not be universal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 nurse training in insertion of iGel or oropharyngeal airways
Wider context from the report “2. Training of nurses in CPR (NHS England)
Nurses attending the Code Blue had no training insertion of an IGel or oropharyngeal tube , nor was an airway available in the emergency bags. Paramedics reported that resuscitation being provided by nurses was ineffective (too low and too fast) and that they had an inadequate handover. These deficiencies have been addressed locally and all nurses in Oxleas NHS Trust are trained annually to ILS level and airways are available. The concern is that this standard of training of nurses working in detention settings nationally may not be universal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 prison officer training for assessment, removal and immediate CPR of prisoners on top bunks
Wider context from the report “1. Deaths on top bunks (HMPPS)
The first prison officer to arrive and find Mr Forrester unresponsive to voice, blue and cold, decided she was too small to be able to get him off his top bunk, even with a colleague, and left the cell. A second officer, having confirmed no pulse or response to pain, stated that there was no specific training on how to manage an arrest and CPR of a person on a top bunk . He tried unsuccessfully to bring him down. A third officer attending did not attempt to do so. After some delay, nurses brought him down to floor level when they arrived. The Head of Safer Custody has asked the local health service provider to advise how prison officers should be trained to manage assessment, removal and immediate CPR of a prisoner on a top bunk. The concern is that this training gap may exist in other establishments.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish service specifications requiring prison healthcare providers to develop emergency-response protocols and CPR training.
Verbatim wording from the response “The Service Specification, ‘primary care service, medical and nursing for prisons in England’, published in March 2020, includes a section on unplanned and emergency. This outlines the requirements for the healthcare provider to develop and implement protocols, specific to each prison, for responding to and managing emergencies including training for staff in CPR. Immediate Life Support (ILS) training provides healthcare professionals with the skills needed to respond in an emergency.” 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 Prison primary-care healthcare professionals are outside ALS categories, so advanced procedures may exceed their registered clinical competence.
Verbatim wording from the response “The Resuscitation Council UK also outlines that Advanced Life Support (ALS), which includes the use of supraglottic airway devices such as an iGel, is appropriate for healthcare professionals who would undertake ALS as part of their clinical duties.” 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 HMPPS is responsible for training prison officers to manage prisoners on top bunks and will respond directly.
Verbatim wording from the response “1. Deaths on top bunks (HMPPS)” Source location Response from NHS England
Open published response
26 Jan 2023 Zachary KLEMENT · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Home Treatment Teams failing to provide continuity of staff and set appointment times for people with ASD View source Unavailability of inpatient options tailored to patients with neurodiverse conditions in acute crisis View source Lack of consideration for neurodiverse conditions in available care options View source Lack of availability of appropriate therapies for neurodiverse conditions View source Lack of availability of psychological interventions for neurodiverse conditions View source See 2 more concerns
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AI-generated summary
Zachary KLEMENT · 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
Zachary KLEMENT was found suspended in the bedroom of his supported accommodation on 2 March 2021 and was pronounced deceased by attending paramedics. The report raised concerns about the lack of mental health care and therapies tailored to people with neurodiverse conditions, including the absence of suitable inpatient options, limited continuity from Home Treatment Teams, and the limited availability of psychological interventions.
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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 Home Treatment Teams failing to provide continuity of staff and set appointment times for people with ASD
Wider context from the report “Home Treatment Teams do not offer continuity of staff or set appointment times , as they are a crisis team allocated according to demand. This stability is required by those suffering from ASD;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unavailability of inpatient options tailored to patients with neurodiverse conditions in acute crisis
Wider context from the report “Inpatient mental health units adversely affect those with neurodiverse conditions since they require calm and structure. There are no inpatient options tailored to patients with neurodiverse conditions presenting in acute 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 Lack of consideration for neurodiverse conditions in available care options
Wider context from the report “Zachary had a history of mental illness from childhood. His diagnosed conditions of Autistic Spectrum Disorder (ASD) and Emotionally Unstable Personality Disorder required care tailored to his neurodiverse needs. Concern was expressed by two Consultant Psychiatrists who cared for him in life, and the Court appointed Expert Consultant Psychiatrist, regarding the lack of consideration for those with neurodiverse conditions in the care options available , and the lack of availability of appropriate therapies;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 availability of appropriate therapies for neurodiverse conditions
Wider context from the report “Zachary had a history of mental illness from childhood. His diagnosed conditions of Autistic Spectrum Disorder (ASD) and Emotionally Unstable Personality Disorder required care tailored to his neurodiverse needs. Concern was expressed by two Consultant Psychiatrists who cared for him in life, and the Court appointed Expert Consultant Psychiatrist, regarding the lack of consideration for those with neurodiverse conditions in the care options available, and the lack of availability of appropriate therapies ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 availability of psychological interventions for neurodiverse conditions
Wider context from the report “There is a lack of availability of psychological interventions , being the main treatment for neurodiverse conditions, including art therapy, Dialectical Behaviour Therapy (DBT) and Systems Training for Emotional Predictability and Problem Solving (STEPPS) (Zachary was placed on a waiting list)
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish the Mental Health, Learning Disability and Autism Inpatient Quality Transformation Programme to support cultural and care-model change across NHS-funded inpatient settings.
Verbatim wording from the response “In response to this, a new Mental Health, Learning Disability and Autism Inpatient Quality Transformation Programme was established in 2022 to support cultural change and a new bold, reimagined model of care for the future across all NHS-funded mental health, learning disability and autism inpatient settings. More information about this new programme of work is available here.” 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 understanding and diagnosis of autism and co-occurring mental health conditions through collaboration supporting best-practice treatment.
Verbatim wording from the response “We are aware across both the mental health and learning disability and autism programmes that autistic people can have mental health conditions. Part of our ongoing work is to ensure a greater understanding of the impact of autism on, and better diagnosis for, both autism and the mental health conditions that autistic people may have. We are working with the Royal College of Psychiatrists, and others, to support best practice in diagnosis and treatment for mental health conditions for people who are autistic.” 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 Expand and improve Crisis Resolution and Home Treatment provision for people with acute mental health needs through the Urgent and Emergency Care Recovery Plan.
Verbatim wording from the response “Through the Long Term Plan, there has also been significant investment in Crisis Resolution and Home Treatment teams, the majority of which are now open-access and operating 24/7 in line with national expectations. While access and capacity has improved significantly since 2017, we know variation in experience and outcomes still exists, and in light of this the recently published Urgent and Emergency Care Recovery Plan sets out that NHS England will support systems to build on the expansion of Home Treatment teams for people with acute mental health needs, with a clear focus on the quality of provision going forward.” Source location Response from NHS England
Open published response
Concerns raised 2 Failure to ask about family history of sudden cardiac death during reception health screening View source Failure to record and clearly flag family history of sudden cardiac death in SystmOne 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
Joseph Andrew Price · 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 Andrew Price was found dead in his cell at HMP Durham on 20 September 2020, after being remanded there ten days earlier. The pathologist concluded that the medical cause of death was Sudden Cardiac Death, following evidence of a paternal family history of premature cardiac-related deaths. The principal concern was that this family history had not been recorded or elicited during healthcare assessments, making it unavailable to inform possible genetic screening; symptoms before death were also potentially confusable with drug withdrawal and mental or emotional distress.
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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 ask about family history of sudden cardiac death during reception health screening
Wider context from the report “The best, in some cases the only, way to predict a pre-disposition to a death of this nature is by reference to family medical history of such, or similar, occurrences. Once this is known, the person can then be referred for genetic screening. Sadly, in Andrew`s case no one in healthcare, some of whom had been familiar with him for years from previous terms of imprisonment, had any knowledge of the family history, as it did not feature on system one, and Andrew had never volunteered it. Equally, he had never been asked about it. This is not a criticism, simply a statement of fact made starkly relevant by the circumstances, unusual though they are.
The head of healthcare at HMP Durham gave evidence, when asked directly by me, that provision for a question in the reception health screen template about any family history of sudden cardiac death could help to prevent deaths of this kind recurring at the prison . She, with the health care provider for HMP Durham (Spectrum Community Health), has helpfully and very pro-actively put this into immediate effect locally (at HMP Durham and those other prisons covered by the health care provider). Specifically, the second health screen template (see attached - at pages 7 and 8) now shows that a question with regards family history (FH) of a ‘FH: Cardiac Disorder (incl. Sudden Cardiac Death)’ has been added to the second reception screen. The updating of the first reception health screen template is currently in hand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to record and clearly flag family history of sudden cardiac death in SystmOne
Wider context from the report “Additionally, the health care provider proposed the introduction of a read code specifically for ‘FH: Sudden Cardiac Death’ in the SystmOne template. This read code does not currently exist in SystmOne and so locally, the health care provider has now added it as a prompt in the read code for ‘FH: Cardiac Disorder (XM1JV)’ and add to this (‘incl. Sudden Cardiac Death’). By adding ‘FH: Sudden Cardiac Death’ as a read code in its own right, it will make it easier to search for and flag on the SystmOne records of prisoners so staff can clearly see and be aware of this previous family history .
” 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 Refresh the secondary health screening template to add a specific prompt about family history of sudden cardiac death.
Verbatim wording from the response “In relation to your concern raised over a lack of appropriate read code for sudden cardiac death, there is no specific read code for sudden death syndrome on any clinical system, which is likely due to the fact there is no evidence to screen for it. NHS England is however refreshing the secondary health screening template to include a specific prompt for users to ask relevant questions relating to family history.” 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 No specific read code for sudden death syndrome is provided because there is no evidence supporting screening for the condition.
Verbatim wording from the response “In relation to your concern raised over a lack of appropriate read code for sudden cardiac death, there is no specific read code for sudden death syndrome on any clinical system, which is likely due to the fact there is no evidence to screen for it. NHS England is however refreshing the secondary health screening template to include a specific prompt for users to ask relevant questions relating to family history.” Source location Response from NHS England
Open published response
Concerns raised 9 Failure to undertake anaesthetic morbidity and mortality reviews and share learning View source Failure to disseminate institutional learning from unexpected deaths View source Failure to download and interrogate anaesthetic machine data after a suspected equipment-related event View source Failure to investigate potential anaesthetic-related causes of unexpected deaths View source Failure to remove and assess anaesthetic equipment for faults after a suspected equipment-related event View source Lack of a robust system to trigger investigations into unexpected deaths View source Delays in recognition of surgical emphysema during cardiac arrest View source Failure to comply with the Statutory Duty of Candour by sharing investigation findings and prevention steps View source Failure to consider and exclude tension pneumothorax during PEA cardiac arrest 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
Teegan Marie Barnard · 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
Teegan Marie Barnard suffered a prolonged PEA cardiac arrest during emergence from general anaesthesia after an emergency caesarean section, following significant postpartum haemorrhage and bilateral tension pneumothoraces. She sustained a non-survivable hypoxic brain injury and died at home six weeks later. Concerns included failure to consider and promptly recognise tension pneumothoraces during resuscitation, and inadequate investigation, clinical governance and learning after her death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake anaesthetic morbidity and mortality reviews and share learning
Wider context from the report “3. Investigation after Teegan’s death
Following this incident, and despite Teegan being intubated and ventilated at the time, with a real possibility of this being an anaesthetic related event, no steps were taken by the anaesthetic department at St Richard’s Hospital, Chichester, either before or after the publication of the HSIB report, to explore potential iatrogenic or other anaesthetic related causes (such as exposure of Teegan’s lungs to excessive volume or pressure) as a possible or probable cause of Teegan’s death.
Furthermore, the anaesthetic machine/ventilator was not taken out of service and assessed to see if there was a fault. Neither was the data from the anaesthetic machine downloaded and interrogated, which may have assisted in establishing how Teegan came to develop bilateral tension pneumothoraces during her emergence from general anaesthesia.
The failure of the anaesthetic department to undertake any morbidity or mortality review/meeting following Teegan’s death led to a lost opportunity to share any possible learning opportunities both within and outside their department to prevent future deaths , and as a corollary to have been in a position to fully assist both the investigation by the HSIB and the inquest hearing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 disseminate institutional learning from unexpected deaths
Wider context from the report “4. Trust Clinical Governance procedures
The senior management team within the Trust have not acknowledged that there was a lack of a proper and robust system in place to trigger an investigation into all the circumstances of the death of a 17-year-old patient, with no steps taken by them to do so either before or after the publication of the HSIB report or at any time prior to the Inquest hearing.
This gives rise to a concern of a lack of insight within the senior management team of the importance of undertaking a comprehensive investigation into unexpected deaths within their organisation and for there to be wider dissemination of any institutional learning with the aim of preventing future deaths .
The failure of the Trust to fully investigate how Teegan came by her death also gives rise to a concern regarding the Trust’s obligation to comply with the Statutory Duty of Candour and their requirement to share their findings with both the regulators and Teegan’s family as well as to indicate the steps, if any, they have taken to 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 Failure to download and interrogate anaesthetic machine data after a suspected equipment-related event
Wider context from the report “3. Investigation after Teegan’s death
Following this incident, and despite Teegan being intubated and ventilated at the time, with a real possibility of this being an anaesthetic related event, no steps were taken by the anaesthetic department at St Richard’s Hospital, Chichester, either before or after the publication of the HSIB report, to explore potential iatrogenic or other anaesthetic related causes (such as exposure of Teegan’s lungs to excessive volume or pressure) as a possible or probable cause of Teegan’s death.
Furthermore, the anaesthetic machine/ventilator was not taken out of service and assessed to see if there was a fault. Neither was the data from the anaesthetic machine downloaded and interrogated , which may have assisted in establishing how Teegan came to develop bilateral tension pneumothoraces during her emergence from general anaesthesia.
The failure of the anaesthetic department to undertake any morbidity or mortality review/meeting following Teegan’s death led to a lost opportunity to share any possible learning opportunities both within and outside their department to prevent future deaths, and as a corollary to have been in a position to fully assist both the investigation by the HSIB and the inquest hearing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate potential anaesthetic-related causes of unexpected deaths
Wider context from the report “3. Investigation after Teegan’s death
Following this incident, and despite Teegan being intubated and ventilated at the time, with a real possibility of this being an anaesthetic related event, no steps were taken by the anaesthetic department at St Richard’s Hospital, Chichester, either before or after the publication of the HSIB report, to explore potential iatrogenic or other anaesthetic related causes (such as exposure of Teegan’s lungs to excessive volume or pressure ) as a possible or probable cause of Teegan’s death.
Furthermore, the anaesthetic machine/ventilator was not taken out of service and assessed to see if there was a fault. Neither was the data from the anaesthetic machine downloaded and interrogated, which may have assisted in establishing how Teegan came to develop bilateral tension pneumothoraces during her emergence from general anaesthesia.
The failure of the anaesthetic department to undertake any morbidity or mortality review/meeting following Teegan’s death led to a lost opportunity to share any possible learning opportunities both within and outside their department to prevent future deaths, and as a corollary to have been in a position to fully assist both the investigation by the HSIB and the inquest hearing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 remove and assess anaesthetic equipment for faults after a suspected equipment-related event
Wider context from the report “3. Investigation after Teegan’s death
Following this incident, and despite Teegan being intubated and ventilated at the time, with a real possibility of this being an anaesthetic related event, no steps were taken by the anaesthetic department at St Richard’s Hospital, Chichester, either before or after the publication of the HSIB report, to explore potential iatrogenic or other anaesthetic related causes (such as exposure of Teegan’s lungs to excessive volume or pressure) as a possible or probable cause of Teegan’s death.
Furthermore, the anaesthetic machine/ventilator was not taken out of service and assessed to see if there was a fault . Neither was the data from the anaesthetic machine downloaded and interrogated, which may have assisted in establishing how Teegan came to develop bilateral tension pneumothoraces during her emergence from general anaesthesia.
The failure of the anaesthetic department to undertake any morbidity or mortality review/meeting following Teegan’s death led to a lost opportunity to share any possible learning opportunities both within and outside their department to prevent future deaths, and as a corollary to have been in a position to fully assist both the investigation by the HSIB and the inquest hearing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 robust system to trigger investigations into unexpected deaths
Wider context from the report “4. Trust Clinical Governance procedures
The senior management team within the Trust have not acknowledged that there was a lack of a proper and robust system in place to trigger an investigation into all the circumstances of the death of a 17-year-old patient, with no steps taken by them to do so either before or after the publication of the HSIB report or at any time prior to the Inquest hearing.
This gives rise to a concern of a lack of insight within the senior management team of the importance of undertaking a comprehensive investigation into unexpected deaths within their organisation and for there to be wider dissemination of any institutional learning with the aim of preventing future deaths.
The failure of the Trust to fully investigate how Teegan came by her death also gives rise to a concern regarding the Trust’s obligation to comply with the Statutory Duty of Candour and their requirement to share their findings with both the regulators and Teegan’s family as well as to indicate the steps, if any, they have taken to 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 Delays in recognition of surgical emphysema during cardiac arrest
Wider context from the report “2. Surgical emphysema
There was a delay in the recognition of surgical emphysema by clinical attendees at the cardiac arrest (medical specialist registrar, consultant obstetricians, anaesthetic core trainee, anaesthetic specialist registrar and the on call consultant anaesthetist) despite indicative clinical signs of deep cyanosis, gross whole body swelling with the need to remove the increasingly constrictive hospital wrist band and endotracheal tube tie, alongside sub-cutaneous crepitus and an abdominal drainage bag noted to be tense with air .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 comply with the Statutory Duty of Candour by sharing investigation findings and prevention steps
Wider context from the report “4. Trust Clinical Governance procedures
The senior management team within the Trust have not acknowledged that there was a lack of a proper and robust system in place to trigger an investigation into all the circumstances of the death of a 17-year-old patient, with no steps taken by them to do so either before or after the publication of the HSIB report or at any time prior to the Inquest hearing.
This gives rise to a concern of a lack of insight within the senior management team of the importance of undertaking a comprehensive investigation into unexpected deaths within their organisation and for there to be wider dissemination of any institutional learning with the aim of preventing future deaths.
The failure of the Trust to fully investigate how Teegan came by her death also gives rise to a concern regarding the Trust’s obligation to comply with the Statutory Duty of Candour and their requirement to share their findings with both the regulators and Teegan’s family as well as to indicate the steps, if any, they have taken to 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 Failure to consider and exclude tension pneumothorax during PEA cardiac arrest
Wider context from the report “1. Resuscitation algorithm (4 H’s & 4 T’s)* for PEA cardiac arrest
I heard evidence that the 4 H’s and 4 T’s should be considered and excluded in any PEA cardiac arrest situation . Steps were taken to treat anaphylaxis, but in the absence of any improvement in Teegan’s clinical condition, and whilst it was mentioned, no steps were taken to exclude possible bilateral tension pneumothoraces . Evidence was heard at the Inquest that it is the only one of the 4 H’s and 4 T’s (see footnote) that directly results in a sudden inability to ventilate, with the HSIB report indicating that there was sufficient time to consider and exclude this possibility given the length of time of the PEA cardiac arrest.
” 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 Ask regional Regulation 28 Working Group members to share learning with Integrated Care Boards for onward dissemination to trusts across England.
Verbatim wording from the response “Bilateral pneumothoraces occurring as it did in this case is rare and we note that both the Royal College of Anaesthetists (RCoA) and Association of Anaesthetists has stated that most anaesthetists will never encounter such a situation. NHS England’s National Patient Safety Team forms part of the Safe Anaesthesia Liaison Group (SALG), together with the RCoA and the Association of Anaesthetists, who will therefore be sharing the learnings from Teegan’s death across its network of relevant organisations. The national Regulation 28 Working Group will also be asking its regional members to share the learnings with their Integrated Care Boards (ICBs) for onward sharing to Trusts across England.” 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 from Teegan’s death through the Safe Anaesthesia Liaison Group network and relevant organisations.
Verbatim wording from the response “Bilateral pneumothoraces occurring as it did in this case is rare and we note that both the Royal College of Anaesthetists (RCoA) and Association of Anaesthetists has stated that most anaesthetists will never encounter such a situation. NHS England’s National Patient Safety Team forms part of the Safe Anaesthesia Liaison Group (SALG), together with the RCoA and the Association of Anaesthetists, who will therefore be sharing the learnings from Teegan’s death across its network of relevant organisations. The national Regulation 28 Working Group will also be asking its regional members to share the learnings with their Integrated Care Boards (ICBs) for onward sharing to Trusts across England.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group to share learning, identify trends and consider further review or action.
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 receive 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 Launch the Patient Safety Incident Response Framework for developing and maintaining systems to respond to incidents and improve patient safety.
Verbatim wording from the response “With regard to the concerns around the subsequent investigation into Teegan’s death, and the fact that there was no local investigation run in parallel to the Healthcare Safety Investigation Branch’s (HSIB’s) investigation, the NHS England National Patient Safety Team has recently launched a new Patient Safety Incident Response Framework (PSIRF), which ‘sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety’.” 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 RCoA is responsible for clarifying anaesthetic-machine arrangements in its guidance, while CQC will respond to the report and recommendations.
Verbatim wording from the response “Regarding your concerns around there being no temporary removal of the anaesthetic machine used in this case, or the downloading of information from the machine, we welcome RCoA’s commitment to update its guidance accordingly, to ensure responsibilities around this are made more explicit. We are also aware that the Care Quality Commission (CQC) will be issuing a response to your Report and will review their response and any recommendations made in due course.” 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 existing ALS course adequately covers the resuscitation algorithm and cardiac arrest in pregnancy, so no course change is required.
Verbatim wording from the response “NHS England also consulted with the Resuscitation Council UK as part of its review of your Report. It should be noted that as a result of Teegan’s death, the Resuscitation Council reviewed the existing ALS guidance and materials, to include consultation of relevant experts. It was concluded that the ALS course did adequately cover the algorithm as well as cardiac arrest in pregnancy.” 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 Where HSIB undertakes a maternity investigation, a separate local patient safety learning response is not required under PSIRF.
Verbatim wording from the response “With regard to the concerns around the subsequent investigation into Teegan’s death, and the fact that there was no local investigation run in parallel to the Healthcare Safety Investigation Branch’s (HSIB’s) investigation, the NHS England National Patient Safety Team has recently launched a new Patient Safety Incident Response Framework (PSIRF), which ‘sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety’.” 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 identified care, evidence-handling, Duty of Candour and investigation concerns fall outside HEE’s current role and statutory responsibilities.
Verbatim wording from the response “I write in response to your report of 17 January 2023, made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. I have been asked to respond on behalf of Health Education England. Please may I start by offering my sincere condolences to the family of Teegan Marie Bernard, following her tragic death. However, having carefully considered the report, together with the facts of the case, we believe that whilst there are valuable lessons to be learned; Unfortunately, these do not come within the scope of HEE’s current role and statutory responsibilities.” Source location Response from Health Education England
Open published response
Concerns raised 2 Failure to understand the implementation, significance and effect of Section 5(2) doctors holding power View source Failure to properly complete Section 5(2) Mental Health Act paperwork View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mollie Rose Stansfield · 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
Mollie Rose Stansfield, aged 22, died on 10 July 2019 after falling at Princes Quay, Hull, following her discharge from a place of safety under section 136 of the Mental Health Act 1983. The report identified failures at Hull Royal Infirmary to understand and correctly implement section 5(2) of the Mental Health Act 1983, with the relevant paperwork being invalid while Mollie was apparently subject to that section and subsequently absconded.
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 understand the implementation, significance and effect of Section 5(2) doctors holding power
Wider context from the report “There was a failure at Hull Royal Infirmary to understand the process of implementing Section 5(2) of the Mental Health act 1983 [MHA] (Doctors Holding Power) as well as general uncertainty about its significance and effect . Mollie absconded from the ward whilst apparently under this section. The paperwork for the implementation of this section of the MHA 1983 was in fact not properly completed and hence invalid. Whilst the Hull & East Yorkshire NHS Trust has taken steps to educate doctors about this power, these were only local measures and I believe that all doctors working in England and Wales should be aware of section 5(2) and nurses of their equivalent power pursuant to section 5(4) of the MHA 1983 and that appropriate awareness and training should be given.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 properly complete Section 5(2) Mental Health Act paperwork
Wider context from the report “There was a failure at Hull Royal Infirmary to understand the process of implementing Section 5(2) of the Mental Health act 1983 [MHA] (Doctors Holding Power) as well as general uncertainty about its significance and effect. Mollie absconded from the ward whilst apparently under this section. The paperwork for the implementation of this section of the MHA 1983 was in fact not properly completed and hence invalid . Whilst the Hull & East Yorkshire NHS Trust has taken steps to educate doctors about this power, these were only local measures and I believe that all doctors working in England and Wales should be aware of section 5(2) and nurses of their equivalent power pursuant to section 5(4) of the MHA 1983 and that appropriate awareness and training should be given.
” 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 Run a pilot enabling SAS doctors to gain Section 5(2) competence through the portfolio route.
Verbatim wording from the response “In order to enable additional further capacity, HEE is also currently undertaking a pilot to allow Specialty and Associate Specialist (SAS) doctors to gain competence via the same portfolio route as non-medical staff. SAS doctors are employed in the NHS in a non-training post and will have at least seven years’ experience of working in psychiatry, four of which at a senior level.” Source location Response from NHS England
Open published response
Concerns raised 2 Lack of a service level agreement for treatment of patients from Cornwall when the UHP service is unavailable View source Unavailability of a 24/7 thrombectomy service for RCHT 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
Anthony James REEDMAN · 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
Anthony James Reedman suffered a basilar artery stroke while at home, but an ambulance delay meant thrombolysis was administered 4.5 hours after the stroke. He died following a further brain haemorrhage after the unsuccessful thrombolysis attempt. The principal concerns were the lack of a 24/7 thrombectomy service for Royal Cornwall Hospital Trust patients and the absence of a service level agreement with the nearest 24/7 service when the local service was unavailable.
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 service level agreement for treatment of patients from Cornwall when the UHP service is unavailable
Wider context from the report “(2) The nearest 24/7 thrombectomy service is at NHS North Bristol. However, there is no service level agreement between Southmead and RCHT for the treatment of patients from Cornwall when the UHP service is unavailable . This limits the options available to RCHT clinicians in considering treatment for stroke patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a 24/7 thrombectomy service for RCHT patients
Wider context from the report “(1) There is no thrombectomy service available 24/7 for RCHT patients. Thrombectomy is considered by clinicians to be a lifesaving procedure. On average, successful outcomes for treatment for a basilar artery stroke are 13% for thrombolysis, and 37% for thrombectomy. Over the last year it is estimated that 75 stroke patients in Cornwall who would otherwise be suitable for thrombectomy procedure did not receive this procedure because it is not available 24/7 in Cornwall, unlike for example those who live in Bristol. A clinical witness described this situation as a postcode lottery.
” Open source report
Concerns raised 4 Absence of deputy or ward manager cover at weekends View source Failure of the system for auditing observations and documentation View source Failure to conduct higher-level investigations into patterns of missed observations and falsified records View source Failure to ensure sufficiently experienced nursing staff in charge of the specialist high-risk unit 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
Rowan Louis Thompson · 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
Rowan Louis Thompson was a detained patient at the Gardner Unit who was found in his room on 3 October 2020, thought to be having a seizure, and died shortly after arriving at hospital. The investigation and inquest identified severe hypokalaemia, failures to communicate blood test results, missed and falsified observation records, inadequate emergency response arrangements, and concerns about staffing and auditing.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Absence of deputy or ward manager cover at weekends
Wider context from the report “3. Given the specialist nature of the Gardner, the fact that this is a high risk environment and somewhere where the situation can change in an instant given the nature of the patients the experience of the staff in charge on the 3rd October 2020 was a concern. There was no rationale other than commissioning why a deputy or ward manager was not working at a weekend (when there are less activities to occupy the patients). The evidence heard suggested to the court that a more experienced nurse was always required on this unit.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of the system for auditing observations and documentation
Wider context from the report “1. System by which observations and documentation are audited lacks rigour and is ineffective.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 higher-level investigations into patterns of missed observations and falsified records
Wider context from the report “2. At the time of the CCTV review and investigation following Rowan’s death there was a missed opportunity for management to understand the gravity and nature of the situation. There was no higher level investigation , so for example:
a) Whether the staff who failed to complete observations/falsify records did so when working a particular shift ie night shift
b) Whether the staff who failed to complete observations/falsify records did so when working weekends rather than during the week
c) Whether there was any correlation between missed observations / falsifying of records and shifts when there was no deputy or ward manager on duty.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 sufficiently experienced nursing staff in charge of the specialist high-risk unit
Wider context from the report “3. Given the specialist nature of the Gardner, the fact that this is a high risk environment and somewhere where the situation can change in an instant given the nature of the patients the experience of the staff in charge on the 3rd October 2020 was a concern . There was no rationale other than commissioning why a deputy or ward manager was not working at a weekend (when there are less activities to occupy the patients). The evidence heard suggested to the court that a more experienced nurse was always required on this unit.
” 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 Conduct a nationally commissioned independent review of patient services, escalation, oversight and staff culture across Greater Manchester Mental Health NHS Foundation Trust.
Verbatim wording from the response “In addition, NHS England’s (NHSE) have nationally commissioned an Independent Review which is being managed and led by the Northwest Region. An external Independent Chair has been appointed who is currently in the process of developing the Terms of Reference for the review. As part of the review process the Independent Chair will be making contact with Rowan’s family, to understand their experiences of the care Rowan received.” 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 Greater Manchester Mental Health NHS Foundation Trust is responsible for addressing the specific operational changes arising from the concerns.
Verbatim wording from the response “We understand you have also addressed this Report to Greater Manchester Mental Health NHS Foundation Trust. They will address specifics as to the changes being implemented on the ground.” Source location Response from NHS England
Open published response
16 Nov 2022 Susan Elizabeth SKILLEN · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 2 Unclear criteria for reviewing patient literature after reports of methotrexate phototoxicity View source Failure to include methotrexate phototoxicity in literature given to 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
Susan Elizabeth SKILLEN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Susan Elizabeth Skillen, aged 61, was admitted to hospital on 26 May 2022 after being found at home with reduced consciousness, low blood pressure, hypoglycaemia and severe neutropenia, and died later that day. The inquest concluded that she died from neutropenic sepsis, with skin loss associated with phototoxicity considered the most likely source of infection and the combined effects of sun exposure and rheumatoid arthritis medication contributing. The substantive concern was that phototoxicity is an extremely rare side effect of methotrexate but did not appear in the literature provided to patients, and it was unclear whether the patient literature required review.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unclear criteria for reviewing patient literature after reports of methotrexate phototoxicity
Wider context from the report “Phototoxicity is an extremely rare side effect of methotrexate but does not appear in literature given to patients. The hospital were requested to complete the Yellow Card system but it was unclear if the literature for patients needed to be reviewed depending upon how many other patients had suffered this side effect.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to include methotrexate phototoxicity in literature given to patients
Wider context from the report “Phototoxicity is an extremely rare side effect of methotrexate but does not appear in literature given to patients. The hospital were requested to complete the Yellow Card system but it was unclear if the literature for patients needed to be reviewed depending upon how many other patients had suffered this side effect.
” Open source report
Concerns raised 5 Lack of Standard Operating Procedure instructions to contact the local DNO during electrical hazards View source Fragmented DNO emergency contact arrangements across ambulance service boundaries View source Delays to life-saving treatment due to uncertainty about whether OHPLs remain live View source Unavailability and poor accessibility of correct DNO emergency numbers to ambulance control centre operators View source Risk to bystanders and emergency services from approaching patients near live OHPLs 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
Levi Louis Alleyne · 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
Levi Louis Alleyne, a grab lorry delivery driver, died by electrocution at a building site after raising his lorry’s crane arm beneath overhead power lines. CPR was delayed because it was unclear whether the electricity remained live, and the ambulance control operator had no procedure or readily accessible emergency contact information for the relevant electricity network operator. The report identifies risks of delayed life-saving treatment or people approaching live electrical hazards and notes that similar mitigating procedures may not be adopted across England and Wales.
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 Standard Operating Procedure instructions to contact the local DNO during electrical hazards
Wider context from the report “According to the evidence heard at the inquest:
1. At the time of the incident, the SCAS operator did not have any instruction in their Standard Operating Procedure to contact the local [DNO] to ensure that the electricity was cut off . There is no such instruction in the national Standard Operating Procedure .
2. The SCAS operator did identify and try to contact the DNO after the 999 call had ended. However, as they did not contact the correct emergency number provided by SSEN, they were kept on hold for several minutes. The emergency numbers are not incorporated into the software used by the ambulance control centre (CAD) and are not widely known.
3. There is considerable potential for confusion for ambulance control centres as there is not one national DNO emergency number to contact. There are 14 licensed DNOs and 12 ambulance service trusts in England and Wales with different boundaries. Ambulance control centres frequently pick up calls from other ambulance trust areas at times of high demand. The ambulance control centre must find the relevant DNO to contact and the relevant number for that DNO.
4. There was a delay in Mr Alleyne receiving CPR due to concerns about electricity still being live. There are thousands of incidents every day involving OHPLs. There is a risk that future deaths may occur due to confusion regarding electrical hazards.
5. The potential for future deaths is two-fold:
▪ unnecessary delay to life-saving treatment being given due to the fear (well-founded or otherwise) that OHPLs are still live,
▪ or potentially, by-standers or emergency services putting their lives at risk by approaching patients near electrical hazards where OHPLs remain live.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Fragmented DNO emergency contact arrangements across ambulance service boundaries
Wider context from the report “According to the evidence heard at the inquest:
1. At the time of the incident, the SCAS operator did not have any instruction in their Standard Operating Procedure to contact the local [DNO] to ensure that the electricity was cut off. There is no such instruction in the national Standard Operating Procedure.
2. The SCAS operator did identify and try to contact the DNO after the 999 call had ended. However, as they did not contact the correct emergency number provided by SSEN, they were kept on hold for several minutes. The emergency numbers are not incorporated into the software used by the ambulance control centre (CAD) and are not widely known.
3. There is considerable potential for confusion for ambulance control centres as there is not one national DNO emergency number to contact . There are 14 licensed DNOs and 12 ambulance service trusts in England and Wales with different boundaries . Ambulance control centres frequently pick up calls from other ambulance trust areas at times of high demand . The ambulance control centre must find the relevant DNO to contact and the relevant number for that DNO .
4. There was a delay in Mr Alleyne receiving CPR due to concerns about electricity still being live. There are thousands of incidents every day involving OHPLs. There is a risk that future deaths may occur due to confusion regarding electrical hazards.
5. The potential for future deaths is two-fold:
▪ unnecessary delay to life-saving treatment being given due to the fear (well-founded or otherwise) that OHPLs are still live,
▪ or potentially, by-standers or emergency services putting their lives at risk by approaching patients near electrical hazards where OHPLs remain live.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 to life-saving treatment due to uncertainty about whether OHPLs remain live
Wider context from the report “According to the evidence heard at the inquest:
1. At the time of the incident, the SCAS operator did not have any instruction in their Standard Operating Procedure to contact the local [DNO] to ensure that the electricity was cut off. There is no such instruction in the national Standard Operating Procedure.
2. The SCAS operator did identify and try to contact the DNO after the 999 call had ended. However, as they did not contact the correct emergency number provided by SSEN, they were kept on hold for several minutes. The emergency numbers are not incorporated into the software used by the ambulance control centre (CAD) and are not widely known.
3. There is considerable potential for confusion for ambulance control centres as there is not one national DNO emergency number to contact. There are 14 licensed DNOs and 12 ambulance service trusts in England and Wales with different boundaries. Ambulance control centres frequently pick up calls from other ambulance trust areas at times of high demand. The ambulance control centre must find the relevant DNO to contact and the relevant number for that DNO.
4. There was a delay in Mr Alleyne receiving CPR due to concerns about electricity still being live . There are thousands of incidents every day involving OHPLs. There is a risk that future deaths may occur due to confusion regarding electrical hazards.
5. The potential for future deaths is two-fold:
▪ unnecessary delay to life-saving treatment being given due to the fear (well-founded or otherwise) that OHPLs are still live ,
▪ or potentially, by-standers or emergency services putting their lives at risk by approaching patients near electrical hazards where OHPLs remain live.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 poor accessibility of correct DNO emergency numbers to ambulance control centre operators
Wider context from the report “According to the evidence heard at the inquest:
1. At the time of the incident, the SCAS operator did not have any instruction in their Standard Operating Procedure to contact the local [DNO] to ensure that the electricity was cut off. There is no such instruction in the national Standard Operating Procedure.
2. The SCAS operator did identify and try to contact the DNO after the 999 call had ended. However, as they did not contact the correct emergency number provided by SSEN, they were kept on hold for several minutes . The emergency numbers are not incorporated into the software used by the ambulance control centre (CAD) and are not widely known .
3. There is considerable potential for confusion for ambulance control centres as there is not one national DNO emergency number to contact. There are 14 licensed DNOs and 12 ambulance service trusts in England and Wales with different boundaries. Ambulance control centres frequently pick up calls from other ambulance trust areas at times of high demand. The ambulance control centre must find the relevant DNO to contact and the relevant number for that DNO.
4. There was a delay in Mr Alleyne receiving CPR due to concerns about electricity still being live. There are thousands of incidents every day involving OHPLs. There is a risk that future deaths may occur due to confusion regarding electrical hazards.
5. The potential for future deaths is two-fold:
▪ unnecessary delay to life-saving treatment being given due to the fear (well-founded or otherwise) that OHPLs are still live,
▪ or potentially, by-standers or emergency services putting their lives at risk by approaching patients near electrical hazards where OHPLs remain live.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Risk to bystanders and emergency services from approaching patients near live OHPLs
Wider context from the report “According to the evidence heard at the inquest:
1. At the time of the incident, the SCAS operator did not have any instruction in their Standard Operating Procedure to contact the local [DNO] to ensure that the electricity was cut off. There is no such instruction in the national Standard Operating Procedure.
2. The SCAS operator did identify and try to contact the DNO after the 999 call had ended. However, as they did not contact the correct emergency number provided by SSEN, they were kept on hold for several minutes. The emergency numbers are not incorporated into the software used by the ambulance control centre (CAD) and are not widely known.
3. There is considerable potential for confusion for ambulance control centres as there is not one national DNO emergency number to contact. There are 14 licensed DNOs and 12 ambulance service trusts in England and Wales with different boundaries. Ambulance control centres frequently pick up calls from other ambulance trust areas at times of high demand. The ambulance control centre must find the relevant DNO to contact and the relevant number for that DNO.
4. There was a delay in Mr Alleyne receiving CPR due to concerns about electricity still being live. There are thousands of incidents every day involving OHPLs. There is a risk that future deaths may occur due to confusion regarding electrical hazards.
5. The potential for future deaths is two-fold:
▪ unnecessary delay to life-saving treatment being given due to the fear (well-founded or otherwise) that OHPLs are still live,
▪ or potentially, by-standers or emergency services putting their lives at risk by approaching patients near electrical hazards where OHPLs remain live .
” 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 scene-safety elements within the NHS Pathways triage system to identify any relevant learning or changes.
Verbatim wording from the response “There are also system prompts for the Health Advisor to consider whether the situation also requires the attendance of other emergency services for any type of electrical hazard that has the potential to make the scene ‘unsafe’. Although such tragic incidents are rare, NHS Pathways are fully supportive of identifying any further learning from this case and are currently reviewing the scene safety elements within the triage system. The initial discovery has commenced, and any identified changes would be subject to review and sign off from the National Clinical Assurance Group and, if relevant, from the Emergency Call Prioritisation Advisory Group (ECPAG). The purpose of the ECPAG is to advise NHS England and Department of Health & Social Care (DHSC) on issues of ambulance call prioritisation.” Source location Response from NHS Digital
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 Preparing or overseeing local or national standard operating procedures and nationally overseeing 111 or 999 operations fall outside NHS Pathways’ remit.
Verbatim wording from the response “NHS Pathways remit does not extend to preparing or overseeing local or national standard operating procedures or providing national oversight of 111 or 999 operations. Standard operating procedures relating to a range of operational requirements are locally set by 111 and 999 providers. NHS Pathways is a clinical decision support system and more operationally focused content such as how to contact a utility provider sits outside the remit of the NHS Pathways system.” Source location Response from NHS Digital
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 111 and 999 providers are responsible for setting standard operating procedures relating to operational requirements.
Verbatim wording from the response “NHS Pathways remit does not extend to preparing or overseeing local or national standard operating procedures or providing national oversight of 111 or 999 operations. Standard operating procedures relating to a range of operational requirements are locally set by 111 and 999 providers. NHS Pathways is a clinical decision support system and more operationally focused content such as how to contact a utility provider sits outside the remit of the NHS Pathways system.” Source location Response from NHS Digital
Open published response
Concerns raised 2 Lack of national guidance for healthcare staff on the use of force in prison View source Absence of a local operating policy on the use of force between prison and healthcare services View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Bradleigh Trevor Barnes · 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
Bradleigh Trevor Barnes was found suspended by a ligature in his cell at HMP YOI Portland on 28 December 2019. The inquest concluded that the death was suicide. Concerns included a lack of national NHS guidance for healthcare staff on the use of force in prison and the absence of a local operating policy between the prison and healthcare provider at HMP YOI Portland.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for healthcare staff on the use of force in prison
Wider context from the report “i. There is a lack of national guidance to healthcare staff on the use of force in prison and I request consideration is given by NHS England to providing such national guidance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Absence of a local operating policy on the use of force between prison and healthcare services
Wider context from the report “ii. There is no local operating policy on the use of force at HMP YOI Portland between the healthcare and the prison and I request that the Governor of HMP YOI Portland and the Chief Executive of Oxleas consider putting a local instruction policy in place.
” 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 Write to prison healthcare providers requiring agreed local procedures covering healthcare roles during restraint and monitoring, recording and response to vital signs during and after incidents.
Verbatim wording from the response “Whilst the guidance and PSA referred to above were already in place around the time of Bradleigh’s death, NHS England recognises there is learning to be taken from the sad events in this case, and will be writing to all prison healthcare providers, via our seven regional commissioning teams, requiring them to work with their prison governor and have an agreed local operating procedure in place that includes:” 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 Request assurance from regional commissioning directors that the required local procedures have been implemented and evidenced by April 2023.
Verbatim wording from the response “NHS England’s central team will request assurance from our regional Directors of Commissioning that the above actions have been implemented and evidenced by April 2023. We are happy to provide you with a further update at this time if you consider this would assist?” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with HMPPS on the planned revision of PSO 1600, providing clinical leadership to enhance its healthcare roles and responsibilities section.
Verbatim wording from the response “In addition to the above, NHS England will be working with colleagues in the HM Prison and Probation Service (HMPPS) to assist with their planned review and revision of PSO 1600: Use of Force. We will be supporting this review through providing clinical leadership on the revision and enhancement of section 6 and the roles and responsibilities of healthcare.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England cannot issue prison use-of-force guidance independently of the operational PSIs, PSOs and Policy Frameworks governing prisons.
Verbatim wording from the response “Firstly, I would like to clarify that the Prison Service Instructions (PSIs), Prison Service Orders (PSOs) and Policy Frameworks set out the framework for the operational running of a prison. NHS England and prison healthcare providers are required to ensure that all prison healthcare policies and service delivery are aligned to the appropriate PSI, PSO or policy framework. NHS England cannot deliver guidance that is not cognisant with these documents. In this case, as you have highlighted, PSO 1600 Use of Force is the operational instruction that includes the use of manual restraint, and section 6 outlines the roles of healthcare in the planned and unplanned use of force.” Source location Response from NHS England
Open published response
Concerns raised 3 Lack of resources across primary, secondary and social care View source Delays in handing over ambulance patients at A&E departments View source Failure to match ambulance response capacity to demand 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
Charles Stephen Rothwell · 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
Charles Stephen Rothwell was diagnosed with a chest infection on 5 January 2022, deteriorated the following day, and died after repeated 999 calls and a delayed ambulance response. The principal concern was that emergency ambulance demand continued to outstrip available capacity, creating a risk of future deaths, with wider pressures across primary, secondary and social care contributing to delays.
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 resources across primary, secondary and social care
Wider context from the report “1) NWAS have developed a new triage system and have adopted NHS Pathways, which means that the initial call would now be triaged as Category 1 or 2. However, the problem of demand outstripping supply remains, such that if the same 999 call were made today the outcome would be the same.
2) NWAS continues to experience “exceptionally high demand” with the effect that “the demand completely outstrips the capability [they] have got.”
3) By way of example, I was told that yesterday afternoon Category 2 responses (which should attract attendance within 18 minutes) were sitting at an average of 75 minutes, Category 3 responses (which should attract attendance within 120 minutes) were sitting at an average of 10.5h and category 4 responses (which should prompt a further telephone assessment within 90 – 180 minutes) were sitting at an average of 11.5h.
4) With the approach of winter NWAS are also beginning to see an even greater increase in demand on top of the existing demand.
5) The problem is not due to a shortage of NWAS ambulances or staff but instead is the result of a wider issue linked to the lack of resources in primary, secondary and social care . This results in demand for ambulances outstripping supply and a backlog of ambulances waiting to handover patients at A&E departments because of a shortage of A&E beds, which in turn is because of shortages in social care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in handing over ambulance patients at A&E departments
Wider context from the report “1) NWAS have developed a new triage system and have adopted NHS Pathways, which means that the initial call would now be triaged as Category 1 or 2. However, the problem of demand outstripping supply remains, such that if the same 999 call were made today the outcome would be the same.
2) NWAS continues to experience “exceptionally high demand” with the effect that “the demand completely outstrips the capability [they] have got.”
3) By way of example, I was told that yesterday afternoon Category 2 responses (which should attract attendance within 18 minutes) were sitting at an average of 75 minutes, Category 3 responses (which should attract attendance within 120 minutes) were sitting at an average of 10.5h and category 4 responses (which should prompt a further telephone assessment within 90 – 180 minutes) were sitting at an average of 11.5h.
4) With the approach of winter NWAS are also beginning to see an even greater increase in demand on top of the existing demand.
5) The problem is not due to a shortage of NWAS ambulances or staff but instead is the result of a wider issue linked to the lack of resources in primary, secondary and social care. This results in demand for ambulances outstripping supply and a backlog of ambulances waiting to handover patients at A&E departments because of a shortage of A&E beds , which in turn is because of shortages in social care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to match ambulance response capacity to demand
Wider context from the report “1) NWAS have developed a new triage system and have adopted NHS Pathways, which means that the initial call would now be triaged as Category 1 or 2. However, the problem of demand outstripping supply remains , such that if the same 999 call were made today the outcome would be the same.
2) NWAS continues to experience “exceptionally high demand” with the effect that “the demand completely outstrips the capability [they] have got .”
3) By way of example, I was told that yesterday afternoon Category 2 responses (which should attract attendance within 18 minutes) were sitting at an average of 75 minutes , Category 3 responses (which should attract attendance within 120 minutes) were sitting at an average of 10.5h and category 4 responses (which should prompt a further telephone assessment within 90 – 180 minutes) were sitting at an average of 11.5h .
4) With the approach of winter NWAS are also beginning to see an even greater increase in demand on top of the existing demand.
5) The problem is not due to a shortage of NWAS ambulances or staff but instead is the result of a wider issue linked to the lack of resources in primary, secondary and social care. This results in demand for ambulances outstripping supply and a backlog of ambulances waiting to handover patients at A&E departments because of a shortage of A&E beds, which in turn is because of shortages in social care.
” Open source report
29 Sep 2022 Ms Aleksandra Markowska · Prevention of Future Deaths report East London
View report summary
Concerns raised 1 Lack of direct access for BPAS patients with pregnancy-related mental health decline to perinatal psychiatry teams 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
Ms Aleksandra Markowska · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ms Aleksandra Markowska was found unresponsive on 30 September 2021 after jumping from 21 Gardner Close, and her death was pronounced at the scene. The inquest concluded that she took her own life while suffering from pregnancy-related depression and anxiety, after seeking help but not receiving a review by a perinatal psychiatrist. The principal concern was the lack of direct access for BPAS patients experiencing pregnancy-related mental health decline to perinatal psychiatry teams.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of direct access for BPAS patients with pregnancy-related mental health decline to perinatal psychiatry teams
Wider context from the report “The British Pregnancy Advisory Service (BPAS) is a charity whose services are often commissioned by the NHS. As a charity, BPAS does not have direct access to NHS perinatal psychiatrists. Referrals would have to be made either via the patient's GP or via an unwieldy safeguarding concern (as happened in this case). Referrals via the GP are not possible where the patient does not wish their identity to be revealed.
It is a matter of concern that there is no direct access for BPAS patients who are suffering from pregnancy related mental health decline, to peri-natal psychiatry teams .
Direct and confidential access to peri-natal psychiatry teams may reduce the risk of future deaths.
” Open source report
26 Sep 2022 Sandra Kirk · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Limited risk reduction from observation frequency for high-risk patients View source Lack of guidance for identifying and minimising potential ligatures, including hazardous clothing View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sandra Kirk · 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 Kirk was found unresponsive in the ensuite bathroom of her bedroom at Cygnet Hospital on 2 August 2021 and was declared deceased after resuscitation attempts were unsuccessful. The inquest found that she died from asphyxia due to a ligature around her neck. Concerns included inadequate guidance on identifying and removing potential ligatures, including items of clothing, and the limited risk reduction provided by observation intervals.
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 risk reduction from observation frequency for high-risk patients
Wider context from the report “- The evidence in this inquest was that Cygnet’s Ligature Risk Reduction Policy and the Ligature Audit Tool/Ligature Risk Assessment are standard documents used by Mental Health inpatient providers, including NHS Psychiatric Trusts.
- The Ligature Risk Reduction Policy quotes the CQC guidance of 2015, that “Three-quarters of people who kill themselves whilst on a psychiatric ward do so by hanging or strangulation”.
- Whilst these documents provide detailed guidance in respect of minimising ligature anchor points, they do not give guidance as to minimising potential ligatures themselves, which are defined as “Any item which can be used to make a loop or noose with the intention of limiting the supply of oxygen to an individual by hanging or asphyxiation”.
- Rather than emphasising the very real risk that specific items of clothing, ████████, can pose to vulnerable patients, the document places emphasis on avoiding ‘blanket restrictions’ which does not assist in identifying where the real risks lie.
- Death by the use of a ligature is likely to occur within a few minutes , whereas observations for a high-risk patient not assessed as being in immediate crisis, will generally be carried out four times in every hour, which therefore provides only a limited degree of risk reduction. Consideration should be given as to efficacy of such a policy and whether this can be improved by recognising that some items of clothing will be more obvious ligature risks and may need to be removed in all cases.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for identifying and minimising potential ligatures, including hazardous clothing
Wider context from the report “- The evidence in this inquest was that Cygnet’s Ligature Risk Reduction Policy and the Ligature Audit Tool/Ligature Risk Assessment are standard documents used by Mental Health inpatient providers, including NHS Psychiatric Trusts.
- The Ligature Risk Reduction Policy quotes the CQC guidance of 2015, that “Three-quarters of people who kill themselves whilst on a psychiatric ward do so by hanging or strangulation”.
- Whilst these documents provide detailed guidance in respect of minimising ligature anchor points, they do not give guidance as to minimising potential ligatures themselves , which are defined as “Any item which can be used to make a loop or noose with the intention of limiting the supply of oxygen to an individual by hanging or asphyxiation”.
- Rather than emphasising the very real risk that specific items of clothing, ████████, can pose to vulnerable patients, the document places emphasis on avoiding ‘blanket restrictions’ which does not assist in identifying where the real risks lie.
- Death by the use of a ligature is likely to occur within a few minutes, whereas observations for a high-risk patient not assessed as being in immediate crisis, will generally be carried out four times in every hour, which therefore provides only a limited degree of risk reduction. Consideration should be given as to efficacy of such a policy and whether this can be improved by recognising that some items of clothing will be more obvious ligature risks and may need to be removed in all cases.
” 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 risk-assessment guidance and assess moving to an evidence-based, personalised safety-planning approach.
Verbatim wording from the response “Regarding the national guidance around risk assessments (relevant to your comments around observations and risk reduction), I would like to provide my assurance that this is currently being reviewed and work is underway to assess a move to a more personalised safety planning approach, in line with an evidence base. The concerns raised in PFD reports, including your Report dated 26 September 2022, are communicated to the national policy and programme teams to help inform their work around this.” Source location Response from NHS England (2)
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Cygnet is responsible for addressing its Ligature Risk Reduction Policy and Ligature Audit Tool.
Verbatim wording from the response “In respect of the specific concerns in your Report regarding Cygnet’s Ligature Risk Reduction Policy and Ligature Audit Tool / Risk Assessment, these are outside of NHS England’s remit and are more matters for Cygnet to action, which is why our previous response did not fully address the same. However, I can confirm that NHS England” Source location Response from NHS England (2)
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Cygnet’s Ligature Risk Reduction Policy and Ligature Audit Tool are outside NHS England’s remit.
Verbatim wording from the response “In respect of the specific concerns in your Report regarding Cygnet’s Ligature Risk Reduction Policy and Ligature Audit Tool / Risk Assessment, these are outside of NHS England’s remit and are more matters for Cygnet to action, which is why our previous response did not fully address the same. However, I can confirm that NHS England” Source location Response from NHS England (2)
Open published response
14 Sep 2022 Maureen Harrop · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to provide surgery within 36 hours View source Lack of support for patients during prolonged emergency department waits View source Lack of theatre capacity View source Lack of emergency department bed capacity 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
Maureen Harrop · 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
Maureen Harrop, a care home resident, suffered an accidental fall resulting in a fracture to the neck of her femur. She experienced prolonged waits in the Emergency Department and for surgery, which was delayed because of limited bed and theatre capacity. She later developed a urinary tract infection, deteriorated, and died from urosepsis; the report raised concerns about the impact of these delays on her condition.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide surgery within 36 hours
Wider context from the report “2. The evidence at the Inquest was that the NICE guidance promotes surgery within 36 hours . In Mrs Harrop’s case that was not achieved due to a lack of theatre capacity. The impact of the delay on her overall physiological reserves was significant
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of support for patients during prolonged emergency department waits
Wider context from the report “1. The inquest heard that Mrs Harrop had a prolonged stay in the ED at the Hospital because of lack of bed capacity. The Inquest heard that given her age and the fracture the impact of the prolonged wait on her was significant particularly in light of the lack of support available to her ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of theatre capacity
Wider context from the report “2. The evidence at the Inquest was that the NICE guidance promotes surgery within 36 hours. In Mrs Harrop’s case that was not achieved due to a lack of theatre capacity . The impact of the delay on her overall physiological reserves was significant
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 emergency department bed capacity
Wider context from the report “1. The inquest heard that Mrs Harrop had a prolonged stay in the ED at the Hospital because of lack of bed capacity . The Inquest heard that given her age and the fracture the impact of the prolonged wait on her was significant particularly in light of the lack of support available to her;
” 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 Submit daily hip-fracture data to the National Hip Fracture Database to support quality improvement and guideline-aligned care.
Verbatim wording from the response “The Trust also submits data to the National Hip Fracture Database, which specifically looks at care for patients over the age of 60, who undergo surgery following a hip fracture. This includes data to improve care through quality improvement, in line with NICE guidelines and the National Falls and Fragility Fracture Audit Programme (FFFAP). Data is submitted by the trauma coordinators daily.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement and monitor a divisional fractured-neck-of-femur improvement programme through senior leadership and quality-governance oversight.
Verbatim wording from the response “In addition to this, the Trust has implemented a Divisional fractured neck of femur improvement programme, which is reported and monitored daily via the Divisional senior leadership team. Oversight of Divisional compliance with this pathway is also monitored via the Service Quality and Governance Group, which is chaired by the Executive Director of Nursing and Integrated Governance.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an enhanced bed-allocation pathway to identify hip-fracture patients and support timely transfer from the Emergency Department to trauma and orthopaedics beds.
Verbatim wording from the response “The Surgical and Medical Division have worked closely together to design and implement an enhanced bed allocation process. The process supports those patients with hip fractures from the moment that the patient has had their fracture confirmed in the ED, through to admission to a trauma and orthopaedics bed. The pathway redesign has included both in and out of hours actions required by the clinical teams, with support from the Trust’s patient flow team. Each Trust bed meeting, which occurs five times per day, highlights any patient within the ED who will require a Trauma and Orthopaedic bed due to a hip fracture.” 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 Report surgery delays, complete root-cause analyses, review findings weekly, and monitor compliance through internal returns.
Verbatim wording from the response “Where the Trust is not able to meet the 36 hour timeframe for surgery for a patient with a hip fracture, a clinical incident report is submitted. Following the incident, a root cause analysis (RCA) is completed by the trauma coordinators to identify the reasons for the delay and opportunities for learning. The RCA investigations are reviewed weekly in the “Neck Of Femur (NOF) Review Meeting” for comment, action and approval. This meeting is attended by the Clinical Lead for Neck of Femur, the Matron for Trauma and Orthopaedics and the Directorate Manager. Compliance is monitored through regular internal returns.” 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 Operate daily trauma and surgical bed-planning processes to identify patients awaiting hip-fracture surgery, agree care plans, and track waiting times and required pre-operative tests.
Verbatim wording from the response “The trauma and orthopaedic department run a daily trauma meeting, where all patients with hip fractures who are awaiting surgery are identified. Individual plans of care and management are agreed clinically with the on-call orthopaedic consultant and trauma coordination team. An overview of these patients is also provided to the surgical bed meeting each morning, including the status of each patient and the current wait time for surgery.” 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 Schedule clinically suitable hip-fracture patients for surgery within 36 hours and escalate unavailable theatre capacity through urgent trauma and elective-list review and divisional approval.
Verbatim wording from the response “In response to your second concern, the Trust recognises that best practice and NICE guidance states that patients that have sustained a hip fracture should have timely surgery to repair the injury within 36 hours of admission, where the patient is clinically stable to undergo surgery - Overview | Hip fracture: management | Guidance | NICE. To manage these patients within the appropriate timeframe alongside competing priorities within the trauma and elective services, the Division of Surgery, Women’s and Children’s services (SWC) have reviewed and strengthened their processes.” Source location Response from NHS England
Open published response
Concerns raised 5 Lack of progress in reviewing or renegotiating the inter-Trust Service Level Agreement View source Ongoing firewall problems between the two Trusts causing reliance on email rather than automatic electronic systems View source Insufficient clarity about key contacts during inter-provider transfers between SASH and RSFT View source Lack of clarity for GPs about where to raise concerns regarding hospital or tertiary-care treatment View source Insufficient guidance or refresher training for hospital doctors on use of the relevant Datix system 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
Stephen WELLS · 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 Wells was treated for colon cancer with liver metastases, but after liver surgery he received no further contact or oncology follow-up for one year because communication and referral processes between two NHS trusts failed. He later developed widespread liver and lung metastases and died at home on 4 October 2021. The report raises concerns about inter-provider referrals, tracking systems, communication between trusts, use of the Datix system, and clarity over patients’ key contacts.
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 progress in reviewing or renegotiating the inter-Trust Service Level Agreement
Wider context from the report “b) I also heard evidence from SASH that they would not have expected Mr Wells to be transferred back to them after the liver surgery as further chemotherapy was needed. Conversely, RSFT were unable to explain why Mr Wells did not remain on the Somerset Cancer Registry (SCR) tracking system following discharge and the MDT discussion on 10 August 2020. I was told that the safety net to avoid a cancer patient such as Mr Wells failing to receive further treatment is an inter-provider transfer (IPT) to ensure the responsibility for care is further transferred. In this case, a local process of consultant-to- consultant referrals, in other words a workaround, had evolved and both the hardcopy letter between doctors and an email from the CNS to two separate doctor’s secretaries had failed resulting in no further appointment being made. It was accepted that the communication failure was not identified in a timely manner and that communication systems between both Trusts had blurred with the suggestion that these could be clarified by a renegotiation of the Service Level Agreement (SLA). I was provided with a copy of the current SLA dated 1 January 2015 and note that the particulars state the contract term was 36 months with an end date of 31 December 2017. Given the importance of good systems of communication between Trusts and the IPT system I remain concerned about:
i. the lack of progress made in reviewing/renegotiating the SLA bearing in mind the difficulties in this case were drawn to the attention of the Trusts in September 2021.
ii. an ongoing firewall problem between the two Trusts as this places a current reliance on email rather than automatic electronic systems especially given the failure of emails in this case to secure a much-needed appointment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Ongoing firewall problems between the two Trusts causing reliance on email rather than automatic electronic systems
Wider context from the report “b) I also heard evidence from SASH that they would not have expected Mr Wells to be transferred back to them after the liver surgery as further chemotherapy was needed. Conversely, RSFT were unable to explain why Mr Wells did not remain on the Somerset Cancer Registry (SCR) tracking system following discharge and the MDT discussion on 10 August 2020. I was told that the safety net to avoid a cancer patient such as Mr Wells failing to receive further treatment is an inter-provider transfer (IPT) to ensure the responsibility for care is further transferred. In this case, a local process of consultant-to- consultant referrals, in other words a workaround, had evolved and both the hardcopy letter between doctors and an email from the CNS to two separate doctor’s secretaries had failed resulting in no further appointment being made. It was accepted that the communication failure was not identified in a timely manner and that communication systems between both Trusts had blurred with the suggestion that these could be clarified by a renegotiation of the Service Level Agreement (SLA). I was provided with a copy of the current SLA dated 1 January 2015 and note that the particulars state the contract term was 36 months with an end date of 31 December 2017. Given the importance of good systems of communication between Trusts and the IPT system I remain concerned about:
i. the lack of progress made in reviewing/renegotiating the SLA bearing in mind the difficulties in this case were drawn to the attention of the Trusts in September 2021.
ii. an ongoing firewall problem between the two Trusts as this places a current reliance on email rather than automatic electronic systems especially given the failure of emails in this case to secure a much-needed appointment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 clarity about key contacts during inter-provider transfers between SASH and RSFT
Wider context from the report “c) I heard evidence that Mr Wells was told his key contact in SASH was a named Clinical Nurse Specialist. When his care transferred to RSFT, witnesses expected his key contact to be changed to a CNS based within the St Luke’s Cancer Centre in Guildford. During the inquest I asked to whom the CNS was at RSFT and following enquiries learnt that the St Luke’s staff believed the key contact was the SASH CNS. I remain concerned that there is insufficient clarity for both patients and staff when there is an IPT from SASH to RSFT and vice versa .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 for GPs about where to raise concerns regarding hospital or tertiary-care treatment
Wider context from the report “a) I heard evidence that Mr Wells GP wrote two urgent letters to the RSFT consultant oncologist and HPB surgeon dated 22 September 2021 raising concerns that the patient had heard nothing further after the liver surgery in September 2020. These letters were sent to the East Surrey hospital by the GP. I heard evidence that both consultants hold clinics in two East Surrey hospitals as well as within their own Trust area. Principally the letters were about lack of treatment for a cancer patient and I heard evidence during the inquest that the RSFT witness assisting the court on governance & risk issues did not know the doctors had received the letters and presumably were not logged on the Datix system thereby raising concerns regarding:
i. whether additional guidance may be appropriate for GPs to know where to raise concerns about patient treatment in hospital or tertiary care ; and
ii. whether further guidance or refresher training is needed for hospital doctors regarding use of the relevant Datix 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 Insufficient guidance or refresher training for hospital doctors on use of the relevant Datix system
Wider context from the report “a) I heard evidence that Mr Wells GP wrote two urgent letters to the RSFT consultant oncologist and HPB surgeon dated 22 September 2021 raising concerns that the patient had heard nothing further after the liver surgery in September 2020. These letters were sent to the East Surrey hospital by the GP. I heard evidence that both consultants hold clinics in two East Surrey hospitals as well as within their own Trust area. Principally the letters were about lack of treatment for a cancer patient and I heard evidence during the inquest that the RSFT witness assisting the court on governance & risk issues did not know the doctors had received the letters and presumably were not logged on the Datix system thereby raising concerns regarding:
i. whether additional guidance may be appropriate for GPs to know where to raise concerns about patient treatment in hospital or tertiary care; and
ii. whether further guidance or refresher training is needed for hospital doctors regarding use of the relevant Datix system .
” 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 Notify regional and ICB patient-safety teams about incidents occurring outside primary care for escalation to the other organisation.
Verbatim wording from the response “NHS England can advise that it is routine practice in primary care to have local systems in place to monitor cancer cases among patients. By September 2023, every local risk management supplier including Datix will need to connect to the Learn from patient safety events (LFPSE) service. The reporter can log the incident as occurring elsewhere by completing the question: “Under which organisation’s care did the incident occur”. NHS England’s Regulation 28 Working Group will notify regions and ICB (Integrated Care Board) quality teams / ICB patient safety specialists of any incident of concern occurring outside of primary care, so that this can be escalated to the other organisation.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing local primary-care systems routinely monitor cancer cases, addressing the need for additional guidance when GPs raise concerns about hospital or tertiary treatment.
Verbatim wording from the response “NHS England can advise that it is routine practice in primary care to have local systems in place to monitor cancer cases among patients. By September 2023, every local risk management supplier including Datix will need to connect to the Learn from patient safety events (LFPSE) service. The reporter can log the incident as occurring elsewhere by completing the question: “Under which organisation’s care did the incident occur”. NHS England’s Regulation 28 Working Group will notify regions and ICB (Integrated Care Board) quality teams / ICB patient safety specialists of any incident of concern occurring outside of primary care, so that this can be escalated to the other organisation.” 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 Annual mandatory consultant training already covers Datix use and incident reporting, addressing the need for refresher training for hospital doctors.
Verbatim wording from the response “The Royal Surrey County Hospital NHS Foundation Trust (RSFT) have assured us that all consultants undertake yearly mandatory training, which includes the use of the Datix system and the expectation for Datix reporting of incidents.” Source location Response from NHS England
Open published response
Concerns raised 12 Failure of commissioners to obtain assurance about ligature practice and individual safety View source Inadequate assessment and clarification of capacity-based information-sharing wishes View source Failure to recognise and respond appropriately to repeated ligature incidents View source Failure to regularly revisit capacity and information-sharing decisions View source Failure to debrief prior ligature and self-harm incidents for future risk planning View source Failure to critically explore allegations and trauma-related experiences View source Failure to adequately assess the impact of ending face-to-face visits on detained young people View source Unpractised and delayed ligature identification and knife response View source Inadequate review of evolving diagnoses and relevant diagnostic information View source Failure to provide clear CPR leadership and task structure View source Failure to equip staff to respond to a crisis when alone with a young person View source Failure of commissioners to independently assure a family information-sharing decision View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Chelsea Blue Louise Mooney · 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
Chelsea Blue Louise Mooney died two days after tying two non-fixed ligatures while in hospital, following inadequate observations and delays in the emergency response. Principal concerns included insufficient review of her diagnosis, inadequate exploration of allegations and information-sharing decisions, a failure to learn from previous ligature incidents, uncertainty among staff about responding to her, and delays and poor coordination during the final emergency response.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of commissioners to obtain assurance about ligature practice and individual safety
Wider context from the report “9. There were opportunities for commissioners to support Cygnет earlier when case managing Chelsea's package of care. The new behaviour of using ligatures should have invited professional curiosity from Commissioners who should have sought assurance about the overall practice of ligature use and intervention from Cygnет but also what that meant specifically for Chelsea and how Cygnет were keeping her safe . This may have led to a review by Cygnет and a better understanding of Chelsea's ligature use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 assessment and clarification of capacity-based information-sharing wishes
Wider context from the report “3. The decision not to share information with family was made based on one capacity assessment. This did not fully address the issues with Chelsea of understanding the consequences of that decision and neither does it adequately break down the information which Cygnет may wish to share with family . This appears to have been a blanket decision and once a capacity assessment determined that Chelsea had the capacity to make that decision there is not evidence available to me of conversations with Chelsea to establish exactly what she would and would not share with family and that the consequences of those decisions were adequately explored with her. I would have expected; at Chelsea's age, that a social worker would be involved in supporting her with this decision and reviewing it regularly. This decision about her capacity and information sharing were also not revisited which they ought to have been regularly. Not least because Chelsea's mother was responsible for supporting her with s17 leave and was entitled to fully understand the risks to Chelsea or herself through this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and respond appropriately to repeated ligature incidents
Wider context from the report “5. There was limited concern about the number of ligature incidents collectively across the ward. They appear to have been accepted as normal behaviour. There was no record of Chelsea using ligatures prior to her admission onto this ward. This reality for staff appears to have led to a downgrading of the seriousness of the use of ligatures. With staff describing in evidence when they would and would not intervene and what would and would not constitute a serious incident in relation to ligatures (i.e., a hospital admission would be required before it was regarded as a serious incident requiring immediate changes to risk levels and observations). It may be that this approach to ligatures also contributed to the delay in Chelsea's final ligature being removed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 regularly revisit capacity and information-sharing decisions
Wider context from the report “3. The decision not to share information with family was made based on one capacity assessment. This did not fully address the issues with Chelsea of understanding the consequences of that decision and neither does it adequately break down the information which Cygnет may wish to share with family. This appears to have been a blanket decision and once a capacity assessment determined that Chelsea had the capacity to make that decision there is not evidence available to me of conversations with Chelsea to establish exactly what she would and would not share with family and that the consequences of those decisions were adequately explored with her. I would have expected; at Chelsea's age, that a social worker would be involved in supporting her with this decision and reviewing it regularly. This decision about her capacity and information sharing were also not revisited which they ought to have been regularly. Not least because Chelsea's mother was responsible for supporting her with s17 leave and was entitled to fully understand the risks to Chelsea or herself through this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to debrief prior ligature and self-harm incidents for future risk planning
Wider context from the report “4. There was no evidence of debrief after prior incidents of ligatures or other self-harm attempts and therefore crucial information about Chelsea's state of mind, motivation and methods was missing from future planning and risk assessments.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to critically explore allegations and trauma-related experiences
Wider context from the report “2. Whilst it is important that the young person is believed and has confidence in those with a therapeutic relationship that she will be believed when she makes disclosures; there was almost no professional curiosity about the allegations and whether they spoke to something else going on with Chelsea. The allegations that were made were blindly accepted by the team and one example where this was problematic is the part of Chelsea's PTSD diagnosis that was based on flashbacks. One of the flashbacks which she described related to finding her aunt dead. Her Aunt was not dead and in fact attended the inquest proceedings however this had not been clarified with the family and the treating team accepted this information from Chelsea unequivocally. It is clear there is a very fine balance to tread as it is clear that Chelsea was suffering from flashbacks and had suffered trauma, there was no demonstrable exploration of this .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately assess the impact of ending face-to-face visits on detained young people
Wider context from the report “10. Commissioners also ought to have spoken to Chelsea themselves and assured themselves about the decision not to share information with her family; particularly her mother who had been a huge support for Chelsea prior to Covid-19. The impact of the cessation of face-to-face visits on anyone detained under the mental health act, but particularly young people like Chelsea appears to have been underestimated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unpractised and delayed ligature identification and knife response
Wider context from the report “7. The approach of three members of staff checking Chelsea before the ligature knife was brought and used led to avoidable delay. I am aware from the evidence that there are practise exercises involving the 'Red Bag' however I am not clear that the same is practised in relation to the check, identification of a ligature and obtaining and using the ligature knife in these situations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 review of evolving diagnoses and relevant diagnostic information
Wider context from the report “1. The diagnosis whilst described as not being fixed, was not adequately reviewed. The primary witness for Cygnет in relation to diagnosis lacked professional curiosity even when asked questions in evidence. For example dismissing the potential that Chelsea may be hyperbolic in some of her descriptions of incidents and could that be relevant to diagnosis or treatment; evidence from the family about another member of the family with an autism diagnosis was not followed up (the evidence from Cygnет being that they had not been aware the family wished to explore this); nonetheless in evidence it was dismissed as a possibility.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear CPR leadership and task structure
Wider context from the report “8. Whilst in evidence I have heard about the practice exercises using the 'Red Bag' it is clear that there was limited confidence and clarity around the CPR needed for Chelsea. There was not a clear structure of one person leading and others knowing exactly what and how to do tasks.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 equip staff to respond to a crisis when alone with a young person
Wider context from the report “6. Male staff were nervous and uncertain of how to approach Chelsea when they were alone. Clear guidance needed to be made available to them on how to deal with this. Although in evidence staff said that if there was an emergency they would attend even if alone this was not the case in practice as the male member of staff sought female support before recognising that Chelsea was in 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 commissioners to independently assure a family information-sharing decision
Wider context from the report “10. Commissioners also ought to have spoken to Chelsea themselves and assured themselves about the decision not to share information with her family ; particularly her mother who had been a huge support for Chelsea prior to Covid-19. The impact of the cessation of face-to-face visits on anyone detained under the mental health act, but particularly young people like Chelsea appears to have been underestimated.
” Open source report
Concerns raised 2 Lack of adequate numbers of suitably trained CAMHS staff View source Excessive consultant caseloads in CAMHS 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
Lily May Girton · 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
Lily May Girton, who had anxiety, depression and emotional dysregulation, died after taking her own life while suffering from mental illness. The inquest found that her death was contributed to by failures in the community CAMHS team concerning psychiatric assessment, risk management and titration of antidepressant medication. It also raised concerns that inadequate staffing and resources in CAMHS services pose a risk of future deaths of young people.
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 adequate numbers of suitably trained CAMHS staff
Wider context from the report “The Inquest heard that CAMHS services nationally have a lack of adequate staffing levels in the form of doctors, in the form of psychiatrists, registered mental health nurses and psychotherapy staff . The Inquest heard that consultants often have an average of 130 to 150 active cases on their caseloads. This is substantially higher than the recommended caseloads by the Royal College of Psychiatrists.
The lack of staffing and resources contributed to Lily’s death and there is a concern that the ongoing shortages of suitably trained staff within CAMHS teams poses a risk of future deaths of 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 Excessive consultant caseloads in CAMHS
Wider context from the report “The Inquest heard that CAMHS services nationally have a lack of adequate staffing levels in the form of doctors, in the form of psychiatrists, registered mental health nurses and psychotherapy staff. The Inquest heard that consultants often have an average of 130 to 150 active cases on their caseloads . This is substantially higher than the recommended caseloads by the Royal College of Psychiatrists .
The lack of staffing and resources contributed to Lily’s death and there is a concern that the ongoing shortages of suitably trained staff within CAMHS teams poses a risk of future deaths of young people.
” Open source report
29 Jul 2022 Asher William Robert Sinclair · Prevention of Future Deaths report West London
View report summary
Concerns raised 5 Failure to conduct mandatory care-package quality checks and reviews View source Failure to escalate and follow up concerns raised about the care package View source Inadequate training for staff involved in the care package View source Lack of scrutiny and reconciliation of the care package View source Failure to provide prescribed 2:1 care View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Asher William Robert Sinclair · 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
Asher William Robert Sinclair was a ventilator-dependent child who died in hospital on 8 October 2019 after life support was withdrawn, following a displaced tracheal tube and a prolonged loss of oxygen. The report identified concerns about inadequate staffing, training, planning, oversight, review and escalation within his complex care package, including that he was left in the care of a sole nurse who did not follow the emergency procedure.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct mandatory care-package quality checks and reviews
Wider context from the report “The care package, despite being described as one of the most complex and most expensive was not appropriately reviewed and there was no mandatory system of quality checks or formal review when there was a significant change in family circumstances . Quarterly reviews were not carried out without explanation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate and follow up concerns raised about the care package
Wider context from the report “The primary responsibility fell upon the family members, namely Asher’s parents, who were also responsible for other children in the family and employed as teachers. Concerns raised by the parents were not taken for discussion to case conference or professional’s meetings and essentially not followed up at all , leaving the situation in the house dangerous with an ultimately calamitous outcome.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 training for staff involved in the care package
Wider context from the report “Training for the staff involved was unclear to the court and seemingly not in place or inadequate . A high turnover of staff was cited as one of the reasons, but this should have highlighted a need for increased training and scrutiny.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 scrutiny and reconciliation of the care package
Wider context from the report “There was a lack of scrutiny or reconciliation of Asher’s care package , which could have identified gaps that needed to be addressed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prescribed 2:1 care
Wider context from the report “Asher was entirely dependent upon a complex package of care as a highly vulnerable ventilator dependent child. Evidence at inquest was that on numerous occasions he was not provided with the prescribed 2:1 care .
” Open source report
Concerns raised 2 Unavailability of shared-record-system access for one care or treatment organisation View source Lack of policy, procedure or guidance on considering when to hold multi-agency information-sharing meetings 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
Lewis Martyn POWTER · 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
Lewis Martyn Powter, an IPP offender with emotionally unstable personality disorder and a long history of drug addiction, died from a self-administered overdose on 10 May 2020 after a period of abstinence and reduced drug tolerance. The concern was that there was no policy or guidance encouraging multi-agency meetings to share information about complex-needs IPP offenders, particularly where one care provider lacked access to the shared record 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 Unavailability of shared-record-system access for one care or treatment organisation
Wider context from the report “that, where an IPP offender with complex needs is released and is not subject to MAPPA, but is subject to multi-agency intervention co-ordinated by the National Probation Service, there is no policy/procedure/guidance encouraging consideration to be given to the issues of whether and when to hold multi-agency meetings for the purposes of sharing information about the offender. The need for consideration to be given to holding such meetings is particularly acute where one of the organisations responsible for delivering care/treatment does not have access to the shared record system used by the other two parties .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of policy, procedure or guidance on considering when to hold multi-agency information-sharing meetings
Wider context from the report “that, where an IPP offender with complex needs is released and is not subject to MAPPA, but is subject to multi-agency intervention co-ordinated by the National Probation Service, there is no policy/procedure/guidance encouraging consideration to be given to the issues of whether and when to hold multi-agency meetings for the purposes of sharing information about the offender . The need for consideration to be given to holding such meetings is particularly acute where one of the organisations responsible for delivering care/treatment does not have access to the shared record system used by the other two parties.
” Open source report
5 Jul 2022 Antony Christopher MCLELLAN · Prevention of Future Deaths report North Yorkshire and York
View report summary
Concerns raised 4 Failure to provide autism treatment in North Yorkshire View source Higher suicide risk among the expanding population of autistic individuals open to mental health services View source Failure to incorporate autism into assessment and management of self-harm risk View source Underdeveloped and insufficiently accessible specialist autism support for mental health patients View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Antony Christopher MCLELLAN · 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
Antony Christopher McLellan was found unresponsive, hanging by a ligature in the garage at his home on 9 July 2021; his death was recognised that afternoon and the inquest concluded that he died by suicide. Concerns included that assessment and formulation of risks and safety did not fully explore the impact of his autism, including how he might communicate distress and risk, and that autism-informed support and services required significant improvement and expansion.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide autism treatment in North Yorkshire
Wider context from the report “1 Mr McLellan was diagnosed over 2016/16 as being autistic with a designation of Asperger’s Syndrome. He was also diagnosed as experiencing Bipolar Disorder, an attribution he did not accept which he repeatedly asserted to both previous Mental Health care providers and the subsequent Trust clinicians tasked with supporting him at the time of his death, Tees Esk and Wear Valleys NHS Foundation Trust (“TEWV”)
2 He insisted his difficulties were linked to his autism and not mental disorder. It was accepted that he experienced autism and that was part of his individuality and that in addition he may have had a mental health disorder. It was accepted that his care and treatment cannot unbundle the two but he should be treated holistically.
3 Assessment and formulation of risks and safety summary did not fully explore the impact of his autism. There was little to suggest that TEWV staff) considered the higher prevalence of suicide for individuals with a diagnosis of autism and that Mr McLellan may have communicated his distress and risks information differently to an individual without a diagnosis of autism during his periods of crisis or increased risk and c) made sufficient reasonable adjustments in relation to the impact of his autism.
4 At the time of his death, TEWV had progressed from a low baseline in the Trust’s work in North Yorkshire to address perceived underdevelopment in their services for the autistic patient when presenting with a mental health disorder. It had expanded the use of a specialist team (Autism Project Team- “APT”) to extend its work into North Yorkshire caseload. The steps taken were incremental and not all staff understood that Team and access to that important resource. It is recognised that improvements would take time and be resource dependent as well however.
5 APT has three specialist and autism dedicated practitioners working exclusively with autism across the whole Trust in both its regions of commissioned care although there are also non-dedicated clinicians with some expertise of autism within TEWV. TEWV does not treat autism in North Yorkshire.
6 TEWV in its recent audit indicates about 17% of the individuals open to TEWV (over 10,000 in number) have an autism marker or have an ICD-10 diagnosis of autism or experience suspected/confirmed autism or have a referral including being suspected as autistic.
7 There was no direct causation to the suicide found that directly attributed the acts he took to his autism from the evidence. However Mr McLellan’s distress and stressors before his death included his feelings that he was not getting what he saw to be the right help and that he would not lose his feelings of helplessness such that he took his own life.
The concern is that the very significant number of those open to TEWV with an autism marker has increased and will continue to do so and that the higher prevalence of suicide within that expanding group will lead to higher risk of, and numbers of, autistic individuals dying because of suicide both within TEWV locally but also nationally.
Urgent solutions are required to prevent further deaths of autistic individuals especially those with mental health disorder by rapidly improving and expanding provisions for assessment and management of risk of harm to themselves for individuals within the autism spectrum while presenting with a mental health disorder.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Higher suicide risk among the expanding population of autistic individuals open to mental health services
Wider context from the report “1 Mr McLellan was diagnosed over 2016/16 as being autistic with a designation of Asperger’s Syndrome. He was also diagnosed as experiencing Bipolar Disorder, an attribution he did not accept which he repeatedly asserted to both previous Mental Health care providers and the subsequent Trust clinicians tasked with supporting him at the time of his death, Tees Esk and Wear Valleys NHS Foundation Trust (“TEWV”)
2 He insisted his difficulties were linked to his autism and not mental disorder. It was accepted that he experienced autism and that was part of his individuality and that in addition he may have had a mental health disorder. It was accepted that his care and treatment cannot unbundle the two but he should be treated holistically.
3 Assessment and formulation of risks and safety summary did not fully explore the impact of his autism. There was little to suggest that TEWV staff) considered the higher prevalence of suicide for individuals with a diagnosis of autism and that Mr McLellan may have communicated his distress and risks information differently to an individual without a diagnosis of autism during his periods of crisis or increased risk and c) made sufficient reasonable adjustments in relation to the impact of his autism.
4 At the time of his death, TEWV had progressed from a low baseline in the Trust’s work in North Yorkshire to address perceived underdevelopment in their services for the autistic patient when presenting with a mental health disorder. It had expanded the use of a specialist team (Autism Project Team- “APT”) to extend its work into North Yorkshire caseload. The steps taken were incremental and not all staff understood that Team and access to that important resource. It is recognised that improvements would take time and be resource dependent as well however.
5 APT has three specialist and autism dedicated practitioners working exclusively with autism across the whole Trust in both its regions of commissioned care although there are also non-dedicated clinicians with some expertise of autism within TEWV. TEWV does not treat autism in North Yorkshire.
6 TEWV in its recent audit indicates about 17% of the individuals open to TEWV (over 10,000 in number) have an autism marker or have an ICD-10 diagnosis of autism or experience suspected/confirmed autism or have a referral including being suspected as autistic.
7 There was no direct causation to the suicide found that directly attributed the acts he took to his autism from the evidence. However Mr McLellan’s distress and stressors before his death included his feelings that he was not getting what he saw to be the right help and that he would not lose his feelings of helplessness such that he took his own life.
The concern is that the very significant number of those open to TEWV with an autism marker has increased and will continue to do so and that the higher prevalence of suicide within that expanding group will lead to higher risk of, and numbers of, autistic individuals dying because of suicide both within TEWV locally but also nationally.
Urgent solutions are required to prevent further deaths of autistic individuals especially those with mental health disorder by rapidly improving and expanding provisions for assessment and management of risk of harm to themselves for individuals within the autism spectrum while presenting with a mental health disorder.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate autism into assessment and management of self-harm risk
Wider context from the report “1 Mr McLellan was diagnosed over 2016/16 as being autistic with a designation of Asperger’s Syndrome. He was also diagnosed as experiencing Bipolar Disorder, an attribution he did not accept which he repeatedly asserted to both previous Mental Health care providers and the subsequent Trust clinicians tasked with supporting him at the time of his death, Tees Esk and Wear Valleys NHS Foundation Trust (“TEWV”)
2 He insisted his difficulties were linked to his autism and not mental disorder. It was accepted that he experienced autism and that was part of his individuality and that in addition he may have had a mental health disorder. It was accepted that his care and treatment cannot unbundle the two but he should be treated holistically.
3 Assessment and formulation of risks and safety summary did not fully explore the impact of his autism. There was little to suggest that TEWV staff) considered the higher prevalence of suicide for individuals with a diagnosis of autism and that Mr McLellan may have communicated his distress and risks information differently to an individual without a diagnosis of autism during his periods of crisis or increased risk and c) made sufficient reasonable adjustments in relation to the impact of his autism.
4 At the time of his death, TEWV had progressed from a low baseline in the Trust’s work in North Yorkshire to address perceived underdevelopment in their services for the autistic patient when presenting with a mental health disorder. It had expanded the use of a specialist team (Autism Project Team- “APT”) to extend its work into North Yorkshire caseload. The steps taken were incremental and not all staff understood that Team and access to that important resource. It is recognised that improvements would take time and be resource dependent as well however.
5 APT has three specialist and autism dedicated practitioners working exclusively with autism across the whole Trust in both its regions of commissioned care although there are also non-dedicated clinicians with some expertise of autism within TEWV. TEWV does not treat autism in North Yorkshire.
6 TEWV in its recent audit indicates about 17% of the individuals open to TEWV (over 10,000 in number) have an autism marker or have an ICD-10 diagnosis of autism or experience suspected/confirmed autism or have a referral including being suspected as autistic.
7 There was no direct causation to the suicide found that directly attributed the acts he took to his autism from the evidence. However Mr McLellan’s distress and stressors before his death included his feelings that he was not getting what he saw to be the right help and that he would not lose his feelings of helplessness such that he took his own life.
The concern is that the very significant number of those open to TEWV with an autism marker has increased and will continue to do so and that the higher prevalence of suicide within that expanding group will lead to higher risk of, and numbers of, autistic individuals dying because of suicide both within TEWV locally but also nationally.
Urgent solutions are required to prevent further deaths of autistic individuals especially those with mental health disorder by rapidly improving and expanding provisions for assessment and management of risk of harm to themselves for individuals within the autism spectrum while presenting with a mental health disorder.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Underdeveloped and insufficiently accessible specialist autism support for mental health patients
Wider context from the report “1 Mr McLellan was diagnosed over 2016/16 as being autistic with a designation of Asperger’s Syndrome. He was also diagnosed as experiencing Bipolar Disorder, an attribution he did not accept which he repeatedly asserted to both previous Mental Health care providers and the subsequent Trust clinicians tasked with supporting him at the time of his death, Tees Esk and Wear Valleys NHS Foundation Trust (“TEWV”)
2 He insisted his difficulties were linked to his autism and not mental disorder. It was accepted that he experienced autism and that was part of his individuality and that in addition he may have had a mental health disorder. It was accepted that his care and treatment cannot unbundle the two but he should be treated holistically.
3 Assessment and formulation of risks and safety summary did not fully explore the impact of his autism. There was little to suggest that TEWV staff) considered the higher prevalence of suicide for individuals with a diagnosis of autism and that Mr McLellan may have communicated his distress and risks information differently to an individual without a diagnosis of autism during his periods of crisis or increased risk and c) made sufficient reasonable adjustments in relation to the impact of his autism.
4 At the time of his death, TEWV had progressed from a low baseline in the Trust’s work in North Yorkshire to address perceived underdevelopment in their services for the autistic patient when presenting with a mental health disorder. It had expanded the use of a specialist team (Autism Project Team- “APT”) to extend its work into North Yorkshire caseload. The steps taken were incremental and not all staff understood that Team and access to that important resource. It is recognised that improvements would take time and be resource dependent as well however.
5 APT has three specialist and autism dedicated practitioners working exclusively with autism across the whole Trust in both its regions of commissioned care although there are also non-dedicated clinicians with some expertise of autism within TEWV. TEWV does not treat autism in North Yorkshire.
6 TEWV in its recent audit indicates about 17% of the individuals open to TEWV (over 10,000 in number) have an autism marker or have an ICD-10 diagnosis of autism or experience suspected/confirmed autism or have a referral including being suspected as autistic.
7 There was no direct causation to the suicide found that directly attributed the acts he took to his autism from the evidence. However Mr McLellan’s distress and stressors before his death included his feelings that he was not getting what he saw to be the right help and that he would not lose his feelings of helplessness such that he took his own life.
The concern is that the very significant number of those open to TEWV with an autism marker has increased and will continue to do so and that the higher prevalence of suicide within that expanding group will lead to higher risk of, and numbers of, autistic individuals dying because of suicide both within TEWV locally but also nationally.
Urgent solutions are required to prevent further deaths of autistic individuals especially those with mental health disorder by rapidly improving and expanding provisions for assessment and management of risk of harm to themselves for individuals within the autism spectrum while presenting with a mental health disorder.
” 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 expanding and transforming integrated community mental health services, including intensive and community support for autistic people and people with learning disabilities.
Verbatim wording from the response “The NHS Long Term Plan, which is a plan for the future of the NHS, also includes ambitious investment to expand and transform community mental health services for adults and older adults with severe mental illness. From April 2021, all areas are receiving significant additional, ring-fenced funding on a fair-share basis to develop fully integrated primary and community mental health services, that enable people with severe mental illness to have greater choice and control over their care and support them to live well in their communities. By 2023/24, this investment will amount to almost £1billion extra per year for adults and older adults with severe mental illness.” 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 TEWV is responsible for delivering mental health services and making autism-related reasonable adjustments under its contract.
Verbatim wording from the response “The CCG (and now ICB) commission Tees, Esk, Wear Valley NHS Trust (TEWV) to provide the Mental Health provision to the residents of North Yorkshire. This would be the case whatever the Mental Health condition is and whether that is suspected, being assessed or diagnosed. The contract requires this provision of service. In addition to this where an individual with mental health conditions also has a diagnosis of autism, the contractual expectation would be that TEWV would make reasonable adjustments to their service to ensure that it is delivered to meet the needs of those individuals with autism and a mental health condition.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Integrated Care Board is responsible for commissioning North Yorkshire mental health services, rather than this respondent.
Verbatim wording from the response “The Humber and North Yorkshire Integrated Care Board (ICB) is the Commissioner that has adopted the contracts which were held by NHS North Yorkshire Clinical Commissioning Group (CCG) and have shared their response with me.” Source location Response from NHS England
Open published response
Concerns raised 7 Insufficient understanding of the L&D police custody suite model’s role and limitations View source Inadequate training of L&D practitioners View source Lack of clarity about responsibility for mentally unwell persons in custody View source Failure to learn sufficient lessons from the incident View source Inadequate experience of L&D practitioners View source Lack of commissioned psychiatrists within the L&D police custody suite model View source Inadequate supervision of L&D practitioners View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Khalid Seneen Yousef · 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
Khalid Seneen Yousef was decapitated during a sustained knife assault at a premises in Birmingham on 4 January 2018. The report identifies concerns that a Liaison and Diversion clinician failed to recognise the perpetrator’s psychosis and refer him for mental health assessment, and that the custody-suite model lacked commissioned psychiatrists, with wider concerns about responsibility, training and supervision.
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 understanding of the L&D police custody suite model’s role and limitations
Wider context from the report “3. West Midlands Police officers and BSMHFT staff do not sufficiently understand the role and limitations of the L&D police custody suite model .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 training of L&D practitioners
Wider context from the report “4. BSMHFT have not learnt sufficient lessons from the incident and need to review experience, training and supervision of L&D practitioners .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 mentally unwell persons in custody
Wider context from the report “2. Liaison and clarity is needed between Chief Constables and the Trusts providing L&D services on who has responsibility for mentally unwell persons in custody .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to learn sufficient lessons from the incident
Wider context from the report “4. BSMHFT have not learnt sufficient lessons from the incident and need to review experience, training and supervision of L&D practitioners.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 experience of L&D practitioners
Wider context from the report “4. BSMHFT have not learnt sufficient lessons from the incident and need to review experience , training and supervision of L&D practitioners .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 commissioned psychiatrists within the L&D police custody suite model
Wider context from the report “1. The L&D police custody suite model has not commissioned psychiatrists .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 supervision of L&D practitioners
Wider context from the report “4. BSMHFT have not learnt sufficient lessons from the incident and need to review experience, training and supervision of L&D practitioners .
” 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 Commission and publish a career and competency framework defining L&D roles and required competencies.
Verbatim wording from the response “NHS England commissioned Health Education England (HEE) and Skills for Health (SfH) to produce a career and competency framework for L&D services Career and Competence Framework | Info Hub | Skills for Health. This framework was published on 31 May 2018 and clearly sets out the respective job roles required within a multi-disciplinary L&D team, and the competencies required to discharge those roles. HEE and SfH are currently reviewing the content, as part of a wider piece of work to develop a career and competency framework across all of our Health & Justice non-custodial programmes of work.” 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 Present the respective PCHS and L&D responsibilities for mental health crises at the NPCC Custody Forum Conference.
Verbatim wording from the response “NHS England works collaboratively with all agencies and stakeholders to ensure a clear understanding of responsibilities for mentally unwell persons in custody. Recently, NHS England presented at the NPCC Custody Forum Conference (September 2022) and took the opportunity to emphasise the respective roles and reinforce the responsibilities of the PCHS and L&D service when responding to those in mental health crisis.” 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 Address BSMHFT’s training, supervision and experience issues through regular NHS England regional contract review meetings.
Verbatim wording from the response “I am assured that NHS England’s regional Health & Justice commissioning team are addressing this matter directly with the BSMHFT through regular contract review meetings.” 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 Discuss Regulation 28 reports through the national working group and share learning across NHS national and regional services.
Verbatim wording from the response “I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical” 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 Have NHS England regional Health and Justice commissioners regard the L&D career and competency framework when addressing provider workforce and quality issues.
Verbatim wording from the response “NHS England regional Health & Justice commissioners will have regard to the framework when addressing workforce and quality issues with providers.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update the Health and Justice career and competency framework across non-custodial programmes.
Verbatim wording from the response “NHS England commissioned Health Education England (HEE) and Skills for Health (SfH) to produce a career and competency framework for L&D services Career and Competence Framework | Info Hub | Skills for Health. This framework was published on 31 May 2018 and clearly sets out the respective job roles required within a multi-disciplinary L&D team, and the competencies required to discharge those roles. HEE and SfH are currently reviewing the content, as part of a wider piece of work to develop a career and competency framework across all of our Health & Justice non-custodial programmes of work.” 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 Discuss Regulation 28 reports through the national working group and share relevant learning across national and regional NHS teams.
Verbatim wording from the response “I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain a published career and competency framework defining L&D roles and required competencies.
Verbatim wording from the response “NHS England commissioned Health Education England (HEE) and Skills for Health (SfH) to produce a career and competency framework for L&D services Career and Competence Framework | Info Hub | Skills for Health. This framework was published on 31 May 2018 and clearly sets out the respective job roles required within a multi-disciplinary L&D team, and the competencies required to discharge those roles. HEE and SfH are currently reviewing the content, as part of a wider piece of work to develop a career and competency framework across all of our Health & Justice non-custodial programmes of work.” 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 Present the respective PCHS and L&D responsibilities for mental health crises at the NPCC Custody Forum Conference.
Verbatim wording from the response “NHS England works collaboratively with all agencies and stakeholders to ensure a clear understanding of responsibilities for mentally unwell persons in custody. Recently, NHS England presented at the NPCC Custody Forum Conference (September 2022) and took the opportunity to emphasise the respective roles and reinforce the responsibilities of the PCHS and L&D service when responding to those in mental health crisis.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue collaborative work with Police and Crime Commissioner counterparts to align PCHS, Liaison and Diversion specifications, responsibilities and locally commissioned services.
Verbatim wording from the response “The Home Office’s position usually indicates that it is for each PCC to determine the level of healthcare provision required for their area, however, NHS England acknowledges that unless each PCHS is designed to fit with the L&D service specification and other locally commissioned services, then the potential for gaps in service provision will remain. It would not be practicable for NHS England to commission a service to take on the role of the PCHS, and instead the PCHS and L&D service should continue to work closely, ensuring that the service specifications and responsibilities are clear, aligned and understood. NHS England’s national Health & Justice team officials will continue to work collaboratively with their counterparts at the PCC in this regard.” 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 Including psychiatrists in Liaison and Diversion teams is not presently considered necessary because their specified functions are covered through other services.
Verbatim wording from the response “The NPCC national service specification (Annex 1) specifically includes responsibility for responding to individuals in mental health crisis, including placing a requirement on the provider to facilitate assessments under the Mental Health Act. The NHS England L&D national service specification, by design, specifically excludes these functions.” 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 service specifications sufficiently clarify which services are responsible for responding to people in mental health crisis in custody.
Verbatim wording from the response “The PCHS and L&D national service specifications are written to complement each other, and to make clear which service is responsible for responding to those in mental health crisis. NHS England’s national Health & Justice team officials work closely with their counterparts at the NPCC to ensure that the two specifications remain aligned.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for responding to mental health crises in custody rests with police custody healthcare services, not Liaison and Diversion services.
Verbatim wording from the response “The inclusion of psychiatric provision within the makeup of L&D multi-disciplinary teams is not presently considered necessary. If and when an L&D practitioner identifies secondary mental health needs, that do not require immediate intervention, a supported referral is made to the appropriate local community mental health service. The PCHS operates within police custody suites 24 hours a day, whereas L&D services are generally present for 12 hours a day. In the event of a Mental Health Act assessment being required, this would be facilitated by the provider through the PCHS rather than L&D. As stated below, the two services work closely and their specifications make clear who has responsibility for responding to those in mental health crisis.” 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 PCHS, rather than L&D, is responsible for responding to people in mental health crisis and facilitating required Mental Health Act assessments.
Verbatim wording from the response “In summary, it is not the responsibility for L&D services to respond to those in mental health crisis, that function falls to PCHC services. Where an L&D practitioner has concerns regarding an individual’s mental health, that falls short of requiring an immediate crisis response, the expectation is that they will liaise with that individuals community mental health team for further advice (which may involve speaking with a psychiatrist or psychologist) and if the person has disengaged will provide a supported referral back into that service.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing PCHS and L&D service specifications sufficiently clarify responsibility for responding to people in mental health crisis.
Verbatim wording from the response “The PCHS and L&D national service specifications are written to complement each other, and to make clear which service is responsible for responding to those in mental health crisis. NHS England’s national Health & Justice team officials work closely with their counterparts at the NPCC to ensure that the two specifications remain aligned.” 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 Psychiatrists are not presently considered necessary within L&D teams because non-urgent needs receive supported community mental health referrals.
Verbatim wording from the response “The inclusion of psychiatric provision within the makeup of L&D multi-disciplinary teams is not presently considered necessary. If and when an L&D practitioner identifies secondary mental health needs, that do not require immediate intervention, a supported referral is made to the appropriate local community mental health service. The PCHS operates within police custody suites 24 hours a day, whereas L&D services are generally present for 12 hours a day. In the event of a Mental Health Act assessment being required, this would be facilitated by the provider through the PCHS rather than L&D. As stated below, the two services work closely and their specifications make clear who has responsibility for responding to those in mental health crisis.” 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 It would not be practicable for NHS England to commission a service to take on the Police Custody Healthcare Service role.
Verbatim wording from the response “The Home Office’s position usually indicates that it is for each PCC to determine the level of healthcare provision required for their area, however, NHS England acknowledges that unless each PCHS is designed to fit with the L&D service specification and other locally commissioned services, then the potential for gaps in service provision will remain. It would not be practicable for NHS England to commission a service to take on the role of the PCHS, and instead the PCHS and L&D service should continue to work closely, ensuring that the service specifications and responsibilities are clear, aligned and understood. NHS England’s national Health & Justice team officials will continue to work collaboratively with their counterparts at the PCC in this regard.” Source location Response from NHS England
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16 Jun 2022 Lee Anthony CARUANA · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1 Delays in handing over ambulance patients at hospitals View source
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AI-generated summary
Lee Anthony CARUANA · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lee Anthony CARUANA died at the Queen Elizabeth Hospital, Birmingham, on 6 October 2021 after suffering from COVID-19 and experiencing a delay in ambulance attendance. The report identified delays caused by ambulance crews waiting to hand over patients at hospitals, compromising ambulance availability and creating a risk to life.
Read the report on judiciary.uk
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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 Delays in handing over ambulance patients at hospitals
Wider context from the report “1. During the inquest, evidence was given on behalf of West Midlands Ambulance Service from Clinical Governance Lead ████████ and Trust Investigations Officer ████████ that at the time of Mr Caruana's death the Trust was experiencing unprecedented demand due to high call volume and delays in handing over patients to hospitals . At the time Mr Caruana was identified as needing an ambulance following a 999 call at 23:53 on the 6 October 2021, 71 of the Trusts 253 ambulance crews on duty were at hospital awaiting handover, the longest wait that day had been 7 hours and 45 minutes for a crew waiting at Birmingham Heartlands Hospital.
2. Since October 2021 the number of calls received has started to reduce to normal levels. However, the problem of paramedic crews being stuck at hospitals awaiting handover has increased . As an Investigations Officer ████████ said she is continuing to see incidents where ambulance attendance has been delayed because a crew was not available due to the number of crews waiting at hospital . Her evidence was that this is putting lives at risk.
3. ████████, Governance and Performance Manager at London Ambulance Service, gave evidence to the inquest as an independent expert. In the course of his evidence, he explained that the problem of ambulance crews being stuck awaiting handover is a national issue . Based on his anecdotal experience and observations the number of calls that a crew is able to attend to in a 12 hour shift has dropped by approximately 1/3 as a result of this issue.
4. The evidence from West Midlands Ambulance Service is that they have raised awareness of this issue locally, they have taken steps to free up ambulances (such as leaving multiple patients under the care of one paramedic crew at hospital to free up other crews to leave and diverting patients to other services where possible) and there is nothing further that they can do.
5. In the circumstances it is my conclusion that the availability of ambulance crews is being compromised by delays at hospitals resulting in delays in response times which creates a risk to life .
” 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 a wider support programme for acute trusts to improve ambulance handover performance.
Verbatim wording from the response “NHSE continue to provide targeted support to some of the hospitals facing the greatest delays in the handover of patients, helping them to identify short- and longer-term interventions to improve delays and get ambulances swiftly back out on the road. The 10 trusts with the highest amount of hours lost to ambulance handover delays are receiving intensive support from NHSE (including capital and revenue as required). In addition, NHSE are developing a wider support programme for all acute trusts to deliver improvements in ambulance handover. Work is taking place across all Integrated Care Boards to determine the amount of capacity needed to support” 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 Hold follow-up meetings with care systems and require them to set out plans for tackling handover delays and sharing system-level risks.
Verbatim wording from the response “For NHS England (NHSE), resolving handover delays and the related impact on ambulance response is of the highest priority. A national letter (Appendix A) was issued jointly from NHSE and the Care Quality Commission in February 2022, setting out the need for integrated care systems to come together to address the risk of harm to patients in the community caused by long delays in handing over patients at Emergency Departments. This was followed up with meetings between systems and the NHSE Chief Operating Officer, where systems were asked to set out plans to tackle handover delays and share risks across health and care services at system level.” 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 Issue a joint national letter requiring systems to address risks from prolonged ambulance handover delays.
Verbatim wording from the response “For NHS England (NHSE), resolving handover delays and the related impact on ambulance response is of the highest priority. A national letter (Appendix A) was issued jointly from NHSE and the Care Quality Commission in February 2022, setting out the need for integrated care systems to come together to address the risk of harm to patients in the community caused by long delays in handing over patients at Emergency Departments. This was followed up with meetings between systems and the NHSE Chief Operating Officer, where systems were asked to set out plans to tackle handover delays and share risks across health and care services at system level.” Source location Response from NHS England
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue national guidance on increasing urgent and emergency care capacity and operational resilience, including action on Category 2 response times and ambulance handover delays.
Verbatim wording from the response “In addition, NHSE set out the next steps in increasing capacity and operational resilience in urgent and emergency care ahead of winter, in a letter on 12 August 2022 (Appendix B). This again highlighted the need to target Category 2 response times and ambulance handover delays.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work across Integrated Care Boards to determine the capacity required to support performance and how it can be delivered.
Verbatim wording from the response “NHSE continue to provide targeted support to some of the hospitals facing the greatest delays in the handover of patients, helping them to identify short- and longer-term interventions to improve delays and get ambulances swiftly back out on the road. The 10 trusts with the highest amount of hours lost to ambulance handover delays are receiving intensive support from NHSE (including capital and revenue as required). In addition, NHSE are developing a wider support programme for all acute trusts to deliver improvements in ambulance handover. Work is taking place across all Integrated Care Boards to determine the amount of capacity needed to support” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide targeted and intensive support, including capital and revenue support where required, to trusts experiencing the greatest ambulance handover delays.
Verbatim wording from the response “NHSE continue to provide targeted support to some of the hospitals facing the greatest delays in the handover of patients, helping them to identify short- and longer-term interventions to improve delays and get ambulances swiftly back out on the road. The 10 trusts with the highest amount of hours lost to ambulance handover delays are receiving intensive support from NHSE (including capital and revenue as required). In addition, NHSE are developing a wider support programme for all acute trusts to deliver improvements in ambulance handover. Work is taking place across all Integrated Care Boards to determine the amount of capacity needed to support” Source location Response from NHS England
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations