Concerns raised 1 Excessive delays in handing over patients at hospital 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
Shaun Mansell · 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
Shaun Mansell, aged 50, was found deceased at home after an ambulance response to a 999 call was delayed by 8 hours and 15 minutes. The post-mortem cause of death was acute gastrointestinal haemorrhage and liver disease due to chronic alcoholism, but the medical evidence could not determine whether the delay contributed to his death. The principal concerns were excessive ambulance handover delays at hospital and a welfare call during the delay that involved no direct contact with Shaun and was conducted by a paramedic without prior training for such calls.
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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 Excessive delays in handing over patients at hospital
Wider context from the report “(1) There were excessive delays in handing over patients at hospital . The West Midlands Ambulance Service issued a recent report found that there were excessive handover of patients at the Royal Stoke University Hospital, with some holding for over 4 hours . This impacted on the ability of the West Midlands Ambulance Service getting to patients. Oral evidence was given to the effect that this was a national issue, and not limited to the acute trusts within the West Midlands.
” 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 Support systems to improve hospital flow by reducing length of stay and enabling timely discharge.
Verbatim wording from the response “Handover delays can be linked to patient flow issues, and NHS England and NHS Improvement are also supporting systems to improve hospital flow through reducing length of stay and supporting timely discharge.” Source location 2021-0383-Response-from-NHS-England-and-NHS-Improvement_Published
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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 Reiterate communications to systems on eliminating ambulance handover delays and share measures addressing those delays.
Verbatim wording from the response “On 13 December, as part of “Preparing the NHS for the potential impact of the Omicron variant and other winter pressures”, NHS England and NHS Improvement wrote to systems to reiterate earlier communication regarding the need to eliminate ambulance handover delays to ensure vehicles and paramedic crews are available to respond to urgent 999 calls. A range of measures, which have demonstrated benefits in addressing handover delays, were previously shared with all systems. I can also confirm that additional funding was made available for winter 2021/22 to support investment in Hospital Ambulance Liaison Officer staff to support handover of care.” Source location 2021-0383-Response-from-NHS-England-and-NHS-Improvement_Published
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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 Make additional winter funding available to support investment in Hospital Ambulance Liaison Officer staff.
Verbatim wording from the response “On 13 December, as part of “Preparing the NHS for the potential impact of the Omicron variant and other winter pressures”, NHS England and NHS Improvement wrote to systems to reiterate earlier communication regarding the need to eliminate ambulance handover delays to ensure vehicles and paramedic crews are available to respond to urgent 999 calls. A range of measures, which have demonstrated benefits in addressing handover delays, were previously shared with all systems. I can also confirm that additional funding was made available for winter 2021/22 to support investment in Hospital Ambulance Liaison Officer staff to support handover of care.” Source location 2021-0383-Response-from-NHS-England-and-NHS-Improvement_Published
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with ambulance services to eliminate hospital handover delays.
Verbatim wording from the response “The NHS Long Term Plan made a commitment to work with ambulance services to eliminate hospital handover delays. Ambulance services continue to, where appropriate and safe to do so, use alternative approaches to taking patients to Emergency Departments (EDs) and therefore reduce front door congestion, including increasing use of ‘See and Treat’, and conveying patients to non-ED settings such as urgent treatment centres.” Source location 2021-0383-Response-from-NHS-England-and-NHS-Improvement_Published
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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 Set a national policy requiring hospital handovers to take no more than 15 minutes.
Verbatim wording from the response “I can confirm that national policy has set out that handovers should take no more than 15 minutes, ensuring patients receive necessary emergency care and allowing ambulances to get back on the road responding to patients in the community. We recognise however that hospital handover delays are a significant challenge for ambulance services and acute trusts both regionally and nationally and tackling this is a high priority for NHS England and NHS Improvement.” Source location 2021-0383-Response-from-NHS-England-and-NHS-Improvement_Published
Open published response
Concerns raised 5 Failure of SystmOne to make vital prison healthcare information readily identifiable View source Failure to identify prisoners’ health information during large-cohort reception View source Lack of observations and welfare checks for prisoners found under the influence of psychoactive substances View source Lack of healthcare staff attendance at ACCT reviews View source Lack of 24-hour healthcare across the prison estate View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what this recipient says about the concern when it does not describe a specific action. 7
Position
The bespoke prison SystmOne module, templates and integrated summary care record are considered adequate existing adaptations for accessing and highlighting relevant patient information.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
HMPPS is responsible for responding to national guidance and ensuring healthcare attendance at reviews of prisoners at risk.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
Position
HMPPS is responsible for deciding whether local welfare, substance intervention and life-support processes should be rolled out nationally.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
Position
Existing needs-based commissioning and round-the-clock external, emergency, general-practitioner and first-responder access are considered sufficient without universal onsite 24/7 healthcare.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
NHSEI sets HJIS policy and holds the bespoke HJIS contract, rather than NHS Digital.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
Position
Matters of concern i, ii, iii and v do not relate to NHS Digital, so it has no comment on them.
Outside remitThe respondent said that this matter was outside its role or authority. View source
Position
NHS Digital is unable to comment further on HJIS design and functionality under the current contractual arrangements.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action. View source See 6 more positions
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AI-generated summary
Anthony John Larcher · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 21 March 2018, Anthony John Larcher, a serving prisoner at HMP Guys Marsh, was found in his cell. The report identifies concerns about monitoring prisoners under the influence of psychoactive substances, the lack of round-the-clock healthcare, healthcare involvement in ACCT reviews, the accessibility of medical information, and the reception of prisoners arriving in large cohorts.
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 SystmOne to make vital prison healthcare information readily identifiable
Wider context from the report “iv. I am concerned that vital information contained within a prisoner’s medical health records stored on SystmOne, could be missed due to fact the software is more adapted to GP practice than prison healthcare . This could result in a future death and I request consideration is given to adapting SystmOne for better use in prisons to ensure information, especially where there are complex care needs, is easily assessable and highlighted to avoid crucial information regarding a patient’s care and safety being missed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to identify prisoners’ health information during large-cohort reception
Wider context from the report “v. I have concerns with the movement of prisoners around the prison estate in large cohorts as it could result in information regarding a prisoner’s health not being identified which could result in a lack of healthcare provision to the prisoner which could result in a future death. I therefore request that consideration be given to the review of the processes when large cohorts are received at prisons and the resources available to prison and healthcare staff prior to the arrival of the prisoner and during the progression of the prisoners through the reception process.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 observations and welfare checks for prisoners found under the influence of psychoactive substances
Wider context from the report “i. There could be future deaths across the prison estate nationally due to a lack of observations and welfare checks upon prisoners who are found under the influence of Spice and I request consideration be given to the rolling out of the local processes adopted at HMP Guys Marsh, nationally. This includes the roll out of their Welfare Checks Policy, the Persistent Psychoactive Substances Intervention Plan (PPSIP) and the Custodial Officer Intermediate Life Support initiative (COILS).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 healthcare staff attendance at ACCT reviews
Wider context from the report “iii. I have concerns that future deaths could occur due to the lack of attendance of healthcare staff at ACCT reviews, especially where the ACCT is closed . I request that consideration is given to providing guidance nationally by way of a safety bulletin or an update to the ACCT version 6 guidance and in the new PSI to be released in the future on the policy on management of prisoners at risk of harm to self, to others and from others, ensuring the attendance of healthcare staff at all ACCT reviews.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 24-hour healthcare across the prison estate
Wider context from the report “ii. I have concerns that future deaths could occur due to the lack of 24 hour healthcare across the prison estate . I would therefore request consideration be given to the provision of healthcare to all prisons 24 hours a day, 7 days a week.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide prison sites access to integrated summary care records containing significant health information, medication and allergy details.
Verbatim wording from the response “All sites have access to the integrated summary care record which houses the latest information regarding a patient’s significant health such as Diabetes, Mental health, for instance, along with regular medication and allergies. This is the same functionality available to other clinicians outside which can be accessed to verify the patient’s condition at that time.” Source location 2021-0356-Response-from-NHS-England-and-NHS-Improvement_Published
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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 SystmOne links to PNOMIS and enable community-record access through GP2GP electronic transfer.
Verbatim wording from the response “Further improvements are planned over the next year to include the ability to link with PNOMIS and the capacity to access community records through GP2GP electronic transfer and, from 2022 should a patient wish to register with the detained estate as their GP practice the full medical record will be sent to the prison via GP2GP.” Source location 2021-0356-Response-from-NHS-England-and-NHS-Improvement_Published
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update healthcare reception and secondary-screening templates, then apply lessons learned across the male estate.
Verbatim wording from the response “Further I can confirm that a review and update of the reception and secondary screening templates for healthcare is ongoing, and this is primarily within the female estate at present. This programme of work package will conclude by April 2022 and then, using lessons learned, the same system will be applied to the male estate during 2022.” Source location 2021-0356-Response-from-NHS-England-and-NHS-Improvement_Published
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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 reception healthcare staff access to digital person escort records before arrivals to identify risks and support correct reception processes.
Verbatim wording from the response “Progress in this area has already been made. Digital Person escort record (DPER) has been live across the prison estate since November 2020. All reception healthcare staff should have access to the DPER prior to arrival of persons at the site. This platform highlights risks pertaining to patients arriving and can be used to ensure the correct processes are followed at reception for healthcare teams.” Source location 2021-0356-Response-from-NHS-England-and-NHS-Improvement_Published
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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 Maintain prison-specific SystmOne templates and prescribing modules adapted for secure healthcare settings.
Verbatim wording from the response “4. Consideration is given to adapting SystmOne for better use in prisons to ensure information, especially where there are complex care needs, is easily assessable (sic) and highlighted to avoid crucial information regarding a patient’s care and safety being missed.” Source location 2021-0356-Response-from-NHS-England-and-NHS-Improvement_Published
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt the Primary Care Registration Management system for HMPPS healthcare when delivered.
Verbatim wording from the response “8) Additionally, NHS Digital is currently supporting HJIS in the following related ways, and considers that these activities will also support improved access to a patient’s medical records within the HMPPS estate and between this and wider primary care:” Source location 2021-0356-Response-from-NHS-Digital_Published
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support the HJIS transformation programme rolling out new Spine functionality across detained-estate sites.
Verbatim wording from the response “8) Additionally, NHS Digital is currently supporting HJIS in the following related ways, and considers that these activities will also support improved access to a patient’s medical records within the HMPPS estate and between this and wider primary care:” Source location 2021-0356-Response-from-NHS-Digital_Published
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider the concern when developing capabilities for the HJIS re-procurement.
Verbatim wording from the response “7) As part of supporting the re-procurement NHS Digital will consider this matter of concern when developing of the set of capabilities for the HJIS re-procurement, and additionally would welcome the opportunity to speak to the witness that made the observations about SystmOne in order to gather more detailed input.” Source location 2021-0356-Response-from-NHS-Digital_Published
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt GP2GP to enable electronic transfer of patient records into HJIS when patients enter the detained estate.
Verbatim wording from the response “8) Additionally, NHS Digital is currently supporting HJIS in the following related ways, and considers that these activities will also support improved access to a patient’s medical records within the HMPPS estate and between this and wider primary care:” Source location 2021-0356-Response-from-NHS-Digital_Published
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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 bespoke prison SystmOne module, templates and integrated summary care record are considered adequate existing adaptations for accessing and highlighting relevant patient information.
Verbatim wording from the response “4. Consideration is given to adapting SystmOne for better use in prisons to ensure information, especially where there are complex care needs, is easily assessable (sic) and highlighted to avoid crucial information regarding a patient’s care and safety being missed.” Source location 2021-0356-Response-from-NHS-England-and-NHS-Improvement_Published
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 HMPPS is responsible for responding to national guidance and ensuring healthcare attendance at reviews of prisoners at risk.
Verbatim wording from the response “3. Consideration is given to providing guidance nationally by way of a safety bulletin or an update to the ACCT V6 guidance and in the new PSI to be released in the future on the policy on management of prisoners at risk of harm to self, to others and from others, ensuring the attendance of healthcare at all ACCT reviews.” Source location 2021-0356-Response-from-NHS-England-and-NHS-Improvement_Published
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 HMPPS is responsible for deciding whether local welfare, substance intervention and life-support processes should be rolled out nationally.
Verbatim wording from the response “1. Consideration be given to the rolling out of the local processes adopted at HMP Guys Marsh, nationally. This includes the roll out of Welfare Checks Policy, the Persistent Psychoactive Substances Intervention Plan (PPSIP), and the Custodial Officer Intermediate Life Support initiatives (COILS).” Source location 2021-0356-Response-from-NHS-England-and-NHS-Improvement_Published
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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 needs-based commissioning and round-the-clock external, emergency, general-practitioner and first-responder access are considered sufficient without universal onsite 24/7 healthcare.
Verbatim wording from the response “All prisons have a health needs assessment (HNA) carried out prior to services being commissioned. This ensures the correct level of healthcare is delivered for the population need.” Source location 2021-0356-Response-from-NHS-England-and-NHS-Improvement_Published
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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 NHSEI sets HJIS policy and holds the bespoke HJIS contract, rather than NHS Digital.
Verbatim wording from the response “1) The IT system used in HM Prison and Probation Service (HMPPS) healthcare settings is known as the health and justice information service (HJIS). HJIS is provided by an independent private sector IT supplier called TPP (tpp-uk.com) pursuant to a contract with NHS England and Improvement (NHSEI). HJIS is a modified version of TPP’s SystmOne product.” Source location 2021-0356-Response-from-NHS-Digital_Published
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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 Matters of concern i, ii, iii and v do not relate to NHS Digital, so it has no comment on them.
Verbatim wording from the response “We do not consider that matters of concern i, ii, iii or v relate to NHS Digital and thus have no comment on these.” Source location 2021-0356-Response-from-NHS-Digital_Published
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS Digital is unable to comment further on HJIS design and functionality under the current contractual arrangements.
Verbatim wording from the response “5) Therefore, NHS Digital is unable to comment further on the current design and functionality for HJIS.” Source location 2021-0356-Response-from-NHS-Digital_Published
Open published response
Concerns raised 8 Failure to protect questionnaire answers from alteration View source Failure to flag refusal to share prescribing information for further enquiry View source Lack of central tracking of prescribed and dispensed drugs View source Lack of required face-to-face consultation before dispensing drugs View source Inadequate questionnaire on the person's medical history View source Failure to notify the person's GP of prescribed drugs View source Limited regulation of the prescribing company View source Failure to prevent drug selection before prescriber contact View source See 5 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.
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AI-generated summary
Jamie Francis O'Connor · 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
Jamie O’Connor was found deceased in the garden of his home in Leicester on 14 October 2018 after his mother became concerned that he was not responding to phone calls. The report identified concerns about online prescribing, including the lack of central tracking, limited information sharing with GPs, no required face-to-face consultation, limited questionnaires, patients requesting specific drugs, and limited regulation; the inquest concluded that this was a drug-related death and recorded the cause as ████████ toxicity.
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 protect questionnaire answers from alteration
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed ;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to flag refusal to share prescribing information for further enquiry
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 central tracking of prescribed and dispensed drugs
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 required face-to-face consultation before dispensing drugs
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed ;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 questionnaire on the person's medical history
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 notify the person's GP of prescribed drugs
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 regulation of the prescribing company
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 prevent drug selection before prescriber contact
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber ;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” Open source report
Concerns raised 2 Lack of mental health inpatient provision for people aged 14-25 View source Failure to provide age-appropriate transitional care when mental health inpatients turn 18 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
Sky Louise Rollings · 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
Sky Louise Rollings was transferred from a child and adolescent mental health hospital to an adult mental health unit on 4 November 2019 and died at Royal Stoke University Hospital on 9 November 2019, following an incident at Harplands Hospital. The inquest heard concerns about differences between child and adult mental health care and the lack of inpatient provision for people aged 14 to 25, which was considered to create a risk of further deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of mental health inpatient provision for people aged 14-25
Wider context from the report “During the inquest evidence was heard about the differences in the way CAMHS Hospitals and Adult mental Health Hospitals approached the care of the patients on their wards. When hearing evidence during the inquest it was established that when a child turned 18, and was a patient on a Mental health ward, once transferred to an adult Mental Health Hospital they would immediately be treated in accordance with the adult provisions.
It was accepted that there is no provision there is currently no one in-patient provision for people between the ages of 14-25 . It was also accepted that simply because a child becomes 18 does not mean that they are an adult. The lack of this provision in a mental health in-patient setting leads me to conclude that there is a risk of further deaths resulting .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 age-appropriate transitional care when mental health inpatients turn 18
Wider context from the report “During the inquest evidence was heard about the differences in the way CAMHS Hospitals and Adult mental Health Hospitals approached the care of the patients on their wards. When hearing evidence during the inquest it was established that when a child turned 18, and was a patient on a Mental health ward, once transferred to an adult Mental Health Hospital they would immediately be treated in accordance with the adult provisions .
It was accepted that there is no provision there is currently no one in-patient provision for people between the ages of 14-25. It was also accepted that simply because a child becomes 18 does not mean that they are an adult. The lack of this provision in a mental health in-patient setting leads me to conclude that there is a risk of further deaths resulting.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing individualised discharge and admission planning, involving relevant professionals and families, addresses transition between child and adult services.
Verbatim wording from the response “Discharge and admission planning processes are in place, and someone would not ‘immediately be treated in accordance with the adult provisions’. The development and clinical decision making in a young person’s care plan and discharge plan are considered by the young person’s current Tier 4 CAMHS provider’s clinical team. This includes multi-agency/ professionals e.g. social worker, community mental health services, the young person and their family’s views and again is individualised to each patient’s needs and circumstances.” Source location 2021-0354-Response-from-NHS-England_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A single 14–25 inpatient ward is not recommended because developmental differences and safeguarding risks could place vulnerable young people at risk.
Verbatim wording from the response “There are safeguarding concerns and implications that need to be taken into consideration in having young people under 18 years and those over 18 years on the same ward, which will usually mean requiring increased observations (which places additional pressure on staffing and can feel restrictive for young people themselves).” Source location 2021-0354-Response-from-NHS-England_Published
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 Young people are not automatically transferred to adult mental health wards when they turn 18.
Verbatim wording from the response “In response to your first concern I can confirm that young people are not all automatically transferred at 18 year of age. Where it is feasible for their episode of” Source location 2021-0354-Response-from-NHS-England_Published
Open published response
Concerns raised 7 Inadequate clinical advisor expertise and assessment of patient condition View source Insufficiently robust and discriminatory NHS abdominal pain pathway View source Failure of 111 call handlers to correctly complete the algorithm View source Misleading designation of 111 call handlers as health advisors View source Failure to provide the public with clear information about the 111 service role, capability and call-handler qualifications View source Failure to recognise complex 111 cases requiring transfer to a more senior member of the service View source Failure of the 111 algorithm and service system to accommodate underlying disabilities and inability to verbalise View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Hannah Elizabeth ROYLE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Hannah Elizabeth ROYLE, a 16-year-old girl with severe learning disability, developed diarrhoea and vomiting before suffering a cardiorespiratory arrest on the way to hospital. She was diagnosed with a massive gastric volvulus and later sustained an irreversible hypoxic brain injury; she was declared brainstem dead on 1 July 2020. The report raised concerns about inadequate 111 triage, insufficient accommodation of disabilities, the clinical advisor’s assessment, public understanding of the service, misleading terminology, and the abdominal pain pathway.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequate clinical advisor expertise and assessment of patient condition
Wider context from the report “3. The skill and expertise of the ‘clinical advisor’ was wholly inadequate for her position as she had no contemporaneous or relevant experience in working in an emergency department as a nurse . She was also insufficiently robust in her assessment and understanding of Hannah’s condition when the call handler contacted her for advice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust and discriminatory NHS abdominal pain pathway
Wider context from the report “6. The NHS pathway for ‘Abdominal Pain’ is insufficiently robust or sufficiently discriminatory to effectively deal with the myriad of potential symptoms associated with this complaint .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 111 call handlers to correctly complete the algorithm
Wider context from the report “1. Both calls to the 111 service were significantly non-compliant; the call handlers did not correctly complete the algorithm , they did not take into consideration Hannah’s disabilities and inability to verbalise, they failed to recognise Hannah as a complex case requiring transfer to a more senior member of the 111 service despite Hannah’s parents providing sufficient information for that to be the case.
2. The 111 service does not have a sufficiently robust system to manage members of the public with underlying disabilities in that no accommodation is given for it in the completion of the algorithm.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Misleading designation of 111 call handlers as health advisors
Wider context from the report “5. The 111 service is not a ‘diagnostic’ service yet the ‘call handlers’ have been renamed ‘health advisors’ . This is misleading to the public as it implies professionalism which is untrue given their underlying skills and unsubstantiated given it is their role to complete an algorithm.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 the public with clear information about the 111 service role, capability and call-handler qualifications
Wider context from the report “4. Members of the public who contact the 111 are ill-informed with a real risk they are being misled over the role and capability of the 111 service . There is little clarity or understanding by the public that it is based on following and completing an algorithm by individuals who have no need for any qualification in health care and who will only receive a short training programme after they are employed . Hannah’s parents indicated that if they knew this, they would have opted to ring 999 and the outcome would have been different.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 complex 111 cases requiring transfer to a more senior member of the service
Wider context from the report “1. Both calls to the 111 service were significantly non-compliant; the call handlers did not correctly complete the algorithm, they did not take into consideration Hannah’s disabilities and inability to verbalise, they failed to recognise Hannah as a complex case requiring transfer to a more senior member of the 111 service despite Hannah’s parents providing sufficient information for that to be the case.
2. The 111 service does not have a sufficiently robust system to manage members of the public with underlying disabilities in that no accommodation is given for it in the completion of the algorithm.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 111 algorithm and service system to accommodate underlying disabilities and inability to verbalise
Wider context from the report “1. Both calls to the 111 service were significantly non-compliant; the call handlers did not correctly complete the algorithm, they did not take into consideration Hannah’s disabilities and inability to verbalise, they failed to recognise Hannah as a complex case requiring transfer to a more senior member of the 111 service despite Hannah’s parents providing sufficient information for that to be the case.
2. The 111 service does not have a sufficiently robust system to manage members of the public with underlying disabilities in that no accommodation is given for it in the completion of the algorithm .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop training materials and lead provider sessions supporting Health Advisors to identify and manage complex calls.
Verbatim wording from the response “A key element of healthcare delivery is recognising when one is at the limit of one’s knowledge or understanding and escalating the matter appropriately. An important safety feature within NHS Pathways is the identification of a ‘complex call’. A complex call is defined as ‘any call which isn’t straightforward and where the Health Advisers determines that they are working at or beyond the limits of their knowledge’. In addition to this broad definition of a ‘complex call’, the following situations would also be classed as ‘complex’:” Source location 2021-0327-Response-from-NHS-Digital_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue reviewing NHS Pathways clinical content using clinical issues, feedback, evidence, guidance and Coroner feedback, with Coroner referrals submitted to the governance group.
Verbatim wording from the response “The NHS Pathways content is continually under review to take account of clinical issues, user feedback, the latest available data and evidence, guidelines from Royal Colleges and other respected bodies and Coroner feedback. Any changes to NHS Pathways clinical content are overseen by the National Clinical Governance Group (NCGG) and Coroner referrals are submitted to NCGG as a standing agenda item.” Source location 2021-0327-Response-from-NHS-Digital_Published
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 Release additional learning content on learning disabilities and telephone communication within mandatory training for NHS 111 and 999 staff.
Verbatim wording from the response “At the time of Miss Royle’s inquest The NHS Pathways Training Team were in the process of developing additional learning content for all users of the system. This has subsequently been released and the content of this new material focuses on:” Source location 2021-0327-Response-from-NHS-Digital_Published
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 Review by NHS Pathways and relevant Royal Colleges concluded that abdominal pain questioning robustly triages possible bowel obstruction and requires no further changes.
Verbatim wording from the response “6. The NHS pathway for ‘Abdominal Pain’ is insufficiently robust or sufficiently discriminatory to effectively deal with the myriad of potential symptoms associated with this complaint.” Source location 2021-0327-Response-from-NHS-Digital_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing NHS Pathways complex-call and Early Exit functions provide appropriate support for callers with learning or developmental needs.
Verbatim wording from the response “As set out in my witness statement to HM Assistant Coroner dated 22 July 2021, NHS Pathways is a comprehensive decision support system, which assesses symptoms presented at the time of a call and signposts to next level of care. Therefore medical history (including disabilities) is not routinely enquired about as it could delay assessment of life-threatening symptoms, and it would not be clinically safe for non-clinical Health Advisors to assess the impact of a patient’s medical history. It would also not be safe or appropriate to apply blanket rules based on the presence of learning disabilities. However, where a certain medical history is relevant to a specific clinical problem, then NHS Pathways will present relevant questions to be asked. For example, within the chest pain pathway, the caller is asked if they have ever been diagnosed with a heart condition.” Source location 2021-0327-Response-from-NHS-Digital_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is responsible for responding to concerns about public understanding of 111's role and the use of the term health advisor.
Verbatim wording from the response “4. Members of the public who contact the 111 are ill-informed with a real risk they are being misled over the role and capability of the 111 service. There is little clarity or understanding by the public that it is based on following and completing an algorithm by individuals who have no need for any qualification in health care and who will only receive a short training programme after they are employed. Hannah’s parents indicated that if they knew this, they would have opted to ring 999 and the outcome would have been different.” Source location 2021-0327-Response-from-NHS-Digital_Published
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 111 provider is responsible for setting clinician employment criteria and conducting ongoing clinician audit and performance management.
Verbatim wording from the response “Safe and appropriate use of NHS Pathways by NHS care providers is governed by way of a ‘Licence to Use’. The ‘Licence to Use’ is managed by NHS Digital and all providers using NHS Pathways must enter into and comply with it. It defines the type of Clinician that can potentially receive training to use NHS Pathways in a clinical capacity as follows:” Source location 2021-0327-Response-from-NHS-Digital_Published
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 South East Coast Ambulance Service is responsible for responding to concerns about non-compliant 111 calls and escalation failures.
Verbatim wording from the response “correctly complete the algorithm, they did not take into consideration Hannah’s disabilities and inability to verbalise, they failed to recognise Hannah as a complex case requiring transfer to a more senior member of the 111 service despite Hannah’s parents providing sufficient information for that to be the case” Source location 2021-0327-Response-from-NHS-Digital_Published
Open published response
28 Sep 2021 Richard Boateng · Prevention of Future Deaths report South London
View report summary
Concerns raised 3 Lack of practical guidance for police conveyance of patients to hospital when ambulances are unavailable View source Lack of guidance for surgeries on managing non-clinical judgments about appointment urgency View source Failure to update and clarify ambulance-service guidance for crews and control staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Richard Boateng · 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
Richard Boateng became very unwell after contacting his GP surgery and was later found on a street bench. Police and ambulance services attended, but he died from Covid 19 shortly after arriving at hospital; concerns included the handling of urgent GP calls, communication between ambulance and police services, and practical guidance for police when ambulances were 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 practical guidance for police conveyance of patients to hospital when ambulances are unavailable
Wider context from the report “(3) College of Policing. Due to the Covid pandemic, no ambulances were available when police attended to Richard. The Metropolitan Police Service had a policy that permitted conveying patients to hospital in an emergency if no ambulances were available. However, the policy included no practical guidance as to how that could be achieved mitigating the risks . I heard that the Metropolitan Police Service is updating the guidance. However, I am concerned that other forces across the country may also lack such practical guidance , which is of particular concern due to ongoing pandemic and the demands that may continue of ambulance services.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for surgeries on managing non-clinical judgments about appointment urgency
Wider context from the report “(1) NHS England. A call to the GP surgery the day before Richard’s death was taken by a receptionist who arranged a routine appointment. She was not a clinician and only had on the job training. The surgery has since introduced a system called Klinik which is safer. It prompts questions and uses an algorithm to alert any urgent or emergency calls that are then flagged. All calls are also reviewed by clinicians. However, I am concerned that other surgeries may employ non-clinicians who may be required to make judgments as to the urgency of appointments , and there is no guidance available to surgeries as to how to mitigate the risks 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 update and clarify ambulance-service guidance for crews and control staff
Wider context from the report “(2) London Ambulance Service. The GP called LAS concerned about Richard’s welfare. LAS attended his home address. Richard was not there. The LAS paramedic advised his sister to call the police. The LAS quality manager accepted in evidence that it would have been better to have taken her number and to pass it on to the police to make contact. I was told that national guidance on this issue was published in the summer. To date, neither guidance to crews nor to control had been updated to make the LAS guidance clearer to those applying it .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Digital First Primary Care guidance for implementing online consultations, including clinical safety, risk management, incident reporting, and limits on online triage.
Verbatim wording from the response “Our Digital First Primary Care (DFPC) guidance for the implementation of Online Consultations puts a lot of focus on safety, though not specifically on the role of non-clinical staff: https://www.england.nhs.uk/wp-content/uploads/2020/01/online-consultations-implementation-toolkit-v1.1-updated.pdf. This provides guidance on:” Source location 2021-0335-Response-from-NHS-England-and-NHS-Improvement_Published
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 care-navigation training materials and funding to support receptionist-led information gathering and emergency-symptom identification.
Verbatim wording from the response “I can confirm that ‘Care Navigation’ as undertaken by receptionists, was fully supported in the NHS GP Forward View, with further training material and funding provided to support its implementation: https://www.england.nhs.uk/blog/plotting-the-right-path-with-care-navigators/.” Source location 2021-0335-Response-from-NHS-England-and-NHS-Improvement_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a training programme with Health Education England for clinical and non-clinical staff supporting care navigation and emergency-symptom identification.
Verbatim wording from the response “We have developed a training pack for administrative staff which is intended to help support them with information gathering, care navigation and identifying emergency symptoms. The training pack is attached.” Source location 2021-0335-Response-from-NHS-England-and-NHS-Improvement_Published
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 Each individual GP practice is responsible for ensuring its staff are suitably trained and experienced for delegated tasks.
Verbatim wording from the response “It is the responsibility of each individual GP practice to ensure all staff are suitably trained and experienced to undertake the tasks that they are delegated.” Source location 2021-0335-Response-from-NHS-England-and-NHS-Improvement_Published
Open published response
16 Sep 2021 Maya ZAB · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 4 Inability of some households to purchase balanced, good-quality nutrition for children View source Failure of other professionals, friends and family to report concerns about children’s health View source Insufficient one-to-one consultations for health professionals to identify signs of anaemia in children View source Increased incidence of severe nutritional anaemia and associated deaths in children 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
Maya ZAB · 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
Maya Zab died from multi-organ failure associated with chronic severe microcytic hypochromic anaemia and severe iron deficiency on 6 August 2020. The report raised concerns about increased severe nutritional anaemia and deaths among children in the Yorkshire & Humber region during 2020, with possible indirect effects of the pandemic including fewer consultations, reduced social contact, and widening socioeconomic inequalities.
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 Inability of some households to purchase balanced, good-quality nutrition for children
Wider context from the report “During the evidence it became clear that in the Yorkshire & Humber region there has been an increased incidence of severe nutritional anaemia in 2020 in a paediatric setting, resulting in 2 deaths, Maya’s death being one of the two. The witness had not seen any deaths previously in her career.
The witness had consulted 9 colleagues over the data. They surmise that a number of factors arising indirectly from the pandemic may explain the findings:
• The “stay at home” message resulted in less 1 to 1 consultations, so health professionals were not able to spot the signs of anaemia
• Limitation of social contact meant other professionals and friends and family were not able to report concerns about a child’s health
• Widening of socio-economic inequalities (including unemployment and reduced household earning capacities) means that certain members of society are not able to purchase a balanced,good quality nutrition for their children
I accept that these are not factors that have been scientifically tested, but nevertheless the increase in the incidents of anaemia and the deaths that are arising are a matter of concern
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 other professionals, friends and family to report concerns about children’s health
Wider context from the report “During the evidence it became clear that in the Yorkshire & Humber region there has been an increased incidence of severe nutritional anaemia in 2020 in a paediatric setting, resulting in 2 deaths, Maya’s death being one of the two. The witness had not seen any deaths previously in her career.
The witness had consulted 9 colleagues over the data. They surmise that a number of factors arising indirectly from the pandemic may explain the findings:
• The “stay at home” message resulted in less 1 to 1 consultations, so health professionals were not able to spot the signs of anaemia
• Limitation of social contact meant other professionals and friends and family were not able to report concerns about a child’s health
• Widening of socio-economic inequalities (including unemployment and reduced household earning capacities) means that certain members of society are not able to purchase a balanced,good quality nutrition for their children
I accept that these are not factors that have been scientifically tested, but nevertheless the increase in the incidents of anaemia and the deaths that are arising are a matter of concern
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 one-to-one consultations for health professionals to identify signs of anaemia in children
Wider context from the report “During the evidence it became clear that in the Yorkshire & Humber region there has been an increased incidence of severe nutritional anaemia in 2020 in a paediatric setting, resulting in 2 deaths, Maya’s death being one of the two. The witness had not seen any deaths previously in her career.
The witness had consulted 9 colleagues over the data. They surmise that a number of factors arising indirectly from the pandemic may explain the findings:
• The “stay at home” message resulted in less 1 to 1 consultations, so health professionals were not able to spot the signs of anaemia
• Limitation of social contact meant other professionals and friends and family were not able to report concerns about a child’s health
• Widening of socio-economic inequalities (including unemployment and reduced household earning capacities) means that certain members of society are not able to purchase a balanced,good quality nutrition for their children
I accept that these are not factors that have been scientifically tested, but nevertheless the increase in the incidents of anaemia and the deaths that are arising are a matter of concern
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Increased incidence of severe nutritional anaemia and associated deaths in children
Wider context from the report “During the evidence it became clear that in the Yorkshire & Humber region there has been an increased incidence of severe nutritional anaemia in 2020 in a paediatric setting, resulting in 2 deaths , Maya’s death being one of the two. The witness had not seen any deaths previously in her career.
The witness had consulted 9 colleagues over the data. They surmise that a number of factors arising indirectly from the pandemic may explain the findings:
• The “stay at home” message resulted in less 1 to 1 consultations, so health professionals were not able to spot the signs of anaemia
• Limitation of social contact meant other professionals and friends and family were not able to report concerns about a child’s health
• Widening of socio-economic inequalities (including unemployment and reduced household earning capacities) means that certain members of society are not able to purchase a balanced,good quality nutrition for their children
I accept that these are not factors that have been scientifically tested, but nevertheless the increase in the incidents of anaemia and the deaths that are arising are a matter of concern
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with NHS Business Services Authority to raise awareness and uptake of the Healthy Start programme.
Verbatim wording from the response “It was agreed that working with the NHS Business Services Authority (NHS BSA) to raise the profile and uptake of the Healthy Start programme would benefit both” Source location 2021-0316-Response-from-NHS-England_Published
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 Repatriate redeployed public health nurses to health visiting services.
Verbatim wording from the response “We recognise the impact the pandemic has had on the delivery of health visiting services. With the onset of COVID-19, some public health nurses were redeployed, however I can confirm that they were all repatriated by the end of July 2020.” Source location 2021-0316-Response-from-NHS-England_Published
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 Transfer Healthy Start support from paper vouchers to digital cards.
Verbatim wording from the response “The Healthy start programme helps parents with children under the age of 4 and pregnant women to buy healthy food and milk. The scheme is in the process of transferring from paper vouchers to a digital cards, this will support quicker application decisions, allow use of the cards anywhere that accepts Mastercard®, automatic top up every 4 weeks, allows partial use of allowance (not previously available) and is discreet payment option.” Source location 2021-0316-Response-from-NHS-England_Published
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 Advise services not to redeploy professionals supporting children and families, and support provision to vulnerable families.
Verbatim wording from the response “In response to Winter Planning in 2020, Public Health England and NHSEI Chief Nurses, together with the Local Government Association, wrote to Directors of Nursing across the country to advise that professionals supporting children and families, such as health visitors, school nurses, designated safeguarding officers and nurses supporting children with special educational needs, should not be redeployed to other services and should be supported to provide services through pregnancy, early years and to the most vulnerable families. (Joint letter on Winter Planning: Support to Children and Families, 7 October 2020 | Local Government Association.)” Source location 2021-0316-Response-from-NHS-England_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish an updated health visiting and school nursing delivery model with commissioning guidance.
Verbatim wording from the response “Further an updated health visiting and school nurse service delivery model, together with commissioning guidance, was also published in March 2021. (Health visiting and school nursing service delivery model - GOV.UK (www.gov.uk).)” Source location 2021-0316-Response-from-NHS-England_Published
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 Restore NHS services following pandemic disruption.
Verbatim wording from the response “Whilst contact with the NHS was reduced during the pandemic, there was also a clear narrative that the NHS remains open for patients who need care, and this remains the message. NHSEI is working hard to restore services across the country.” Source location 2021-0316-Response-from-NHS-England_Published
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 National and regional data do not show a significant increase in malnutrition or iron-deficiency anaemia.
Verbatim wording from the response “National data sets do not show any national or regional increases in malnutrition. The data used was the secondary user service (SUS) data in the NHS England national clinical data repository (NCDR), the equivalent data is available on the NHS Digital website, where the data is available as a provisional dataset.” Source location 2021-0316-Response-from-NHS-England_Published
Open published response
7 Sep 2021 Roger Phelps · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Delays in returning inpatient swab results 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
Roger Phelps · 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
Roger Phelps was admitted to Tameside General Hospital with deteriorating cardiac function and remained on a general medical ward because a Heart Unit bed was unavailable. He contracted Covid-19 as an inpatient, developed sepsis and deteriorated before dying on 4 November 2020; post-mortem examination also identified endocarditis. The principal concern was delays of more than 48 hours in Covid-19 swab results, which could leave infectious patients on non-Covid wards and expose other patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in returning inpatient swab results
Wider context from the report “The inquest heard that whilst the trust were following PHE/NHS guidance in relation to regularity of swabbing of inpatients it was regularly taking in excess of 48 hours for swab results to be returned to the trust . The impact of the delay was that infectious asymptomatic patients were remaining on non Covid wards for some days and spreading infection to other patients .
The trust where Mr Phelps was a patient had now resolved the issue of delay results by buying additional on-site testing machines and results were back within hours rather than days.
It was unclear from evidence given at the inquest whether the issue of delayed results had been addressed by other trusts in a similar way or if the risk remained to other patients in other trusts .
” Open source report
6 Sep 2021 Bituin Pizzaro Pimlott · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Lack of clear guidance on when GPs should directly refer patients to the crisis team View source Failure to provide face-to-face mental health assessment when clinically needed View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Bituin Pizzaro Pimlott · 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
Bituin Pizzaro Pimlott was found suspended from a ligature at the garage of her home on 22 February 2021. The inquest heard that she had been struggling with her mental health and that telephone consultations were used instead of face-to-face appointments during the pandemic. Concerns included the lack of referral by her GP practice to the crisis team and uncertainty about the guidance for making such referrals.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance on when GPs should directly refer patients to the crisis team
Wider context from the report “The inquest heard evidence that Mrs Pimlott had been struggling with her mental health in the weeks preceding her death and had contacted her GP on a number of occasions with anxiety and depression. She was prescribed medication but expressed concerns about the impact of the medication. Telephone consultations rather than face to face appointments continued to be used with her due to the pandemic. Pre Covid it was accepted she would have been seen face to face which would have allowed a more comprehensive assessment of her mental health and her reluctance to use medication.
Her GP practice did not refer her to the crisis team, and it was unclear what guidance the practice had for their GPs about when they should refer directly to the crisis team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 face-to-face mental health assessment when clinically needed
Wider context from the report “The inquest heard evidence that Mrs Pimlott had been struggling with her mental health in the weeks preceding her death and had contacted her GP on a number of occasions with anxiety and depression. She was prescribed medication but expressed concerns about the impact of the medication. Telephone consultations rather than face to face appointments continued to be used with her due to the pandemic. Pre Covid it was accepted she would have been seen face to face which would have allowed a more comprehensive assessment of her mental health and her reluctance to use medication.
Her GP practice did not refer her to the crisis team, and it was unclear what guidance the practice had for their GPs about when they should refer directly to the crisis team.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop joint guidance with the Royal College of General Practitioners on choosing remote or face-to-face consultations, including patient safety and safety-netting.
Verbatim wording from the response “Additionally, guidance was developed jointly between NHS England and the Royal College of General Practitioners (RCGP) on Remote vs Face to Face: which to use and when? and RCGP publish a range of guidance and learning materials on their Covid-19 Resource Hub. These resources underline the importance of ensuring patient safety, shared decision making and that an individual’s needs are paramount.” 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 Produce and iteratively update standard operating procedures for safe remote general-practice services during changing pandemic requirements.
Verbatim wording from the response “The coronavirus (COVID-19) pandemic has brought about an unprecedented acceleration in the adoption of delivering NHS services remotely, and standard operating procedures (SOPs) were produced to ensure general practice is able to operate safely in this context. The SOP which was last published (now retired) which is relevant in this matter is attached for reference. I can confirm that SOPs were iterated throughout the pandemic to meet changing needs and requirements since first publication. This SOP was first published in March 2020.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local mental health services and crisis-referral guidance are commissioned and addressed locally by the CCG, which is best placed to respond.
Verbatim wording from the response “Finally in response to your secondary concern regarding unclear guidance for when GP practices should refer directly to the crisis team, I can confirm that Mental Health services are commissioned locally and to this end I note that the local CCG Medical Director has provided you with a separate response detailing relevant information and confirming steps that have been taken. The CCG are best placed to respond to this concern and they have kindly provided me with a copy of their response, the content of which I note, as well as a copy of the leaflet that has been developed and delivered to all households in the area listing the locally available Mental Health crisis facilities. I note that a reminder is also to be sent to all practices confirming the support available.” 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 remote-consultation procedures require safety-focused triage and clinician selection of consultation method according to each patient’s circumstances.
Verbatim wording from the response “The coronavirus (COVID-19) pandemic has brought about an unprecedented acceleration in the adoption of delivering NHS services remotely, and standard operating procedures (SOPs) were produced to ensure general practice is able to operate safely in this context. The SOP which was last published (now retired) which is relevant in this matter is attached for reference. I can confirm that SOPs were iterated throughout the pandemic to meet changing needs and requirements since first publication. This SOP was first published in March 2020.” Source location Response from NHS England
Open published response
6 Sep 2021 Mark Holden · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 NICE guidance failing to address Covid-19-related D-dimer and clotting risks View source Failure of the Lorenzo electronic system to trigger alerts for markedly raised D-dimer results View source Failure to provide physical examination during telephone GP consultations where clinically needed 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
Mark Holden · 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
Mark Thomas Holden was diagnosed with Covid-19 and subsequently developed a deep vein thrombosis in his left calf, which led to a pulmonary embolus. He collapsed at home on 26 February 2021 and attempts to resuscitate him were unsuccessful. Concerns included the lack of a face-to-face GP examination, failure of the electronic system to alert staff to a markedly raised D-Dimer, and NICE guidance not addressing Covid-19-related clotting risks.
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 NICE guidance failing to address Covid-19-related D-dimer and clotting risks
Wider context from the report “3. The inquest heard that there will often be a raised D- Dimmer with Covid-19 and that in addition there is an increased risk of clots with Covid-19. The evidence before the inquest was that the existing NICE guidance used by clinicians does not deal with the Covid-19 aspects/ recognised risks .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 Lorenzo electronic system to trigger alerts for markedly raised D-dimer results
Wider context from the report “2. The D-Dimmer of over 10,000 did not trigger an alert on the Lorenzo electronic system due to how it was reported and the configuration of Lorenzo at that time at the Trust . The Trust have taken steps to change how the reports are input into Lorenzo to ensure a raised D- Dimmer such as this triggers an alert. It was unclear if that learning has been shared across the NHS to other trusts who use Lorenzo to ensure that alerts are triggered.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 physical examination during telephone GP consultations where clinically needed
Wider context from the report “1. The appointment with the GP was via telephone due to Covid. As a result, there was no examination of Mr Holden and no opportunity to identify the DVT which was present at the time of the telephone consultation .
” Open source report
Concerns raised 1 Failure to assess patients' needs and required measures during the admission process 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
Harold Blackshaw · 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
Harold Blackshaw died from COVID-19 on 1 March 2021 after falls, a fractured neck of femur, hip dislocations, surgery and subsequent admissions to hospital and care homes. The report raised concern that Grange Ward lacked an admission process to assess patients’ individual needs and put appropriate falls-prevention measures in place.
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 assess patients' needs and required measures during the admission process
Wider context from the report “During the course of the inquest evidence was given regarding the admission process for patients admitted to the Haywood Hospital. Specifically the rehabilitation ward which Mr Blackshaw was admitted to (“Grange Ward”). It was heard that this ward was primarily for the rehabilitation of elderly patients that were recovering from injuries; some after falls. Some patients were high risk of falls. The evidence given suggested that there was no admission process which assessed the needs of each patient and what measures should be put in place to meet their needs, before they came to the ward, or when they were on the ward . This gives me concern that a future death could result.
” Open source report
24 Aug 2021 Stanislaw Wieslaw ZIELINSKI · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Delays in offering mental health support View source Failure of GP consultation arrangements to support effective communication about deteriorating health View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stanislaw Wieslaw ZIELINSKI · 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
Stanislaw Wieslaw Zielinski’s mental health deteriorated after he reported anxiety and insomnia, with care provided through telephone GP appointments and delays in mental health support. On 20 October 2020, he fell from an upstairs window and sustained multiple fractures and a subdural haematoma; he later died from a cardiac arrest due to a pulmonary embolism following hospitalisation and surgery. The concerns included difficulties communicating his deteriorating condition through telephone consultations and delays in receiving mental health support during the Covid-19 period.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in offering mental health support
Wider context from the report “2. Mental health services were experiencing delays due to operating under the constraints of Covid and staffing issues . As a result there was a delay in offering him support which would have assisted him. The inquest heard that the existing challenges pre Covid for mental health services had been exacerbated by Covid due to an increased need for their services in part as a result of the impact on mental health of isolation during lockdown.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 GP consultation arrangements to support effective communication about deteriorating health
Wider context from the report “1. Pre Covid Mr Zielinski would have been seen face to face rather than through a series of telephone consultations. The inquest heard that he and his family struggled to communicate with the GP to explain his deteriorating health position as a result of how his GP practice was delivering health care . The inquest heard evidence that as a consequence his deteriorating picture was not fully understood by his GP and he was additional anxious as a result of an inability to express his concerns in person.
” 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 Disseminated information to Healthy Minds self-referrers explaining that the service is not urgent response and listing routes to urgent mental health support.
Verbatim wording from the response “Please find below details of information provided (in a letter) to all people who self-refer to Healthy Minds – I can also confirm that this was sent to Mr Zielinski – it does also clarify that Healthy Minds is not an Urgent Response Service and that if the person feels they need to access help urgently, they should utilise one of the numbers listed below. The Urgent Care Helpline is run by staff from Pennine Care NHSFT, who would have access to details of his contacts with mental Health Services.” Source location 2021-0277-Response-from-NHS-England-and-NHS-Improvement_Published.pdf
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National general practice guidance required remote triage and face-to-face appointments where clinically appropriate, addressing concerns about remote-only care.
Verbatim wording from the response “Since the advent of the Covid-19 pandemic general practice has been delivering health care services according to the national General Practice in the Context of Coronavirus Standard Operating Procedure that has been regularly updated. This national guidance was in force at the time of Mr Zielinski’s death. The aim of this Standard Operating Procedure was to ensure general practice was able to provide health care to patients in a safe environment, limiting the opportunity of Covid-19 infections in staff and patients while reducing the number of absences either by infections or self-isolation.” Source location 2021-0277-Response-from-NHS-England-and-NHS-Improvement_Published.pdf
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 mental health referral and appointment occurred within national IAPT response timeframes and standard service expectations.
Verbatim wording from the response “Mr Zielinski self-referred to the Tameside and Glossop Improving Access to Psychological Therapies (IAPT) Services and was triaged on 01 October 2020. He was subsequently sent an appointment letter on 15 October 2020 and offered a first appointment for 21 October 2020. The National timeframes for response for IAPT services are that 75% of all referrals commence treatment within 6 weeks and 95% within 18 weeks. Mr Zielinski’s referral and subsequent appointment were within the stated, and expected, national timeframes and the standard expectations of service delivery.” Source location 2021-0277-Response-from-NHS-England-and-NHS-Improvement_Published.pdf
Open published response
23 Aug 2021 Maurice Leech · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to provide physical examination during GP consultations View source Lack of NICE guidance for consistent management of femur fractures in elderly patients View source Lack of support for vulnerable patients during hospital assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Maurice Leech · 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
Maurice Leech had an accidental fall at Thorncliffe Grange Nursing Home, later diagnosed as a femur fracture, and died there on 30 April 2020 after being discharged for palliative care. Concerns included a telephone GP review without physical examination, lack of support when he attended hospital during Covid, the missed fracture, and the absence of NICE guidance for managing femur fractures in elderly patients, including pain management.
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 physical examination during GP consultations
Wider context from the report “1. The inquest heard evidence that pre Covid Mr Leech would have been examined face to face by the GP rather than a telephone consultation without an examination . The evidence indicated that a physical examination would probably have resulted in Mr Leech being referred back to hospital at an earlier stage.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 NICE guidance for consistent management of femur fractures in elderly patients
Wider context from the report “3. The inquest heard that he was in significant pain from the fracture to the femur. Unlike the position relating to a fracture to the neck of femur there is no NICE guidance for treatment of such fractures to ensure a consistent approach to management of them in the elderly across the NHS . This included in Mr Leech’s case how to effectively manage his pain and the impact of that on his overall health .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of support for vulnerable patients during hospital assessment
Wider context from the report “2. Mr Leech was very vulnerable and a poor historian. Due to Covid he was sent alone to hospital and seen alone there . The evidence before the inquest was that if support had been available a more accurate picture of his baseline and needs would have assisted staff in treating him and potentially identifying that he should not be discharged back to the care home and that a fracture would not have been missed.
” 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 Produce and iteratively update standard operating procedures for safe remote triage and selection of consultation methods in general practice.
Verbatim wording from the response “The coronavirus (COVID-19) pandemic has brought about an unprecedented acceleration in the adoption of delivering NHS services remotely, and standard operating procedures have been produced to ensure general practice is able to operate safely in this context. The relevant published version of the Standard Operating Procedure is here for reference which was iterated throughout the pandemic to meet changing needs and requirements since it was first published” Source location 2021-0279-Response-from-NHS-England-and-NHS-Improvement_Published.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and maintain joint NHS England–RCGP guidance and learning resources on choosing remote or face-to-face consultations, patient safety and shared decision-making.
Verbatim wording from the response “Professional guidance published by the General Medical Council sets out high level principles of good practice expected of everyone when consulting and or prescribing remotely for the patient https://www.gmc-uk.org/ethical-guidance/learning-materials/remote-prescribing-high-level-principles and guidance to support shared decision making https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/decision-making-and-consent.” Source location 2021-0279-Response-from-NHS-England-and-NHS-Improvement_Published.pdf
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 remote-triage procedures and consultation guidance address patient safety and require face-to-face review where clinically appropriate.
Verbatim wording from the response “The coronavirus (COVID-19) pandemic has brought about an unprecedented acceleration in the adoption of delivering NHS services remotely, and standard operating procedures have been produced to ensure general practice is able to operate safely in this context. The relevant published version of the Standard Operating Procedure is here for reference which was iterated throughout the pandemic to meet changing needs and requirements since it was first published” Source location 2021-0279-Response-from-NHS-England-and-NHS-Improvement_Published.pdf
Open published response
23 Aug 2021 Norma Rushworth · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Failure to clearly convey community management advice and risks to community health professionals and families View source Failure of written documentation to cover communication challenges affecting community care View source Failure to monitor deteriorating health early after discharge into the community View source Limited post-discharge support for vulnerable patients in the community View source Lack of support for vulnerable patients and their decision making at outpatient appointments 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
Norma Rushworth · 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
Norma Rushworth underwent surgery for diverticulitis and was later readmitted for emergency surgery after developing an abdominal dehiscence associated with an unidentified wound infection. She deteriorated after developing a chest infection and suffering a cardiac arrest, and died at Tameside General Hospital on 10 October 2020. Concerns included limited support and monitoring after discharge, unclear communication with community health professionals and family, and delayed recognition of her deterioration in the community, with pandemic restrictions contributing to communication difficulties.
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 clearly convey community management advice and risks to community health professionals and families
Wider context from the report “2. The inquest heard that following her discharge back into the community after surgery support and monitoring was limited notwithstanding how vulnerable she was; the complexity of her surgery and the risk she presented. Advice re management of a patient such as her in the community and risks and management of them was not conveyed clearly to community health professionals and to her family . Covid restrictions meant that communication had been difficult, and the written documentation did not cover the challenges this caused. Her deteriorating health in the community was not as a result recognised at an early stage.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 written documentation to cover communication challenges affecting community care
Wider context from the report “2. The inquest heard that following her discharge back into the community after surgery support and monitoring was limited notwithstanding how vulnerable she was; the complexity of her surgery and the risk she presented. Advice re management of a patient such as her in the community and risks and management of them was not conveyed clearly to community health professionals and to her family. Covid restrictions meant that communication had been difficult, and the written documentation did not cover the challenges this caused . Her deteriorating health in the community was not as a result recognised at an early stage.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 monitor deteriorating health early after discharge into the community
Wider context from the report “2. The inquest heard that following her discharge back into the community after surgery support and monitoring was limited notwithstanding how vulnerable she was; the complexity of her surgery and the risk she presented. Advice re management of a patient such as her in the community and risks and management of them was not conveyed clearly to community health professionals and to her family. Covid restrictions meant that communication had been difficult, and the written documentation did not cover the challenges this caused. Her deteriorating health in the community was not as a result recognised at an early stage .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 post-discharge support for vulnerable patients in the community
Wider context from the report “2. The inquest heard that following her discharge back into the community after surgery support and monitoring was limited notwithstanding how vulnerable she was; the complexity of her surgery and the risk she presented . Advice re management of a patient such as her in the community and risks and management of them was not conveyed clearly to community health professionals and to her family. Covid restrictions meant that communication had been difficult, and the written documentation did not cover the challenges this caused. Her deteriorating health in the community was not as a result recognised at an early stage.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 vulnerable patients and their decision making at outpatient appointments
Wider context from the report “1. The inquest heard that due to the pandemic and restrictions Mrs Rushworth was not supported as she would usually have been at outpatient appointments . The inquest heard that this impacted significantly on the quality of the history available to clinicians; support for a vulnerable patient and her decision making .
” Open source report
17 Aug 2021 Steven Antonio Regoli · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2 Failure to provide needed pathways and help to people who do not engage View source Lack of systems to prevent people who do not engage being left solely in family care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Steven Antonio Regoli · 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
Steven Antonio Regoli died on 26 June 2020 at a Lineside location adjacent to Gipsy Lane following a collision with a train. The report identifies concerns that opportunities for more appropriate help, including inpatient care, were not acted upon, and that there were no systems to support people who did not engage with services, leaving families to provide care alone.
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 needed pathways and help to people who do not engage
Wider context from the report “During the inquest, there were clear signs that Steven needed more in depth help as did his family, but due to him not engaging, which was a major part of his symptoms he was never given the pathway or help he needed and there were no systems in place for this to happen . There needs to be systems in place where people who do not engage are not left with family only to care for them.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of systems to prevent people who do not engage being left solely in family care
Wider context from the report “During the inquest, there were clear signs that Steven needed more in depth help as did his family, but due to him not engaging, which was a major part of his symptoms he was never given the pathway or help he needed and there were no systems in place for this to happen. There needs to be systems in place where people who do not engage are not left with family only to care for them .
” Open source report
Concerns raised 2 Failure to ensure allocation of an appropriate Care Co-Ordinator View source Failure of Care Co-Ordinators to carry out required care coordination tasks 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
Rebecca Claire Pykett · 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
Rebecca Claire Pykett, who had a history of mental health difficulties including PTSD, was found deceased at home on 25 February 2019 after intentionally hanging herself using a tie fashioned into a ligature. The concerns identified included the absence of a system to ensure that a Care Co-Ordinator was allocated, and that the expected care co-ordinator role, including timely patient contact and care planning, was not carried out in her case. The report also describes routine allocation of consultant psychiatrists as a “box ticking” exercise to satisfy the patient 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 Failure to ensure allocation of an appropriate Care Co-Ordinator
Wider context from the report “(1) During the course of the inquest evidence was heard in regard to the fact that each patient who is under the care of the CMHT should be allocated a Care Co-Ordinator. This Care Co-Ordinator will be responsible for co-ordinating the care that each CMHT patient will receive.
(2) The allocation of the Care Co-Ordinator was of concern as there was no system to ensure that a Care Co-Ordinator was actually being allocated into this role . What was taking place was that a clinician was being chosen, in Rebecca Pyketts case, her Consultant Psychiatrist who was no, in fact carrying out the role, and tasks expected as a care co-ordinator.
(3) An example would be that the allocated Care Co-Ordinator should be allocated within 5 days, see their patient within 5 days, and complete a care plan. This did not happen in Rebecca Pyketts’ case.
(4) It appears that there was routine allocation of the allocated Consultant Psychiatrists as care co-ordinator . The reason behind this routine allocation was that Lorenzo (the patient record keeping system employed by the north Staffordshire Combined Healthcare NHS Foundation Trust), required this box to be filled in. Therefore the allocation of the Care Co-Ordinator was being dealt with as a “box ticking” exercise , to satisfy the record keeping system.
(5) Once allocated, in this way, it ws clear from the evidence that was produced at inquest that no such role was carried out by the Care Co-Ordinator.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 Care Co-Ordinators to carry out required care coordination tasks
Wider context from the report “(1) During the course of the inquest evidence was heard in regard to the fact that each patient who is under the care of the CMHT should be allocated a Care Co-Ordinator. This Care Co-Ordinator will be responsible for co-ordinating the care that each CMHT patient will receive.
(2) The allocation of the Care Co-Ordinator was of concern as there was no system to ensure that a Care Co-Ordinator was actually being allocated into this role. What was taking place was that a clinician was being chosen, in Rebecca Pyketts case, her Consultant Psychiatrist who was no, in fact carrying out the role, and tasks expected as a care co-ordinator .
(3) An example would be that the allocated Care Co-Ordinator should be allocated within 5 days, see their patient within 5 days, and complete a care plan . This did not happen in Rebecca Pyketts’ case.
(4) It appears that there was routine allocation of the allocated Consultant Psychiatrists as care co-ordinator. The reason behind this routine allocation was that Lorenzo (the patient record keeping system employed by the north Staffordshire Combined Healthcare NHS Foundation Trust), required this box to be filled in. Therefore the allocation of the Care Co-Ordinator was being dealt with as a “box ticking” exercise, to satisfy the record keeping system.
(5) Once allocated, in this way, it ws clear from the evidence that was produced at inquest that no such role was carried out by the Care Co-Ordinator .
” Open source report
16 Jul 2021 Chimezie DANIELS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Difficulty determining the cause of low oxygen saturations amid simultaneous CPAP alarms in medical wards View source Failure of CPAP alarms to distinguish minor mask leaks from total cessation of oxygen supply View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Chimezie DANIELS · 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
Chimezie Daniels died from SARS CoV-2 infection, with pulmonary sarcoidosis also recorded as a cause. At inquest, concern was raised that CPAP machines may use the same alarm for a minor mask leak and a complete cessation of oxygen supply. Multiple simultaneous alarms in a busy medical ward made it more difficult to identify the cause of Mr Daniels’ low oxygen saturations.
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 Difficulty determining the cause of low oxygen saturations amid simultaneous CPAP alarms in medical wards
Wider context from the report “At inquest, I heard that on most CPAP machines, the alarm that sounds for a very small leak from the mask is no different from the alarm that sounds for total cessation in oxygen supply.
Clinicians told me that it would be much more helpful if very serious matters were denoted by an urgent alarm, and less serious matters in another way.
When the alarm on Mr Daniels’ machine sounded, there were four other alarms sounding simultaneously for the four other patients in the bay where he was being nursed . This gave the determination of the cause of his low oxygen saturations an added complexity , particularly at a time in the pandemic when there was so much pressure on beds that CPAP patients were being nursed on medical wards rather than in the high dependency unit .
I appreciate that there will not always be an intention to connect to an oxygen supply. Nevertheless, I am sure that further consideration can be given to the issue that the inquest touching Mr Daniels’ death has highlighted.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 CPAP alarms to distinguish minor mask leaks from total cessation of oxygen supply
Wider context from the report “At inquest, I heard that on most CPAP machines, the alarm that sounds for a very small leak from the mask is no different from the alarm that sounds for total cessation in oxygen supply .
Clinicians told me that it would be much more helpful if very serious matters were denoted by an urgent alarm, and less serious matters in another way .
When the alarm on Mr Daniels’ machine sounded, there were four other alarms sounding simultaneously for the four other patients in the bay where he was being nursed. This gave the determination of the cause of his low oxygen saturations an added complexity, particularly at a time in the pandemic when there was so much pressure on beds that CPAP patients were being nursed on medical wards rather than in the high dependency unit.
I appreciate that there will not always be an intention to connect to an oxygen supply. Nevertheless, I am sure that further consideration can be given to the issue that the inquest touching Mr Daniels’ death has highlighted.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage with the Faculty for Intensive Care Medicine to include disconnection-alarm guidance addressing alarm indications and response urgency.
Verbatim wording from the response “• The national patient safety team continues to work with the Faculty for Intensive Care Medicine to develop guidance on the setting up of breathing circuits and we will engage with them to include guidance on disconnection alarms to ensure staff are aware of what each alarm may be indicating and the relative urgency to respond to an alarm.” Source location 2021-0255-Response-from-NHS-England-and-NHS-Improvement_Published
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 Changes to CPAP alarm design fall within the Medicines and Healthcare products Regulatory Agency’s remit.
Verbatim wording from the response “The main area of concern that you raised within the Preventing Future Deaths report relates to the alarm sound and whether there should be a different sound for ‘serious matters’. This will require a change in the design of the associated medical devices which would fall into the remit of the Medicines and Healthcare products Regulatory Agency (MHRA).” Source location 2021-0255-Response-from-NHS-England-and-NHS-Improvement_Published
Open published response
17 Jun 2021 Leonard Arthur PRITCHARD · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Inadequate supply of mobility aids in the emergency department View source Lack of a clear completion timeframe for mobility aid procurement View source Lack of clear overall responsibility for assessment, selection and procurement of mobility aids View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Leonard Arthur PRITCHARD · 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
Leonard Arthur Pritchard died on 18 February 2021 in Good Hope Hospital after sustaining injuries in an unwitnessed fall from a chair in an A&E cubicle on 12 February 2021. The report raised concerns about an inadequate supply of mobility aids in the emergency department and unclear responsibility and timescales for their assessment, selection and procurement.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequate supply of mobility aids in the emergency department
Wider context from the report “1. During the course of the inquest, I heard evidence that there is an inadequate supply of mobility aids within the emergency department of Good Hope Hospital which are utilised by the Older People Assessment and Liaison (OPAL) team when assessing patient's mobility, and which are given to patients who are identified as requiring an aid. I heard that there are presently 2 zimmer frames, whilst there are 17 cubicles in majors; 5 resuscitation cubicles; 6 trolleys in the new extension of the emergency department; and 8 chairs in the clinical decision unit. I heard from staff that they consider this mobility aid to patient bed ratio was inadequate. There is a clear risk of death for patients who require mobility aids but can not have access to them. The Trust should consider addressing this as a matter of urgency.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 clear completion timeframe for mobility aid procurement
Wider context from the report “2. Linked to 1) above, I heard evidence that procurement discussions are taking place, but from the evidence it is unclear who has overall responsibility for the assessment; selection; and procurement of aids, and neither is it clear when this process will be completed by . The Trust should consider ensuring that this procurement process takes places as a matter of urgency.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of clear overall responsibility for assessment, selection and procurement of mobility aids
Wider context from the report “2. Linked to 1) above, I heard evidence that procurement discussions are taking place, but from the evidence it is unclear who has overall responsibility for the assessment; selection; and procurement of aids , and neither is it clear when this process will be completed by. The Trust should consider ensuring that this procurement process takes places as a matter of urgency.
” 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 Ensure emergency departments in regional hospitals have access to an adequate supply of mobility aids.
Verbatim wording from the response “However I can confirm that we have shared this Regulation 28 Report and both responses with the Regional NHSE/I teams to ensure that they have sight of this potential problem and will ensure that the ED departments in their hospitals have access to an adequate supply of mobility aids.” Source location 2021-0207-Response-from-NHS-England-and-NHS-Improvement_Published
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 Trust’s local response adequately addresses mobility-aid supply and procurement concerns, so no further national response is proposed.
Verbatim wording from the response “I note that your Regulation 28 Report was also sent to University Hospitals Birmingham NHS Trust. The Trust have kindly shared their response and I have seen that the matters of concern have been dealt with and responded too at a local level. Given the content and adequacy of the Trust’s response I do not propose responding further on a national level.” Source location 2021-0207-Response-from-NHS-England-and-NHS-Improvement_Published
Open published response
10 Jun 2021 Clive Edward Rivers · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure of the discharge assessment framework to account for vulnerability to rapid Covid-19 decline View source Delays in discharge planning and Right to Reside assessment View source Failure to provide Covid-19 vaccination to eligible inpatients 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
Clive Edward Rivers · 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
Clive Edward Rivers was admitted to hospital after a fall, contracted Covid-19 while awaiting discharge, and died at home after being discharged to sheltered accommodation with a care package and a requirement to isolate. Concerns included his not being vaccinated while an inpatient, delays in discharge planning during which he contracted Covid-19, and an assessment framework that did not appear to account for his vulnerability to rapid deterioration while isolating at home.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of the discharge assessment framework to account for vulnerability to rapid Covid-19 decline
Wider context from the report “3. The inquest heard that when he was discharged from hospital, he was known to have Covid-19. He was assessed under the national right to reside policy and it was deemed under that policy that he should be discharged back to sheltered accommodation where he would have to self-isolate with carers coming in at set points in the day to support him. He was found deceased by his carers after being left alone. The assessment framework did not appear to take into account his vulnerability to a rapid decline from Covid-19 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 discharge planning and Right to Reside assessment
Wider context from the report “2. He tested negative for Covid-19 at the point he was medically optimised for discharge however delays in discharge planning including the required assessment under the Right to Reside policy meant that whilst awaiting discharge he contracted Covid-19 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 Covid-19 vaccination to eligible inpatients
Wider context from the report “1. Clive Rivers was vulnerable to Covid-19 by reason of his age but had to go into hospital as a result of a fall. He had a longstanding skin condition that caused him a great deal of distress and discomfort. Whilst an inpatient he was prescribed immunomodulatory therapy and the consultant dermatologist wanted him to be vaccinated due to the increased risk Covid-19 presented to him both in terms of catching it and being able to recover from it. The inquest was told that whilst vaccines were available on the hospital site, they were at that time due to NHS policy only for staff not inpatients . Therefore, Mr Rivers was not vaccinated .
” Open source report
Concerns raised 2 Lack of national guidance or standards for sharing medication risk information and care plans with local pharmacies View source Failure to ensure appropriate pharmacy involvement in medication safety plans for mental health patients aged 16–17 View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
SAMANTHA JANE GOULD (Sam) · 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
Sam took a very large quantity of prescribed medication at home in the early hours of 2 September 2018 and died within at most a couple of hours. The local pharmacy had not been told about a safety plan under which Sam’s parents were responsible for her medication. The report identified a concern that, without national action to ensure pharmacies are involved in medication safety plans for mental health patients aged 16–17, similar fatalities could occur.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance or standards for sharing medication risk information and care plans with local pharmacies
Wider context from the report “(1) There did not appear to be any national guidance or standards that directed or encouraged appropriate sharing of risk information and care plans with the local pharmacy. As a result, the pharmacy was unsighted on the fact that the treating psychiatric team had a safety plan involving Sam’s parents being responsible for handling and administering all medication. Had the pharmacy been aware of this plan, it is likely that they would have refused to provide the medication with which Sam overdosed or, at least, contacted Sam’s parents or General Practitioner.
(2) A local protocol has now been introduced whereby the Cambridgeshire and Peterborough Foundation Trust’s Child and Adolescent Mental Health Service ensures that any pharmacy used regularly by their patients aged 16-17 are (where appropriate) advised of relevant care plans, as well as the responsible GP being so informed. This is now to be part of mandatory training for CAMHS prescribing staff and is to be discussed in the local Joint Prescribing Group to ensure better communication between the local NHS Trusts, G.P.s and local pharmacies. Accordingly, action has already been taken in the local area to prevent similar fatalities.
However,
(3) I am concerned that there is a risk of future fatalities if action is not taken at a national level to ensure that pharmacies are appropriately involved in medication safety plans for mental health patients aged 16 – 17, given that such patients may otherwise be able to obtain prescribed medication with which to overdose.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 appropriate pharmacy involvement in medication safety plans for mental health patients aged 16–17
Wider context from the report “(1) There did not appear to be any national guidance or standards that directed or encouraged appropriate sharing of risk information and care plans with the local pharmacy. As a result, the pharmacy was unsighted on the fact that the treating psychiatric team had a safety plan involving Sam’s parents being responsible for handling and administering all medication. Had the pharmacy been aware of this plan, it is likely that they would have refused to provide the medication with which Sam overdosed or, at least, contacted Sam’s parents or General Practitioner.
(2) A local protocol has now been introduced whereby the Cambridgeshire and Peterborough Foundation Trust’s Child and Adolescent Mental Health Service ensures that any pharmacy used regularly by their patients aged 16-17 are (where appropriate) advised of relevant care plans, as well as the responsible GP being so informed. This is now to be part of mandatory training for CAMHS prescribing staff and is to be discussed in the local Joint Prescribing Group to ensure better communication between the local NHS Trusts, G.P.s and local pharmacies. Accordingly, action has already been taken in the local area to prevent similar fatalities.
However,
(3) I am concerned that there is a risk of future fatalities if action is not taken at a national level to ensure that pharmacies are appropriately involved in medication safety plans for mental health patients aged 16 – 17 , given that such patients may otherwise be able to obtain prescribed medication with which to overdose .
” 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 Establish a working group to develop a national approach to sharing medication-safety information with community pharmacies.
Verbatim wording from the response “I have set out in the annex some information that is relevant to this tragic incident and if used appropriately will help us ensure the risk of this tragic incident happening again is minimised. To assist in this I have asked Dr ████████, Deputy Chief Pharmaceutical Officer, to establish a working group to build on the work of the Joint Prescribing Group you mention, with the aim of rolling it out, or an improved approach, across the country within the next 6 months, and then subsequently to ensure that facilities like the Summary Care Record and other digital means are used to their full benefit.” Source location 2021-0186-Response-from-NHS-England-and-NHS-Improvement_Published
Open published response
21 May 2021 Morris REDDINGTON · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Failure to review the electronic Patient Report Form during emergency department handover View source Failure to resolve electronic Patient Report Form access problems View source Limited availability of 24/7 mechanical thrombectomy for acute ischaemic stroke View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Morris REDDINGTON · 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
Morris Reddington died from a rare stroke involving basilar artery thrombosis, likely caused by dissection of the right vertebral artery. The report identified delays in diagnosis and concerns that electronic ambulance handover records were not routinely reviewed, as well as limited out-of-hours access to mechanical thrombectomy. It also raised concerns about the risk of future deaths from failures in patient-information handover and geographical disparities in access to thrombectomy.
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 review the electronic Patient Report Form during emergency department handover
Wider context from the report “The electronic Patient Report Form (‘ePRF’) is an important template which records all of the pre-hospital interaction with the patient. It forms a crucial part of the professional-to-professional handover of care, and is an adjunct to the concise verbal handover that takes place in the Emergency Department.
The Ambulance Service told me they expect the ePRF to be reviewed by ED staff, rather than staff simply relying on the verbal handover, which can be challenging in the context of a busy hospital environment.
At the point of roll out of the new electronic system, Ambulance Service personnel attended the local Emergency Departments to install software that allowed ED staff to access the electronic Patient Report Form hub from their hospital computers. Further to installing software, the Ambulance Service had also provided ED staff with personalised login details and training to ensure they knew how to access the patient information.
I heard evidence from ED staff that despite having logins and having received training, they did not routinely access the system to review the electronic patient report form . The rationale for this omission, was that the software was “clunky” to use and in some cases it could take up 5 minutes to isolate the correct form; time that busy ED staff do not have. Both Trusts accepted that it had become practise not to review the ePRF instead to rely upon the verbal handover alone .
In this case, had ED staff reviewed the ePRF early in the admission, they would have appreciated from that documentation that Mr Reddington had been suspected of having a stroke, rather than a simple a head injury. His care would then have been provided in accordance with the stroke pathway much earlier in the evening.
I am concerned that ignoring a written handover from a fellow medical professional is not a safe or proportionate solution to the difficulties faced of accessing the electronic system.
I am further concerned that this practise of ignoring the written handover appears to have persisted for a long time without the organisations reaching a sensible solution.
While the Ambulance Service are taking steps to upgrade the system at another local hospital, I heard evidence that there was no agreed plan or date for seeking to resolve the system issues at Kingsmill or Queens Medical Centre.
Whilst ever this problem persists without resolution, there is a risk of future deaths due to failures in the handover of patient information at the point of transfer of care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to resolve electronic Patient Report Form access problems
Wider context from the report “The electronic Patient Report Form (‘ePRF’) is an important template which records all of the pre-hospital interaction with the patient. It forms a crucial part of the professional-to-professional handover of care, and is an adjunct to the concise verbal handover that takes place in the Emergency Department.
The Ambulance Service told me they expect the ePRF to be reviewed by ED staff, rather than staff simply relying on the verbal handover, which can be challenging in the context of a busy hospital environment.
At the point of roll out of the new electronic system, Ambulance Service personnel attended the local Emergency Departments to install software that allowed ED staff to access the electronic Patient Report Form hub from their hospital computers. Further to installing software, the Ambulance Service had also provided ED staff with personalised login details and training to ensure they knew how to access the patient information.
I heard evidence from ED staff that despite having logins and having received training, they did not routinely access the system to review the electronic patient report form. The rationale for this omission, was that the software was “clunky” to use and in some cases it could take up 5 minutes to isolate the correct form; time that busy ED staff do not have. Both Trusts accepted that it had become practise not to review the ePRF instead to rely upon the verbal handover alone.
In this case, had ED staff reviewed the ePRF early in the admission, they would have appreciated from that documentation that Mr Reddington had been suspected of having a stroke, rather than a simple a head injury. His care would then have been provided in accordance with the stroke pathway much earlier in the evening.
I am concerned that ignoring a written handover from a fellow medical professional is not a safe or proportionate solution to the difficulties faced of accessing the electronic system.
I am further concerned that this practise of ignoring the written handover appears to have persisted for a long time without the organisations reaching a sensible solution .
While the Ambulance Service are taking steps to upgrade the system at another local hospital, I heard evidence that there was no agreed plan or date for seeking to resolve the system issues at Kingsmill or Queens Medical Centre .
Whilst ever this problem persists without resolution , there is a risk of future deaths due to failures in the handover of patient information at the point of transfer of care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Limited availability of 24/7 mechanical thrombectomy for acute ischaemic stroke
Wider context from the report “In January 2018, NHS England published its Clinical Commissioning Policy on the use of Mechanical Thrombectomy as treatment for acute ischaemic stroke (all ages).
The aim of the Policy reports to be two-fold; to improve outcomes for adults with stroke, and to improve access to mechanical thrombectomy as soon as possible after the onset of stroke symptoms.
Despite the publication of the policy some 3 years ago, there remains very limited access to 24/7 mechanical thrombectomy . Save for two Trusts in London, and the West Midlands Network, I am not aware of others providing a 24/7 service. There certainly is no such service in the East Midlands .
There is clear geographical disparity in the access to this vital, life-saving service .
Mechanical thrombectomy would likely have avoided Mr Reddington’s death. Instead, because Mr Reddington was unfortunate enough to suffer a stroke outside of the service’s operational hours (Monday to Friday 8am to 4pm), his family were left to watch his deterioration, knowing that a treatment had the potential to save his life, but that such treatment simply was not offered after 4pm .
This is a situation that no family ought to be placed in.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the National Stroke Service Model to support hyper-acute stroke and thrombectomy service development.
Verbatim wording from the response “▪ Pathway optimisation; The National Stroke Service Model (NSSM)⁴ was published in May 2021, with a focus on hyper-acute stroke care, including thrombectomy, to support service development and optimise existing services. Further improvements of services will address the health inequalities gap across the stroke pathway and ensure 24/7 access for the entire population. The NSSM highlights the need for access to appropriate imaging and 24/7 emergency intra-hospital thrombectomy transfer pathways which must be in place for all Acute Stroke Centres. The thrombectomy programme is undertaking extensive mapping of current use of Artificial Intelligence (AI) solutions across stroke pathways which is used to support rapid decision making and speed up the transfer of essential brain scans from a stroke unit to a thrombectomy centre.” Source location 2021-0312-Response-from-NHS-England-and-NHS-Improvement_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a thrombectomy credentialing programme with professional bodies to train additional clinicians to perform thrombectomy.
Verbatim wording from the response “▪ Workforce: the workforce deficit is that there are currently not enough clinicians who are able to perform a thrombectomy. This is one of the key contributory factors to being able to rollout the programme at a more rapid pace. In England, a thrombectomy is performed by an Interventional Neuroradiologist and currently, there are approximately 86 (whole time equivalents). It is estimated that around 150 will be needed to deliver 24/7, sustainable services across England. Since January 2021 the Stroke programme has been engaging with the General Medical Council and Royal College of Radiologists to support the development of a thrombectomy credentialing programme to support non interventional radiologists, such as neuro surgeons, radiologists and cardiologists to be trained and supported to perform thrombectomy and address the workforce gap.” Source location 2021-0312-Response-from-NHS-England-and-NHS-Improvement_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest in 20 Integrated Stroke Delivery Networks and support their thrombectomy improvement priorities and pathway development.
Verbatim wording from the response “▪ Accountability and responsibility; in 2020/21 NHS England has invested in 20 Integrated Stroke Delivery Networks (ISDNs), that have prioritised thrombectomy improvements within their operational plans. Developing and establishing clear stroke management pathways will ultimately improve access to thrombectomy. Improved access to thrombectomy has been agreed as an Integrated Care Systems (ICS) priority and remains a high priority for the NHS overall.” Source location 2021-0312-Response-from-NHS-England-and-NHS-Improvement_Published
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 Allocate programme funding to incentivise services to expand 24/7 thrombectomy pathways and referral routes.
Verbatim wording from the response “▪ Revenue and capital funding There are sufficient financial revenue within the programme to support all services to deliver 24/7 thrombectomy pathways. This has been allocated to incentivise services to expand and support their referral pathways. There is a bid in preparation to secure capital funding for additional equipment which will support services to further improve their scanning machines and angio-suites, where a thrombectomy is performed.” Source location 2021-0312-Response-from-NHS-England-and-NHS-Improvement_Published
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 Prepare a capital-funding bid for equipment to improve scanning machines and thrombectomy angio-suites.
Verbatim wording from the response “▪ Revenue and capital funding There are sufficient financial revenue within the programme to support all services to deliver 24/7 thrombectomy pathways. This has been allocated to incentivise services to expand and support their referral pathways. There is a bid in preparation to secure capital funding for additional equipment which will support services to further improve their scanning machines and angio-suites, where a thrombectomy is performed.” Source location 2021-0312-Response-from-NHS-England-and-NHS-Improvement_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use linked data and pilot a thrombectomy dataset to support transformation and expansion of services.
Verbatim wording from the response “▪ Data gaps: a lack of robust linked data has presented a challenge in ensuring a detailed understanding of provision of thrombectomy and the essential components of the referral pathway. The programme now has access to more detailed linked data and is working with the stroke national audit programme to pilot a thrombectomy dataset that will collect data that will better support ongoing transformation and expansion of services.” Source location 2021-0312-Response-from-NHS-England-and-NHS-Improvement_Published
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 Expand thrombectomy provision through a multi-year programme establishing sustainable 24/7 access nationwide.
Verbatim wording from the response “These patients, often with extensive thrombus, are much less likely to respond to the conventional intravenous thrombolysis and more likely to experience severe disability. Around 40% of ischaemic strokes are caused by a large artery occlusion. The National Programme ambition is to develop robust and sustainable pathways and to increase coverage over a 24/7 period.” Source location 2021-0312-Response-from-NHS-England-and-NHS-Improvement_Published
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 Expansion of sustainable 24/7 thrombectomy services cannot proceed more rapidly because England lacks sufficient clinicians able to perform thrombectomy.
Verbatim wording from the response “▪ Workforce: the workforce deficit is that there are currently not enough clinicians who are able to perform a thrombectomy. This is one of the key contributory factors to being able to rollout the programme at a more rapid pace. In England, a thrombectomy is performed by an Interventional Neuroradiologist and currently, there are approximately 86 (whole time equivalents). It is estimated that around 150 will be needed to deliver 24/7, sustainable services across England. Since January 2021 the Stroke programme has been engaging with the General Medical Council and Royal College of Radiologists to support the development of a thrombectomy credentialing programme to support non interventional radiologists, such as neuro surgeons, radiologists and cardiologists to be trained and supported to perform thrombectomy and address the workforce gap.” Source location 2021-0312-Response-from-NHS-England-and-NHS-Improvement_Published
Open published response
17 May 2021 Stephen Thurm · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to incorporate main carers' care needs into long-term plans View source Lack of designated time for care coordinators to record detailed notes contemporaneously View source Failure to incorporate family information into care plans and risk assessments 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
Stephen Thurm · 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 Thurm died at the scene on 5 February 2020 after being found suspended by a rope from a tree, with the medical cause of death recorded as hanging. The concerns included family information about self-harm risk not being taken into account in care planning and risk assessments, no designated time for care coordinators to write detailed notes contemporaneously, and insufficient consideration of the mental health and care needs of his main carers.
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 incorporate main carers' care needs into long-term plans
Wider context from the report “3. ████████ expressed they were both suffering with a severe effect on their mental health but their care needs as the main carers was not built in to any long term plan .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 designated time for care coordinators to record detailed notes contemporaneously
Wider context from the report “2. The inquest heard that there is no designated gap between service user appointments to allow care coordinators to write up their detailed notes contemporaneously .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 family information into care plans and risk assessments
Wider context from the report “1. The inquest heard that information regarding the risk of self-harm to Stephen was passed by his family to his treating clinicians and his care coordinator but this was not taken into account as Stephen denied a recent attempt to take his own life. What steps could be taken to ensure family information is taken into account in the relevant care plan and risk assessments .
” 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 an updated Care Programme Approach Position Statement setting expectations for involving and supporting carers in care and support planning.
Verbatim wording from the response “Carers are often vital in supporting people with severe mental health problems in the community. There was existing national CPA guidance which sets clear expectations around carer involvement, however, there was a need to bring this guidance (although helpful) up to date. As part of the newly published Care Programme Approach Position Statement, NHS England and NHS Improvement has set out clear expectations for systems to provide support for carers of people with severe mental health problems and to better involve carers in care and support planning from April 2021. Specifically, to use Long Term Plan funding to develop and implement plans to improve the lives of carers of people with severe mental health problems and also to look at specific inequalities’ carers may face.” Source location 2021-0155-Response-from-NHS-Improvement_Published
Open published response
Concerns raised 12 Insufficiently robust systems for managing, treating and safeguarding high-risk students with mental health problems View source Failure to verify the safety of distressed students from self-harm View source Higher incidence of student mental health difficulties, self-harm and suicide View source Failure to implement national guidance to reduce student suicide View source Failure to complete a serious incident report on CWB working practices View source Failure to undertake reflection on CWB working practices View source Lack of national guidance on basic university mental health service requirements View source Failure to secure local NHS mental health service involvement in CWB service provision View source Lack of internal oversight of CWB service provision View source Insufficient communication and learning between CWB and local NHS mental health services View source Lack of external regulatory oversight of CWB service provision View source Failure to establish robust systems confirming student safety 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.
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AI-generated summary
Sarah Margaret Clarke · 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
Sarah Margaret Clarke, a 23-year-old university student with significant mental health difficulties, was found deceased in her university accommodation on 21 November 2019 after sending an email indicating that she intended to end her life. The concerns included inadequate follow-up after she became extremely distressed, insufficiently robust systems for managing and safeguarding students at high risk of self-harm, and failure to implement relevant national guidance or provide adequate oversight and learning.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust systems for managing, treating and safeguarding high-risk students with mental health problems
Wider context from the report “3. The organisation and systems at the CWB were insufficiently robust to appropriately manage, treat and safeguard students known to have mental health problems and be at high risk to themselves on a background of a lack of national guidance of what are the basic requirements for universities to provide such services.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to verify the safety of distressed students from self-harm
Wider context from the report “2. Sarah was known to have significant mental health difficulties exacerbated by a recent bereavement and other personal difficulties. On 19th November 2019 after Sarah hung up on the administrator and was knowingly extremely distressed, CWB staff did not take steps to reassure themselves that Sarah was safe from self-harm .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 incidence of student mental health difficulties, self-harm and suicide
Wider context from the report “1. I heard evidence students have a higher incidence of mental health difficulties, self-harm and suicide exacerbated by multifactorial issues such as being effectively itinerant with work and other social pressures.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to implement national guidance to reduce student suicide
Wider context from the report “4. National guidance issued in September 2018 to reduce the incidence of suicide in the student population had not been implemented by CWB at the time of Sarah’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to complete a serious incident report on CWB working practices
Wider context from the report “7. There was no serious incident report completed by US as to the working practices of the CWB and no reflection has taken place and no steps have been taken to put into place by CWB to provide more robust systems to confirm the safety of students such as Sarah.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 reflection on CWB working practices
Wider context from the report “7. There was no serious incident report completed by US as to the working practices of the CWB and no reflection has taken place and no steps have been taken to put into place by CWB to provide more robust systems to confirm the safety of students such as Sarah.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on basic university mental health service requirements
Wider context from the report “3. The organisation and systems at the CWB were insufficiently robust to appropriately manage, treat and safeguard students known to have mental health problems and be at high risk to themselves on a background of a lack of national guidance of what are the basic requirements for universities to provide such services .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to secure local NHS mental health service involvement in CWB service provision
Wider context from the report “6. There was little communication or learning between and a lack of involvement sought or offered by local NHS mental health services to ensure the service provided by CWB was within an acceptable standard.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 internal oversight of CWB service provision
Wider context from the report “5. There was no internal (by CWB) or external regulatory (by US) oversight as to the service provision at CWB before Sarah’s death or indeed after her death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient communication and learning between CWB and local NHS mental health services
Wider context from the report “6. There was little communication or learning between and a lack of involvement sought or offered by local NHS mental health services to ensure the service provided by CWB was within an acceptable standard.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 external regulatory oversight of CWB service provision
Wider context from the report “5. There was no internal (by CWB) or external regulatory (by US) oversight as to the service provision at CWB before Sarah’s death or indeed after her death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to establish robust systems confirming student safety
Wider context from the report “7. There was no serious incident report completed by US as to the working practices of the CWB and no reflection has taken place and no steps have been taken to put into place by CWB to provide more robust systems to confirm the safety of students such as Sarah.
” Open source report
Concerns raised 1 Unavailability of specialist inpatient eating-disorder beds View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Charlotte Lucy Swift · 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
Charlotte Lucy Swift was found unresponsive at her parents’ home on 9 April 2020 and was pronounced deceased at 19.43 hours. She had an eating disorder and urgently needed specialist inpatient treatment, but no bed became available before her death; the report also describes a national shortage of placements and an administrative error that meant she did not receive an expected update from her Consultant.
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 specialist inpatient eating-disorder beds
Wider context from the report “Charlotte was in urgent need of medical treatment by way of an inpatient bed at a specialist unit for those with eating disorders. Although she had been accepted for such a placement a bed did not become available before she died . Evidence heard at the Inquest indicated that there was a national shortage of placements/beds and this was putting individuals at risk of serious harm and possible death .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake a national inpatient eating-disorder demand and capacity exercise.
Verbatim wording from the response “The national mental health specialised commissioning team is supporting regional teams and wider eating disorder service transformation through specialist expert advice provided by NHSE Clinical Reference Groups and National Programme of Care for Specialised Mental Health. Additionally, a national inpatient Demand & Capacity exercise has recently been undertaken and findings from this will be used to support the reconfiguration of existing eating disorder beds and the development of whole patient pathways through Provider Collaboratives and ICSs as required by the NHS Long Term Plan.” Source location 2021-0150-Response-from-NHS-England-and-NHS-Improvement_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the demand and capacity exercise findings to support reconfiguration of existing eating-disorder beds and development of whole-patient pathways.
Verbatim wording from the response “The national mental health specialised commissioning team is supporting regional teams and wider eating disorder service transformation through specialist expert advice provided by NHSE Clinical Reference Groups and National Programme of Care for Specialised Mental Health. Additionally, a national inpatient Demand & Capacity exercise has recently been undertaken and findings from this will be used to support the reconfiguration of existing eating disorder beds and the development of whole patient pathways through Provider Collaboratives and ICSs as required by the NHS Long Term Plan.” Source location 2021-0150-Response-from-NHS-England-and-NHS-Improvement_Published
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 Implement NHS-led Provider Collaboratives to transform adult and children’s eating-disorder inpatient pathways and develop whole-pathway care models.
Verbatim wording from the response “Specialised Commissioning for inpatient eating disorder beds
The high level of demand for access to Specialised Commissioning AED inpatient beds is being addressed through the development of the Provider Collaboratives and new models of care considering the whole patient pathway from Primary Care to Tier 4 national services. The implementation of NHS-Led Provider Collaboratives began in October 2020, with 19 NHS-Led Provider Collaboratives now live and the remaining Phase One Provider Collaboratives being implemented by 1 October 2021.” Source location 2021-0150-Response-from-NHS-England-and-NHS-Improvement_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with patient representatives, provider collaboratives, regional colleagues and policy teams to develop new eating-disorder care models addressing capacity and access pressures.
Verbatim wording from the response “Local clinical leaders are working with Patient & Public Voice (PPV) and Expert by Experience (EbyE) representatives, regional colleagues, new provider collaboratives clinical, operational and commissioning leads, alongside NHSE Provider Collaboratives and MH Policy teams to support the development of new care models, to address the significant pressures, capacity and access issues across the system and reduce the reliance on inpatient beds in line with the evidence base for Eating Disorders.” Source location 2021-0150-Response-from-NHS-England-and-NHS-Improvement_Published
Open published response
Concerns raised 2 Lack of a central record of issued prescriptions View source Failure of providers to check existing prescriptions across providers before issuing new prescriptions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paris Alan George Lapper · 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
Paris Alan George Lapper, aged 19, was found deceased in his room at the Wolsey Hotel on 13 August 2020 and was declared deceased at 1125hrs. The post-mortem recorded respiratory depression due to opiate and benzodiazepine toxicity. The report raised concerns that he obtained duplicate prescriptions from multiple providers because providers lacked a central record or mechanism to check prescriptions issued elsewhere, creating a risk of medication misuse and fatal outcomes.
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 central record of issued prescriptions
Wider context from the report “Mr Lapper was a young man who was struggling with mental health issues. He had become dependent on prescribed medication. He had made concerted efforts to obtain prescribed medication, in the lead up to his death, from a number of sources. He was able to obtain medication from the local Community Mental Health Team, his GP and A&E at the local hospital whilst also obtaining prescriptions from a Private Psychiatrist. During the evidence heard at the Inquest it was clear that individuals can very easily manipulate the current prescription system. As there is no central record of what prescriptions have been issued it appears very easy for individuals to play the system and thereby obtain excess medication. This can lead to the risk of an individual abusing the medication that can bring about a fatal outcome.
Whilst the GP was made aware of some of the prescriptions that had been issued there is no mechanism in place for any provider to check what the individual has already been prescribed by with other providers before the new prescription is issued. It appears that the NHS and private providers act in isolation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 providers to check existing prescriptions across providers before issuing new prescriptions
Wider context from the report “Mr Lapper was a young man who was struggling with mental health issues. He had become dependent on prescribed medication. He had made concerted efforts to obtain prescribed medication, in the lead up to his death, from a number of sources. He was able to obtain medication from the local Community Mental Health Team, his GP and A&E at the local hospital whilst also obtaining prescriptions from a Private Psychiatrist. During the evidence heard at the Inquest it was clear that individuals can very easily manipulate the current prescription system. As there is no central record of what prescriptions have been issued it appears very easy for individuals to play the system and thereby obtain excess medication. This can lead to the risk of an individual abusing the medication that can bring about a fatal outcome.
Whilst the GP was made aware of some of the prescriptions that had been issued there is no mechanism in place for any provider to check what the individual has already been prescribed by with other providers before the new prescription is issued . It appears that the NHS and private providers act in isolation .
” 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 Fund and support electronic prescribing adoption across NHS trusts, including the remaining trusts.
Verbatim wording from the response “Firstly, there is work underway to support the adoption of electronic prescribing solutions across Trusts, without which information cannot be made available for sharing. Funding has now been provided to support adoption across more than 80% of NHS Trusts so far and work is underway to fund the remaining 20%. This work will conclude by the end of 2024.” Source location 2021-0148-Response-from-NHS-England-and-NHS-Improvement_Published
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 Deliver minimum shared-record view access to currently digitally available medicines information.
Verbatim wording from the response “Secondly, sharing medicines information requires the adoption of common information standards and work is also underway to define the necessary standards with subsequent plans in place to support adoption across health and care organisations, and these standards will be underpinned by the mandate to adopt them. The first early adopters of this programme are due to have these standards in place by the end of this financial year and the work is due to be completed by the end of 2024. This should enable a consolidated view of an individual’s medicines from numerous sources. In the shorter term, the shared record programme aims to deliver a minimum of view access by the end of this year for information that is digitally available now.” Source location 2021-0148-Response-from-NHS-England-and-NHS-Improvement_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Define common medicines-information standards and support their adoption across health and care organisations.
Verbatim wording from the response “Secondly, sharing medicines information requires the adoption of common information standards and work is also underway to define the necessary standards with subsequent plans in place to support adoption across health and care organisations, and these standards will be underpinned by the mandate to adopt them. The first early adopters of this programme are due to have these standards in place by the end of this financial year and the work is due to be completed by the end of 2024. This should enable a consolidated view of an individual’s medicines from numerous sources. In the shorter term, the shared record programme aims to deliver a minimum of view access by the end of this year for information that is digitally available now.” Source location 2021-0148-Response-from-NHS-England-and-NHS-Improvement_Published
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 GMC prescribing guidance sets information and safety responsibilities for NHS and private prescribers.
Verbatim wording from the response “Guidance issued by the General Medical Council (GMC) sets out good prescribing practice (Good practice in prescribing and managing medicines and devices), including specific references to prescriber responsibilities and ensuring prescribers have all the relevant information, including adequate knowledge of the patient’s health, before prescribing. This guidance also applies to prescribers in the private sector. There is also reference to specific considerations such as whether or not the prescriber has sufficient information to prescribe safely and has access to the patient’s medical records.” Source location 2021-0148-Response-from-NHS-England-and-NHS-Improvement_Published
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations