24 Apr 2021 Alfred Jones · Prevention of Future Deaths report Manchester South
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Concerns raised 2 Shortage of qualified radiology staff View source Insufficient MRI scanner capacity and availability 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
Alfred Jones · 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
Alfred Jones was admitted to hospital after an accidental fall at home and sustained further vertebral fractures in a fall on the ward. While awaiting investigation and being medically optimised for discharge, he contracted Covid-19 in hospital and died on 7 September 2020 from bronchopneumonia in combination with Covid-19, with falls and vertebral fractures among the listed contributing conditions. The report raised concerns that shortages of MRI scanner availability and radiology staff prolonged his admission, contributing to the ward fall and Covid-19 infection.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Shortage of qualified radiology staff
Wider context from the report “1. The inquest heard that his stay in hospital was prolonged due to a shortage of availability of slots for the MRI scanner. This the inquest was told is due to a shortage of MRI scanners both in the Trust and the wider NHS. This was compounded by a shortage of radiology staff which the inquest was told formed a wider issue of a national shortage of qualified radiologists and radiographers . This led to a prolonged admission in hospital whilst awaiting tests and led to him having a fall whilst on the ward and contracting Covid-19 whilst an inpatient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 MRI scanner capacity and availability
Wider context from the report “1. The inquest heard that his stay in hospital was prolonged due to a shortage of availability of slots for the MRI scanner . This the inquest was told is due to a shortage of MRI scanners both in the Trust and the wider NHS . This was compounded by a shortage of radiology staff which the inquest was told formed a wider issue of a national shortage of qualified radiologists and radiographers. This led to a prolonged admission in hospital whilst awaiting tests and led to him having a fall whilst on the ward and contracting Covid-19 whilst an inpatient.
” 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 an expanded imaging workforce, including increased radiographer and radiologist training, new Imaging Training Academies and innovative imaging technologies.
Verbatim wording from the response “From a National perspective, in supporting the ambitions of the NHS Long Term Plan, NHS England & Improvement (NHSE&I) commissioned an independent review of diagnostic services. The recently published report (October 2020), Diagnostics: Recovery and Renewal conducted by ████████ also took into account the impact of the Covid-19 pandemic. The recommendations have been accepted by NHSE&I and work has already begun to address the recommendations made, which include an increase in both imaging equipment and imaging workforce in England.” Source location 2021-0135-Response-from-NHS-England-and-NHS-Improvement-Redacted
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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 Commission an independent review of diagnostic services to identify measures addressing diagnostic capacity and resilience.
Verbatim wording from the response “From a National perspective, in supporting the ambitions of the NHS Long Term Plan, NHS England & Improvement (NHSE&I) commissioned an independent review of diagnostic services. The recently published report (October 2020), Diagnostics: Recovery and Renewal conducted by ████████ also took into account the impact of the Covid-19 pandemic. The recommendations have been accepted by NHSE&I and work has already begun to address the recommendations made, which include an increase in both imaging equipment and imaging workforce in England.” Source location 2021-0135-Response-from-NHS-England-and-NHS-Improvement-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase imaging equipment capacity in England to address diagnostic service demand.
Verbatim wording from the response “From a National perspective, in supporting the ambitions of the NHS Long Term Plan, NHS England & Improvement (NHSE&I) commissioned an independent review of diagnostic services. The recently published report (October 2020), Diagnostics: Recovery and Renewal conducted by ████████ also took into account the impact of the Covid-19 pandemic. The recommendations have been accepted by NHSE&I and work has already begun to address the recommendations made, which include an increase in both imaging equipment and imaging workforce in England.” Source location 2021-0135-Response-from-NHS-England-and-NHS-Improvement-Redacted
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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 community diagnostic hubs to expand access to MRI, CT, ultrasound and X-ray services, including for inpatient activity.
Verbatim wording from the response “Funding within the 2021/22 spending review has been targeted to support diagnostics via the development of community diagnostic hubs which will in turn augment access for inpatient activity in acute hospital services through the movement of elective activity to community settings. It is anticipated that MRI, CT scanning, Ultrasound and X-ray services will be the core imaging offer for these new centres and will represent new additional imaging capacity.” Source location 2021-0135-Response-from-NHS-England-and-NHS-Improvement-Redacted
Open published response
Concerns raised 6 Insufficient undergraduate teaching on the health effects of air pollution View source Insufficient postgraduate education on the health effects of air pollution View source Insufficient detail and monitoring capacity for air quality information View source Insufficient professional guidance on communicating the health effects of air pollution View source Low public awareness of sources of national and local pollution information View source National Particulate Matter limits exceeding WHO guideline levels View source See 3 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
Ella Adoo-Kissi-Debrah · 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
Ella Adoo-Kissi-Debrah died aged 9 after an asthmatic episode led to cardiac arrest on 15 February 2013. The report states that air pollution, including exposure to nitrogen dioxide and particulate matter from traffic emissions, significantly contributed to her asthma and death. It also identifies concerns about pollution limits, public access to pollution information, and communication of air-pollution health risks by healthcare professionals.
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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 Insufficient undergraduate teaching on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 postgraduate education on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 detail and monitoring capacity for air quality information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government. The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 professional guidance on communicating the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Low public awareness of sources of national and local pollution information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government . The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation National Particulate Matter limits exceeding WHO guideline levels
Wider context from the report “(1) The national limits for Particulate Matter are set at a level far higher than the WHO guidelines. The evidence at the inquest was that there is no safe level for Particulate Matter and that the WHO guidelines should be seen as minimum requirements. Legally binding targets based on WHO guidelines would reduce the number of deaths from air pollution in the UK.
” 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 stakeholders and partners to develop a postgraduate wraparound professional development offer covering generalist skills and environmental determinants of health.
Verbatim wording from the response “HEE continues to deliver a number of medical education reform proposals to improve the efficacy and flexibility of our medical education system. Building upon the findings of the Future Doctor engagement programme, HEE are working with stakeholders and partners to develop a wraparound professional development offer in postgraduate medical training to enhance the generalist skills of doctors. By embedding generalism in training, we aim to better equip doctors to understand and address the population health and care needs of the communities they serve, including to recognise and evaluate the environmental determinants of health.” Source location 2021-0113-Response-from-Health-Education-England-Redacted
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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 Write to relevant medical Royal Colleges, the GMC and the NMC highlighting that curricula should consider awareness of air pollution’s health impacts.
Verbatim wording from the response “In response to Concern 3 raised in your report, HEE will write to the relevant medical Royal Colleges, GMC and NMC to highlight that improving awareness of the impact of air pollution on health should be considered when developing curricula.” Source location 2021-0113-Response-from-Health-Education-England-Redacted
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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 Postgraduate specialty curricula are set by medical Royal Colleges and faculties, with curricula and assessment systems approved by the GMC.
Verbatim wording from the response “The curricula for postgraduate specialty training are set by individual medical Royal Colleges and faculties, and the GMC approves curricula and assessment systems for each training programme. The Academy Foundation Programme Committee coordinates and facilitates the work of the medical Royal Colleges and faculties to produce the curriculum for the Foundation Programme, the first two years of postgraduate medical training.” Source location 2021-0113-Response-from-Health-Education-England-Redacted
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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 Undergraduate medical and nursing curricula are set by individual schools and universities, subject to standards set and monitored by the GMC and NMC.
Verbatim wording from the response “The standards for medical and nursing education in the UK are set by the respective independent professional regulator, the General Medical Council (GMC) and Nursing & Midwifery Council (NMC).” Source location 2021-0113-Response-from-Health-Education-England-Redacted
Open published response
Concerns raised 7 Failure to align product promotion with safety information about feeding and drainage suitability View source Insufficient product description of the tube bore restriction View source Failure to fully evaluate the size 14FR tube before replacing previous drainage tubes View source Lack of compulsory root cause analysis training for clinicians View source Failure to train sales marketing staff to recognise and communicate the tube bore restriction View source Failure to respond appropriately when NG tubes are not adequately draining View source Wider product labelling failure to communicate the connector-related bore restriction 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
Stephen James Oakes · 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 James Oakes, aged 59, died in hospital on 23 December 2017 after a carefeed 14F nasogastric tube inadequately drained stomach contents, allowing vomit to pass the tube and leading to aspiration pneumonia in the context of metastatic bronchial carcinoma and small bowel obstruction. The principal concerns included inadequate product description and staff training, insufficient hospital evaluation of the tube, failure to recognise inadequate drainage or consider alternatives, and possible wider product-labelling problems.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to align product promotion with safety information about feeding and drainage suitability
Wider context from the report “(6) Despite reports to the MHRA and issue of amended instructions for use and a field safety notice the product continues to be promoted as suitable to feeding and drainage . Please see attached link to the Nursing times. https://www.nursingtimes.net/clinical-archive/nutrition/selection-and-management-of-commonly-used-enteral-feeding-tubes-18-02-2019/
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 product description of the tube bore restriction
Wider context from the report “(1) The product description used by Enteral was insufficient to enable the end user to clearly identify that the tube marketed as a carefeed size 14FR feeding and drainage tube would not operate as a 14Fr tube due to the restricting en-fit connector .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 fully evaluate the size 14FR tube before replacing previous drainage tubes
Wider context from the report “(3) The Hospital Trust did not fully evaluate the size 14FR tube prior to replacing all previous drainage tubes (Ryles) with the carefeed 14F feeding and drainage tube . Feedback was generally difficult to obtain .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 compulsory root cause analysis training for clinicians
Wider context from the report “(5) There is no compulsory training of clinicians required to undertake root cause analysis .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 train sales marketing staff to recognise and communicate the tube bore restriction
Wider context from the report “(2) Enteral sales marketing staff were not trained to recognise the new restriction in the bore of the tube and were consequently unable to advise the end user of the change .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 respond appropriately when NG tubes are not adequately draining
Wider context from the report “(4) Nursing staff did not consider alternative action when the NG tubes were not adequately draining . There was no general recognition of the need to aspirate the tube .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Wider product labelling failure to communicate the connector-related bore restriction
Wider context from the report “(7) This was a joint inquest into the death of two patients who died in quick succession as a result of the Enteral 14F nasogastric tube being used for decompression in an emergency situation. Four similar (non-fatal) incidents followed. It was not clear to the hospital that the Enteral connector reduced the bore of the size 14Fr tube . The inquest was aware that other Hospital Trusts had also need to change the tubes. I am concerned that the product labelling problem identified during these inquests may not be limited to the University Hospital North Midlands but is in fact a much wider problem that merits wider industry investigation and changes.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the report with MHRA colleagues to address concerns within their remit.
Verbatim wording from the response “Further to the email sent on 10 June 2021 from ████████, Business Manager in my Quality Strategy Team, I am conscious that the majority of your concerns would be better placed with the Local Trust, to whom you have sent the report, and colleagues at the Medicines and Healthcare products Regulatory Agency (MHRA). The Small Bore Connector Group, which you refer to in the addressees of the report was discontinued some time ago. On that basis I have shared the report with colleagues at MHRA who I understand will address the concerns relevant to their area of work.” Source location 2021-0114-Response-from-NHS-England-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 Review national incident reports since January 2018 and work with MHRA to determine whether further action is required.
Verbatim wording from the response “In terms of wider patient safety, NHSE/I’s Patient Safety Team have discussed this issue and are currently undertaking a review of the National Reporting and Learning System (NRLS) to see if they can identify any reported incidents since January 2018; when GBUK issued a Field Safety Notice in respect of this issue. Pending the outcome of this review, Patient Safety colleagues will work with MHRA to determine if any further action is required.” Source location 2021-0114-Response-from-NHS-England-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 Develop a procurement framework enabling providers and commissioners to access quality-assured patient safety incident investigation training.
Verbatim wording from the response “NHS England and NHS Improvement are working with the Healthcare Safety Investigation Branch (HSIB), who are testing and introducing national patient safety incident investigation training. In addition, a patient safety incident investigation training procurement framework is also being developed to support healthcare providers and commissioners to access quality assured investigation training.” Source location 2021-0114-Response-from-NHS-England-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 HSIB to test and introduce national patient safety incident investigation training.
Verbatim wording from the response “Recognising that there are well identified and publicised issues with the quality of patient safety investigations in the NHS, there is ongoing work, as part of the NHS Patient Safety Strategy, to pilot a new framework for incident response: the Patient Safety Incident Response Framework (PSIRF). This framework focuses on the importance of conducting a systems-based patient safety incident investigation. Much like the Serious Incident Framework, the PSIRF, and the Patient Safety Incident Investigation Standards which sit alongside it, require investigators to be appropriately trained.” Source location 2021-0114-Response-from-NHS-England-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 NHS investigation requirements already require systems-based investigations conducted by appropriately trained investigators, addressing the concern about compulsory root-cause-analysis training.
Verbatim wording from the response “In relation to concern 5, around Root Cause Analysis training, it is important to note that all NHS trusts are required to comply with the Serious Incident Framework (2015) when conducting patient safety incident investigations into incidents such as the tragic events described. The Framework states that;” Source location 2021-0114-Response-from-NHS-England-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 Concerns concerning the medical device should be addressed by the Medicines and Healthcare products Regulatory Agency.
Verbatim wording from the response “Further to the email sent on 10 June 2021 from ████████, Business Manager in my Quality Strategy Team, I am conscious that the majority of your concerns would be better placed with the Local Trust, to whom you have sent the report, and colleagues at the Medicines and Healthcare products Regulatory Agency (MHRA). The Small Bore Connector Group, which you refer to in the addressees of the report was discontinued some time ago. On that basis I have shared the report with colleagues at MHRA who I understand will address the concerns relevant to their area of work.” Source location 2021-0114-Response-from-NHS-England-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 Concerns concerning local hospital practice should be addressed by the relevant Local Trust.
Verbatim wording from the response “Further to the email sent on 10 June 2021 from ████████, Business Manager in my Quality Strategy Team, I am conscious that the majority of your concerns would be better placed with the Local Trust, to whom you have sent the report, and colleagues at the Medicines and Healthcare products Regulatory Agency (MHRA). The Small Bore Connector Group, which you refer to in the addressees of the report was discontinued some time ago. On that basis I have shared the report with colleagues at MHRA who I understand will address the concerns relevant to their area of work.” Source location 2021-0114-Response-from-NHS-England-NHS-Improvement_Published
Open published response
Concerns raised 8 Lack of compulsory root cause analysis training for clinicians View source Inadequate evaluation and feedback before wholesale replacement of drainage tubes View source Continued promotion of the product as suitable for feeding and drainage despite safety information View source Wider product labelling problem regarding the tube's restricted bore View source Failure to train sales marketing staff to recognise and communicate the tube's restricted bore View source Insufficient product description of the tube's restricted bore View source Lack of recognition of the need to aspirate the tube View source Failure to consider alternative action when nasogastric tubes do not adequately drain View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Peter John Hussey · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter John Hussey died after post-surgical complications following reversal of an ileostomy. A carefeed 14F nasogastric tube inadequately drained his stomach, allowing vomiting and contributing to aspiration pneumonia. Concerns included insufficient product description and staff training, inadequate evaluation of the tube, and failure to recognise poor drainage and consider alternative treatment or escalation.
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 compulsory root cause analysis training for clinicians
Wider context from the report “(5) There is no compulsory training of clinicians required to undertake root cause analysis .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 evaluation and feedback before wholesale replacement of drainage tubes
Wider context from the report “(3) The Hospital Trust did not fully evaluate the size 14FR tube prior to replacing all previous drainage tubes (Ryles) with the carefeed 14Fr feeding and drainage tube . Feedback was generally difficult to obtain .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Continued promotion of the product as suitable for feeding and drainage despite safety information
Wider context from the report “(6) Despite reports to the MHRA and issue of amended instructions for use and a field safety notice the product continues to be promoted as suitable to feeding and drainage . Please see attached link to the Nursing Times. https://www.nursingtimes.net/clinical-archive/nutrition/selection-and-management-of-commonly-used-enteral-feeding-tubes-18-02-2019/
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Wider product labelling problem regarding the tube's restricted bore
Wider context from the report “(7) This was a joint inquest into the deaths of two patients who died in quick succession as a result of the Enteral 14F nasogastric tubes being used for decompression in an emergency situation. Four similar (non-fatal) incidents followed. It was not clear to the hospital that the Enteral connector reduced the bore of the size 14Fr tube. The inquest was aware that other Hospital Trusts had also needed to change the tubes. I am concerned that the product labelling problem identified during these inquests may not be limited to the University Hospital North Midlands but is in fact a much wider problem that merits wider industry investigation and changes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to train sales marketing staff to recognise and communicate the tube's restricted bore
Wider context from the report “(2) Enteral sales marketing staff were not trained to recognise the new restriction in the bore of the tube and were consequently unable to advise the end user of the change .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 product description of the tube's restricted bore
Wider context from the report “(1) The product description used by Enteral was insufficient to enable the end user to clearly identify that the tube marketed as a carefeed size 14FR feeding and drainage tube would not operate as a 14Fr tube due to the restricting en-fit connector .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 recognition of the need to aspirate the tube
Wider context from the report “(4) Nursing staff did not consider alternative action when the nasogastric tubes were not adequately draining. There was no general recognition of the need to aspirate the tube .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to consider alternative action when nasogastric tubes do not adequately drain
Wider context from the report “(4) Nursing staff did not consider alternative action when the nasogastric tubes were not adequately draining . There was no general recognition of the need to aspirate the tube.
” 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 the Healthcare Safety Investigation Branch to test and introduce national patient safety incident investigation training.
Verbatim wording from the response “NHS England and NHS Improvement are working with the Healthcare Safety Investigation Branch (HSIB) who are testing and introducing national patient safety incident investigation training. In addition, a patient safety incident investigation training procurement framework is also being developed to support healthcare providers and commissioners to access quality assured investigation training.” Source location 2021-0115-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 Share the report with Medicines and Healthcare products Regulatory Agency colleagues for action on concerns within their remit.
Verbatim wording from the response “Further to the email sent on 10 June 2021 from ████████, Business Manager in my Quality Strategy Team, I am conscious that the majority of your concerns would be better placed with the Local Trust, to whom you have sent the report, and colleagues at the Medicines and Healthcare products Regulatory Agency (MHRA). The Small Bore Connector Group, which you refer to in the addresses of the report was discontinued some time ago. On that basis I have shared the report with colleagues at MHRA who I understand will address the concerns relevant to their area of work.” Source location 2021-0115-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 Pilot the Patient Safety Incident Response Framework to improve systems-based patient safety incident investigations.
Verbatim wording from the response “Recognising that there are well identified and publicised issues with the quality of patient safety investigations in the NHS, there is ongoing work, as part of the NHS Patient Safety Strategy, to pilot a new framework for incident response: the Patient Safety Incident Response Framework (PSIRF). This framework focuses on the importance of conducting a system-based patient safety incident investigation. Much like the Serious Incident Framework, the PSIRF, and the Patient Safety Incident Investigation Standards which sit alongside it, require investigators to be appropriately trained.” Source location 2021-0115-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 procurement framework enabling healthcare providers and commissioners to access quality-assured patient safety incident investigation training.
Verbatim wording from the response “NHS England and NHS Improvement are working with the Healthcare Safety Investigation Branch (HSIB) who are testing and introducing national patient safety incident investigation training. In addition, a patient safety incident investigation training procurement framework is also being developed to support healthcare providers and commissioners to access quality assured investigation training.” Source location 2021-0115-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 Existing NHS investigation frameworks require systems-based investigations by appropriately trained investigators, addressing the concern about root cause analysis training.
Verbatim wording from the response “In relation to concern 5, around Root Cause Analysis training, it is important to note that all NHS trusts are required to comply with the Serious Incident Framework (2015) when conducting patient safety incident investigations into incidents such as the tragic events described. The Framework states that;” Source location 2021-0115-Response-from-NHS-England-and-NHS-Improvement_Published
Open published response
Concerns raised 1 Cancellation of hospital appointments for vulnerable prisoners 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
Imre Paul Thomas · 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
Imre Paul Thomas died at HMP Garth on 12 September 2019 after an overdose involving tramadol and other prescription medication obtained illicitly. The report raised concern that repeated cancellations of hospital appointments placed vulnerable prisoners at risk, and identified the possibility of prison clinics for visiting hospital consultants as an issue for investigation.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Cancellation of hospital appointments for vulnerable prisoners
Wider context from the report “Cancelled hospital appointments putting vulnerable prisoners at risk.
” Open source report
28 Mar 2021 Bathsheba Shepherd · Prevention of Future Deaths report London (West)
View report summary
Concerns raised 2 Failure of GP registration processes to enable registration without relevant documentary proof View source Failure to resolve the interagency Care Programme Approach 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
Bathsheba Shepherd · 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
Bathsheba Bianca Kay Shepherd, known as Kay, was fatally stabbed by her housemate at some point between 10 and 11 November 2015 and was pronounced deceased on 11 November 2015. The report identified concerns about her being housed with a dangerous and vulnerable housemate, failures in risk assessment and rehousing, and her lack of GP registration and associated support.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of GP registration processes to enable registration without relevant documentary proof
Wider context from the report “(2) I was concerned by evidence in the course of the Inquest that the disengagement of a person with known psychological illness from the process of registration with a GP by her failure to obtain relevant documentary proof to enable registration meant that she could not be registered . Registration with a regular GP would in my mind have provided additional support to her. This may have enabled her to raise concerns or fears relating to her accommodation and housemate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 the interagency Care Programme Approach process
Wider context from the report “(1) I was concerned to find that even though 5 years had elapsed between Kay’s death and the hearing of the Inquest the issue of the way in which the Care Programme Approach was being conducted between the local authority and the NHS Trust was still the subject of discussion and had not been resolved to the satisfaction of the manager responsible for the process . The delay in my view represents a threat to the lives of others in similar situations .
” Open source report
Concerns raised 1 Failure to routinely and regularly test transplant patients’ magnesium levels View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jamie Lee Poole · 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 Lee Poole, who had received a kidney transplant and was taking immunosuppressant medication, was admitted with low magnesium and calcium levels before collapsing in hospital on 28 June 2017. She died on 2 July 2017 after developing significant brain swelling; the recorded causes included cerebral oedema and electrolyte disarray with calcium and magnesium deficiencies. The report raised concern that routine magnesium monitoring for transplant patients varied between healthcare trust areas.
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 routinely and regularly test transplant patients’ magnesium levels
Wider context from the report “(1) Transplant patients are put on strong immunosuppressive medication to prevent rejection of the transplanted organ. The medication, tacrolimus in Jamie Lee Poole case, has a common known side effect of reducing magnesium levels within the body. This can be life threatening. Despite this, it is not standard practice to regularly test transplant patients magnesium levels. I heard evidence at inquest that, whilst the Trust providing care for Jamie Lee Poole, has now remedied this, and routinely test post-transplant patients’ for magnesium levels, this is not the case in other areas. The evidence that I heard was that, whether these levels were tested routinely and regularly, was very much dependant on trust area. In one area, patients may be tested routinely for this in others they would not.
” 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 Undertake an expert clinical review recommending magnesium monitoring for immunosuppressed patients and reviewing proton pump inhibitor and H2 antagonist prescribing with calcineurin inhibitors.
Verbatim wording from the response “We wish to convey our sincere condolences to the family and have taken the matter extremely seriously to prevent future occurrence. We will be instituting the following remedial actions:” Source location 2021-0075-Response-from-NHS-England-and-NHS-Improvement-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate updated guidance to clinical teams caring for kidney transplant recipients through the Renal Networks.
Verbatim wording from the response “- An Expert Clinical review to make recommendations on magnesium monitoring in patients on Immunosuppression, and a review of prescribing PPI and H2 antagonists in patients on CNI. This would be undertaken jointly by the professional societies of UK Renal Pharmacy Group and British Transplant Society/Renal Association. Dissemination of updated guidance will be to all clinical teams involved in the care of kidney transplant recipients through the Renal Networks.” Source location 2021-0075-Response-from-NHS-England-and-NHS-Improvement-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a reminder alert on magnesium monitoring for patients taking proton pump inhibitors who are at risk of hypomagnesemia.
Verbatim wording from the response “We wish to convey our sincere condolences to the family and have taken the matter extremely seriously to prevent future occurrence. We will be instituting the following remedial actions:” Source location 2021-0075-Response-from-NHS-England-and-NHS-Improvement-Redacted
Open published response
Concerns raised 7 Unavailability of consultant-level psychiatric input to eating disorder services View source Inadequate training and knowledge of eating disorders among medical professionals View source Under-reporting and inadequate recording and investigation of eating-disorder-related deaths View source Lack of robust and reliable prevalence data for eating disorders View source Shortage of eating disorder specialists View source Lack of formally commissioned monitoring provision for moderate to high risk Anorexia Nervosa patients View source COVID-19 pandemic exacerbation of eating disorder safety deficiencies View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 24
Action
Use the national eating-disorder benchmarking report and training compendium to support regional and local training responses to identified need.
Stated completedThe respondent said that this action was complete when they made their response on 8 March 2021. View source
Action
Introduce eating-disorder and mental-health learning resources for medical students and foundation doctors.
Stated completedThe respondent said that this action was complete when they made their response on 8 March 2021. View source
Action
Work through a joint eating-disorder expert advisory group to plan future commissioning and determine workforce requirements.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 March 2021. View source
Action
Develop physical-health-check training for eating-disorder care with NHS England and NHS Improvement.
Stated plannedThe respondent said that this action was planned when they made their response on 8 March 2021. View source
Action
Develop a competence framework for psychological interventions for people with eating disorders to guide workforce capability and enhance patient safety.
Stated completedThe respondent said that this action was complete when they made their response on 8 March 2021. View source
Action
Increase psychiatry placements in the Foundation Programme and continue working with the Royal College of Psychiatrists to improve specialty-training fill rates.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 March 2021. View source
Action
Map further psychological-therapy and related-role expansion through a workforce plan to guide local workforce planning and education provision.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 March 2021. View source
Action
Commission BEAT to develop a programme equipping nursing staff to understand, respond compassionately and signpost people with eating disorders.
Stated plannedThe respondent said that this action was planned when they made their response on 8 March 2021. View source
Action
Develop and pilot GP-training enhancements, including longer general-practice placements and enhanced mental-health treatment experience.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 March 2021. View source
Action
Provide nationally accessible eating-disorder e-learning through e-Learning for Healthcare, including resources for professionals, students and foundation doctors.
Stated completedThe respondent said that this action was complete when they made their response on 8 March 2021. View source
Action
Commission and deliver whole-team cognitive behavioural therapy training for eating-disorder staff.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 March 2021. View source
Action
Expand and train the psychological-therapy workforce, including recruiting practitioners, training existing staff and increasing clinical-psychologist trainees.
Stated completedThe respondent said that this action was complete when they made their response on 8 March 2021. View source
Action
Support trusts to develop comprehensive anorexia nervosa policies and procedures aligned with MARSIPAN guidance.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 March 2021. View source
Action
Deliver Adult Eating Disorder Whole Team Training for staff supporting eating disorder services, including primary care staff.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 March 2021. View source
Action
Deliver regional webinars, learning events and conferences on eating disorder care for professionals and parents or carers.
Stated completedThe respondent said that this action was complete when they made their response on 8 March 2021. View source
Action
Deliver Cognitive Behavioural Therapy for Eating Disorders postgraduate training for mental health professionals.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 March 2021. View source
Action
Commission a training provider to deliver Maudsley Model of Anorexia Nervosa Therapy for Adults training.
Stated plannedThe respondent said that this action was planned when they made their response on 8 March 2021. View source
Action
Continue supporting eating disorder services through regional clinical leads during and beyond the COVID-19 pandemic.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 March 2021. View source
Action
Embed mental health practitioners in Primary Care Networks to improve oversight across primary and secondary care for people with severe mental illness, including eating disorders.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 March 2021. View source
Action
Make funding available for acute trusts to provide medical-stabilisation training for staff managing eating disorder and self-harm presentations.
Stated completedThe respondent said that this action was complete when they made their response on 8 March 2021. View source
Action
Participate in the MHSDS steering group to influence future survey questionnaires and improve representation of eating disorders.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 March 2021. View source
Action
Work with Health Education England to improve workforce training for adult eating disorder services.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 March 2021. View source
Action
Share learning from community eating disorder early implementers through the Adult Eating Disorder Clinical Leads forum to support robust medical-monitoring pathways.
Stated plannedThe respondent said that this action was planned when they made their response on 8 March 2021. View source
Action
Promote MARSIPAN guidance in inpatient settings through quality frameworks in adult eating disorder Provider Collaboratives.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 March 2021. View source See 21 more actions
×
AI-generated summary
Averil Hart · 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
Averil Hart died from anorexia nervosa on 15 December 2012, after severe weight loss and deterioration following her discharge from specialist eating-disorder treatment. The report identified concerns about inadequate monitoring and coordination of care, insufficient eating-disorder training and specialist provision, failures to provide nutritional support, delays and miscommunication in hospital care, inadequate data on eating-disorder prevalence and deaths, and the impact of the COVID-19 pandemic.
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 consultant-level psychiatric input to eating disorder services
Wider context from the report “(2) Lack of formally commissioned service level agreement for the provision of robust and effective monitoring of moderate to high risk AN patients by primary or secondary care providers
Evidence confirmed that in response to the PHSO Report an Expert Reference Group (ERG) was convened by NHS England (NHSE) to address the specific recommendation for NHSE to review the existing quality and availability of services to achieve parity for adult ED services with children and young people’s ED services. The National Collaborating Centre for Mental Health (NCCMH) was commissioned to develop new guidance published in August 2019: “Adult Eating Disorders: Community, Inpatient and Intensive Day Patient Care – Guidance for Commissioners and Providers”.
However, the clear and unchallenged evidence received at Averil’s inquest confirmed that there remains a lack of formally commissioned provision for the monitoring of AN patients in primary or secondary care across large parts of the United Kingdom. Whilst the evidence received indicated that Cambridgeshire & Peterborough NHS Foundation Trust are seeking to develop models to ensure the provision of medical monitoring for all ED sufferers, including moderate to high risk patients, there are many areas in the country – including parts of the East of England Region – which still have no such formally commissioned provision. Further, unchallenged evidence identified a number of regions as not even having consultant level psychiatric in-put to the ED services that are purportedly available .
There was unanimity on the part of each of the senior clinicians who gave evidence, as well as a number of independent, instructed experts in the fields of ED and AN, that the continued absence of such monitoring and treatment provision gave rise to not only the risk of avoidable future deaths, but - in the views of many - the inevitability of the same. Evidence confirmed that whilst AN has the highest mortality of any mental disorder affecting young people and adults this should not be simply accepted and that AN and other EDs are treatable mental disorders, with even severe complications such as malnutrition safely reversible. The evidence further established that whilst in the long term primary prevention strategies including early recognition and treatment of the disease was critical, in the short to medium term, improving access to treatment and the effective monitoring of the severely ill is to be regarded as essential to address the risk of avoidable future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequate training and knowledge of eating disorders among medical professionals
Wider context from the report “(1) Inadequate training of doctors and other medical professionals re eating disorders
Evidence from a wide range of clinicians who had engaged with Averil in 2012 echoed the evidence of clinicians attending the four inquests of the women referred to above. All five inquests revealed a common theme of wide-spread and continuing lack of training, knowledge, or experience on the part of physicians and medical staff (including GPs and nurse practitioners, as well as acute hospital doctors, nurses and dieticians) regarding eating disorders (EDs) and specifically Anorexia Nervosa (AN). Many witnesses (from both the death 2012 and those in 2017/2018) conceded that they had only the most superficial knowledge of the often complex issues relating to recognition, monitoring, management and treatment of EDs and AN specifically. Their evidence often reflected a lack of familiarity with the King’s College Guidance for the treatment of AN in the community. The evidence of hospital staff revealed, at best, inconsistent implementation of the Royal College of Psychiatrists MARSIPAN guidance for the emergency treatment of AN patients and, at worst, a failure to implement the Guidance at all .
Evidence at Averil’s inquest (and at those of ████████) suggested that limited progress has been made in respect of the PHSO recommendation with regard to the training of doctors and other medical professionals, (notwithstanding the further recommendations of the PACAC Follow-up Report and the Government Response to the latter’s Recommendations). These concerns have been reiterated by the Position Statement of the Royal College of Psychiatrists (PS04/20) of September 2020 “Improving core skills and competence in risk assessment and management of people with eating disorders: What all doctors need to know.”
The evidence at inquest of senior practitioners in the fields of psychiatry, psychology, acute medicine, dietetics, gastroenterology and GP practice all confirmed that there remains, as there was in 2012, a continuing and serious shortage of eating disorder specialists across the country with many Trusts finding it difficult to fill vacancies; such shortages inevitably impact upon the level and quality of support available to primary care providers and other specialists and therefore, in my view, risks avoidable future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Under-reporting and inadequate recording and investigation of eating-disorder-related deaths
Wider context from the report “(3) Lack of robust and reliable data regarding the prevalence of eating disorders
Evidence also confirmed that the lack of precise information on the prevalence of eating disorders in the United Kingdom, described by the PHSO Report and the PACAC Follow-up Report as “shocking, given the claim that up to 1.25 million people are suffering from an eating disorder and the fact that eating disorders have the highest mortality rate of mental illnesses” persists. The witness evidence also confirmed the view expressed in the PACAC Report. “This vagueness limits the ability of NHS commissioners to gauge what services need to be provided and encourages them to devote resources to better recorded diseases.”
Further, I am concerned that there may also be a significant under-reporting of the extent to which EDs have caused or contributed to deaths , leading to cases either not being referred to the coroner or, if they are, the coroner in question determining that death was one of ‘natural causes’, with only the terminal cause of death, and not the underlying ED cause or contribution to the death, being recorded . In such circumstances there is a concern that a number of such deaths (where, for example, lack of care may have contributed to the death) are neither investigated appropriately by the coroner nor taken to inquest with a concomitant risk of a significant under-estimation of the true mortality rate of EDs.
(I propose to explore this issue in separate correspondence with the Medical Examiner for England and Wales (copied in to this Report), the Office for National Statistics and the Coroners’ Society of England and Wales).
In my view, taken together, the absence of statistically robust data on the numbers of those suffering from EDs and the potential under-estimation of those deaths to which EDs may have caused or contributed, gives rise to an objective risk that avoidable ED deaths will continue in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of robust and reliable prevalence data for eating disorders
Wider context from the report “(3) Lack of robust and reliable data regarding the prevalence of eating disorders
Evidence also confirmed that the lack of precise information on the prevalence of eating disorders in the United Kingdom , described by the PHSO Report and the PACAC Follow-up Report as “shocking, given the claim that up to 1.25 million people are suffering from an eating disorder and the fact that eating disorders have the highest mortality rate of mental illnesses” persists. The witness evidence also confirmed the view expressed in the PACAC Report. “This vagueness limits the ability of NHS commissioners to gauge what services need to be provided and encourages them to devote resources to better recorded diseases.”
Further, I am concerned that there may also be a significant under-reporting of the extent to which EDs have caused or contributed to deaths, leading to cases either not being referred to the coroner or, if they are, the coroner in question determining that death was one of ‘natural causes’, with only the terminal cause of death, and not the underlying ED cause or contribution to the death, being recorded. In such circumstances there is a concern that a number of such deaths (where, for example, lack of care may have contributed to the death) are neither investigated appropriately by the coroner nor taken to inquest with a concomitant risk of a significant under-estimation of the true mortality rate of EDs.
(I propose to explore this issue in separate correspondence with the Medical Examiner for England and Wales (copied in to this Report), the Office for National Statistics and the Coroners’ Society of England and Wales).
In my view, taken together, the absence of statistically robust data on the numbers of those suffering from EDs and the potential under-estimation of those deaths to which EDs may have caused or contributed, gives rise to an objective risk that avoidable ED deaths will continue in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Shortage of eating disorder specialists
Wider context from the report “(1) Inadequate training of doctors and other medical professionals re eating disorders
Evidence from a wide range of clinicians who had engaged with Averil in 2012 echoed the evidence of clinicians attending the four inquests of the women referred to above. All five inquests revealed a common theme of wide-spread and continuing lack of training, knowledge, or experience on the part of physicians and medical staff (including GPs and nurse practitioners, as well as acute hospital doctors, nurses and dieticians) regarding eating disorders (EDs) and specifically Anorexia Nervosa (AN). Many witnesses (from both the death 2012 and those in 2017/2018) conceded that they had only the most superficial knowledge of the often complex issues relating to recognition, monitoring, management and treatment of EDs and AN specifically. Their evidence often reflected a lack of familiarity with the King’s College Guidance for the treatment of AN in the community. The evidence of hospital staff revealed, at best, inconsistent implementation of the Royal College of Psychiatrists MARSIPAN guidance for the emergency treatment of AN patients and, at worst, a failure to implement the Guidance at all.
Evidence at Averil’s inquest (and at those of ████████) suggested that limited progress has been made in respect of the PHSO recommendation with regard to the training of doctors and other medical professionals, (notwithstanding the further recommendations of the PACAC Follow-up Report and the Government Response to the latter’s Recommendations). These concerns have been reiterated by the Position Statement of the Royal College of Psychiatrists (PS04/20) of September 2020 “Improving core skills and competence in risk assessment and management of people with eating disorders: What all doctors need to know.”
The evidence at inquest of senior practitioners in the fields of psychiatry, psychology, acute medicine, dietetics, gastroenterology and GP practice all confirmed that there remains, as there was in 2012, a continuing and serious shortage of eating disorder specialists across the country with many Trusts finding it difficult to fill vacancies ; such shortages inevitably impact upon the level and quality of support available to primary care providers and other specialists and therefore, in my view, risks avoidable future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of formally commissioned monitoring provision for moderate to high risk Anorexia Nervosa patients
Wider context from the report “(2) Lack of formally commissioned service level agreement for the provision of robust and effective monitoring of moderate to high risk AN patients by primary or secondary care providers
Evidence confirmed that in response to the PHSO Report an Expert Reference Group (ERG) was convened by NHS England (NHSE) to address the specific recommendation for NHSE to review the existing quality and availability of services to achieve parity for adult ED services with children and young people’s ED services. The National Collaborating Centre for Mental Health (NCCMH) was commissioned to develop new guidance published in August 2019: “Adult Eating Disorders: Community, Inpatient and Intensive Day Patient Care – Guidance for Commissioners and Providers”.
However, the clear and unchallenged evidence received at Averil’s inquest confirmed that there remains a lack of formally commissioned provision for the monitoring of AN patients in primary or secondary care across large parts of the United Kingdom . Whilst the evidence received indicated that Cambridgeshire & Peterborough NHS Foundation Trust are seeking to develop models to ensure the provision of medical monitoring for all ED sufferers, including moderate to high risk patients, there are many areas in the country – including parts of the East of England Region – which still have no such formally commissioned provision. Further, unchallenged evidence identified a number of regions as not even having consultant level psychiatric in-put to the ED services that are purportedly available.
There was unanimity on the part of each of the senior clinicians who gave evidence, as well as a number of independent, instructed experts in the fields of ED and AN, that the continued absence of such monitoring and treatment provision gave rise to not only the risk of avoidable future deaths, but - in the views of many - the inevitability of the same. Evidence confirmed that whilst AN has the highest mortality of any mental disorder affecting young people and adults this should not be simply accepted and that AN and other EDs are treatable mental disorders, with even severe complications such as malnutrition safely reversible. The evidence further established that whilst in the long term primary prevention strategies including early recognition and treatment of the disease was critical, in the short to medium term, improving access to treatment and the effective monitoring of the severely ill is to be regarded as essential to address the risk of avoidable future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation COVID-19 pandemic exacerbation of eating disorder safety deficiencies
Wider context from the report “(4) The impact of the COVID 19 pandemic
I am concerned that the matters giving rise to the risk of future deaths identified at points (1) to (3) above have been - and will continue to be - significantly exacerbated by the on-going pandemic . I therefore request that responses to the above recognise and expressly address this concern.
” 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 Use the national eating-disorder benchmarking report and training compendium to support regional and local training responses to identified need.
Verbatim wording from the response “In order to gain a comprehensive understanding of eating disorder education and training needs, in 2019 HEE commissioned an England wide benchmarking report, to inform the planning and discharge of future training commissions and to develop a comprehensive compendium of training. This is now being used to support regional system leaders and local systems to manage training in response to local need, drawing on learning resources already available and further training opportunities via HEE commissions.” Source location 2021-0058-Response-from-Health-Education-England-Redacted
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 Introduce eating-disorder and mental-health learning resources for medical students and foundation doctors.
Verbatim wording from the response “Our Postgraduate Deans and Foundation School Directors manage the quality of postgraduate medical education and work with employers to design training programmes that equip doctors with the skills they need to provide high-quality patient care. Since the publication of the PHSO and PACAC reports, HEE has introduced changes to medical education to improve mental health awareness across the medical profession. This includes HEE commissioned learning resources for medical students and Foundation 1 and 2 doctors provided in partnership with BEAT and the Royal College of Psychiatrists.” Source location 2021-0058-Response-from-Health-Education-England-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work through a joint eating-disorder expert advisory group to plan future commissioning and determine workforce requirements.
Verbatim wording from the response “HEE is currently working with NHSE/I within a joint eating disorder expert advisory group to ensure effective planning for future commissioning activities and determine the workforce requirements of eating disorder services across the demographic. This work will include the urgent development of an education and training commissioning framework agreement.” Source location 2021-0058-Response-from-Health-Education-England-Redacted
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 physical-health-check training for eating-disorder care with NHS England and NHS Improvement.
Verbatim wording from the response “Further to this, in support of the whole workforce, HEE has developed the ‘Psychological Interventions for People with Eating Disorders: A competence framework in partnership with University College London, which is aimed at all health workers, trainers and supervisors, clinical managers and service commissioners to guide workforce capability development and enhance patient safety. In 2021/22, HEE will be working with NHSE/I to develop physical health check training relating to eating disorder, that is supported by the Physical Health Competency Framework for Mental Health and Learning Disability Settings (HEE December 2020).” Source location 2021-0058-Response-from-Health-Education-England-Redacted
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 competence framework for psychological interventions for people with eating disorders to guide workforce capability and enhance patient safety.
Verbatim wording from the response “Further to this, in support of the whole workforce, HEE has developed the ‘Psychological Interventions for People with Eating Disorders: A competence framework in partnership with University College London, which is aimed at all health workers, trainers and supervisors, clinical managers and service commissioners to guide workforce capability development and enhance patient safety. In 2021/22, HEE will be working with NHSE/I to develop physical health check training relating to eating disorder, that is supported by the Physical Health Competency Framework for Mental Health and Learning Disability Settings (HEE December 2020).” Source location 2021-0058-Response-from-Health-Education-England-Redacted
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 Increase psychiatry placements in the Foundation Programme and continue working with the Royal College of Psychiatrists to improve specialty-training fill rates.
Verbatim wording from the response “As set out in Stepping forward to 2020/21: The Mental Health Workforce Plan for England, published in July 2017, HEE is working with the Royal College of Psychiatrists (RCPsych) to address the fill rates in psychiatry specialty training. Part of this work has resulted in an increase in the number of doctors in the Foundation Programme working in a four-month psychiatry post to 47% nationally in 2018, and HEE continues to work with the RCPsych to improve on this.” Source location 2021-0058-Response-from-Health-Education-England-Redacted
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 Map further psychological-therapy and related-role expansion through a workforce plan to guide local workforce planning and education provision.
Verbatim wording from the response “Many of the expanded workforce will be delivering psychological interventions for people with an eating disorder, the growth of which has been complemented by the HEE provision of 4,500 adult Improving Access to Psychological Therapies practitioners. For children and young people we have recruited 700 new practitioners and trained 3,400 existing NHS staff between 2016 and 2021. HEE has also increased the number of clinical psychologists in training by 25% in 20/21 and 21/22. A psychological professions workforce plan is in train which will map the further expansion of, psychological therapies and related roles to guide local workforce planning and education provision.” Source location 2021-0058-Response-from-Health-Education-England-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission BEAT to develop a programme equipping nursing staff to understand, respond compassionately and signpost people with eating disorders.
Verbatim wording from the response “HEE has also commissioned BEAT to develop a programme for all nursing staff to gain confidence to understand, respond compassionately, and appropriately signpost clients with eating disorders.” Source location 2021-0058-Response-from-Health-Education-England-Redacted
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 and pilot GP-training enhancements, including longer general-practice placements and enhanced mental-health treatment experience.
Verbatim wording from the response “HEE is also working to develop and pilot enhancements to GP training. One of the priorities for this reform is to enhance the delivery of the mental health elements of the GP Specialty Curriculum. This includes increasing GP trainee time in General Practice to 24 months from 18 months and ensuring that all GP trainees are able to gain enhanced experience in the treatment of mental health in primary care settings.” Source location 2021-0058-Response-from-Health-Education-England-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide nationally accessible eating-disorder e-learning through e-Learning for Healthcare, including resources for professionals, students and foundation doctors.
Verbatim wording from the response “In addition to the above, HEE runs an e-learning platform called e-Learning for Health (e-LfH), working in partnership with the NHS and professional bodies to support patient care by providing e-learning to educate and train the health and social care workforce.” Source location 2021-0058-Response-from-Health-Education-England-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission and deliver whole-team cognitive behavioural therapy training for eating-disorder staff.
Verbatim wording from the response “The additional commissions we subsequently made included Cognitive Behaviour Therapy specifically for eating disorders, delivered via whole team training from late 2020. This training covers the whole range of expertise, including ED specialists (70 trained) as well as other staff delivering care in eating disorders services (270 trained to date).” Source location 2021-0058-Response-from-Health-Education-England-Redacted
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 Expand and train the psychological-therapy workforce, including recruiting practitioners, training existing staff and increasing clinical-psychologist trainees.
Verbatim wording from the response “growth targets, education programmes are being commissioned to upskill the existing workforce working with children and adults in psychological therapies and eating disorder treatments. This training is provided across the whole of the mental health workforce ranging from specialist practitioners such as in CBT in eating disorders, teams via Whole Team Training and general awareness such as upskilling junior doctors and nurses.” Source location 2021-0058-Response-from-Health-Education-England-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support trusts to develop comprehensive anorexia nervosa policies and procedures aligned with MARSIPAN guidance.
Verbatim wording from the response “• The East of England Regional Mental Health Strategy and Transformation Board is supporting Trusts to develop comprehensive policies and procedures to manage patients with Anorexia Nervosa, in line with the MARSIPAN guidelines” Source location 2021-0058-Response-from-NHS-England-and-NHS-Improvement-Redacted
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 Deliver Adult Eating Disorder Whole Team Training for staff supporting eating disorder services, including primary care staff.
Verbatim wording from the response “The training courses that are being offered / developed include:” Source location 2021-0058-Response-from-NHS-England-and-NHS-Improvement-Redacted
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 Deliver regional webinars, learning events and conferences on eating disorder care for professionals and parents or carers.
Verbatim wording from the response “The regional East of England mental health team have worked jointly with HEE to support education and guidance to systems in managing eating disorders, with learning to be shared. This has included:” Source location 2021-0058-Response-from-NHS-England-and-NHS-Improvement-Redacted
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 Deliver Cognitive Behavioural Therapy for Eating Disorders postgraduate training for mental health professionals.
Verbatim wording from the response “The training courses that are being offered / developed include:” Source location 2021-0058-Response-from-NHS-England-and-NHS-Improvement-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission a training provider to deliver Maudsley Model of Anorexia Nervosa Therapy for Adults training.
Verbatim wording from the response “• Maudsley Model of Anorexia Nervosa Therapy for Adults (MANTRA): MANTRA is a cognitive-interpersonal treatment. This course is aimed at experienced mental health professionals, to provide them with the skills necessary to deliver this evidence based and NICE recommended treatment. A training provider will be commissioned to deliver this course in 2021/22.” Source location 2021-0058-Response-from-NHS-England-and-NHS-Improvement-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue supporting eating disorder services through regional clinical leads during and beyond the COVID-19 pandemic.
Verbatim wording from the response “In the April 2020 we held a national webinar to share key messages with service providers and commissioners, to support service continuation throughout the pandemic and beyond this we will continue to support services via the regional clinical leads.” Source location 2021-0058-Response-from-NHS-England-and-NHS-Improvement-Redacted
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 Embed mental health practitioners in Primary Care Networks to improve oversight across primary and secondary care for people with severe mental illness, including eating disorders.
Verbatim wording from the response “In addition, the 2021/22 GP contract and Standard Contract are embedding mental health practitioners in Primary Care Networks (PCNs). Although these practitioners will not directly undertake the medical monitoring themselves, they will be able to liaise with the staff who will undertake it and help to ensure adequate oversight of the care of patients with severe mental illnesses, including eating disorders, across primary and secondary care.” Source location 2021-0058-Response-from-NHS-England-and-NHS-Improvement-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make funding available for acute trusts to provide medical-stabilisation training for staff managing eating disorder and self-harm presentations.
Verbatim wording from the response “• Funding has also been made available for all acute trusts in the region to access training for medical staff in managing patients who present at A&E or require admission to a medical ward for self-harm or an eating disorder that requires medical stabilisation. Cambridgeshire & Peterborough (C&P) and Norfolk” Source location 2021-0058-Response-from-NHS-England-and-NHS-Improvement-Redacted
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 Participate in the MHSDS steering group to influence future survey questionnaires and improve representation of eating disorders.
Verbatim wording from the response “Prevalence data
NHSEI recognise and agree that there is a need to improve the data on the prevalence of eating disorders in adults. We have joined the MHSDS steering group (alongside DHSC and other ALBs) to influence the questionnaires that are included in the next survey to ensure representation of eating disorders.” Source location 2021-0058-Response-from-NHS-England-and-NHS-Improvement-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with Health Education England to improve workforce training for adult eating disorder services.
Verbatim wording from the response “NHSEI are working with Health Education England (HEE) to improve workforce training for the adult eating disorder workforce. This is in line with NHS Long Term Plan commitments and backed by significant investment (funding in place up to 2023/24).” Source location 2021-0058-Response-from-NHS-England-and-NHS-Improvement-Redacted
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 Share learning from community eating disorder early implementers through the Adult Eating Disorder Clinical Leads forum to support robust medical-monitoring pathways.
Verbatim wording from the response “In 2019/20 and 2020/21, 12 STPs/ICSs were funded to test new models of integrated care, which will include CED. Eight of these sites chose to focus on improvements to CED services as a specialty area. We will ensure that the learning from the community early implementers sites will be shared via the Adult ED Clinical Leads forum to support services as they embed robust medical monitoring pathways.” Source location 2021-0058-Response-from-NHS-England-and-NHS-Improvement-Redacted
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 Promote MARSIPAN guidance in inpatient settings through quality frameworks in adult eating disorder Provider Collaboratives.
Verbatim wording from the response “MARSIPAN
The published guidance links to the MARSIPAN (Management of Really Sick Patient with Anorexia Nervosa) guidance. Providers and commissioners are encouraged to develop pathways and protocols in line with this advice. The use of MARISPAN in inpatient settings is being promoted through the development of quality frameworks in the adult eating disorder Provider Collaboratives.” Source location 2021-0058-Response-from-NHS-England-and-NHS-Improvement-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for setting medical education standards and curricula rests with the GMC, medical schools, royal colleges and faculties.
Verbatim wording from the response “The standards for medical education in the UK are set by the independent professional regulator, the General Medical Council (GMC). Each individual medical school sets its own undergraduate medical curriculum, which must meet the standards set by the GMC, who then monitor and check to make sure that these standards are maintained. The curricula for postgraduate specialty training are set by individual royal colleges and faculties, and the GMC approves curricula and assessment systems for each training programme.” Source location 2021-0058-Response-from-Health-Education-England-Redacted
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 HEE, the General Medical Council and partners are responsible for advancing sufficient eating-disorder training for doctors and medical professionals.
Verbatim wording from the response “This is not within our gift to deliver but we stand ready to support HEE, the General Medical Council and partners in their efforts to achieve this objective.” Source location 2021-0058-Response-from-NHS-England-and-NHS-Improvement-Redacted
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 Medical Schools Council can influence curricula and training standards for doctors and medical professionals.
Verbatim wording from the response “I would recommend that this report is extended to the Medical Schools Council; who are able to influence the curriculums and training standards for doctors and medical professionals, in order to support this work.” Source location 2021-0058-Response-from-NHS-England-and-NHS-Improvement-Redacted
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 Delivering sufficient eating-disorder training for doctors and medical professionals is not within the respondent’s ability.
Verbatim wording from the response “NHSEI agree that it is imperative that doctors and other medical professionals receive sufficient training on mental health and in particular eating disorders to support parity of esteem and improve patient care.” Source location 2021-0058-Response-from-NHS-England-and-NHS-Improvement-Redacted
Open published response
2 Mar 2021 Martin Keith Sullivan · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure of the asthma triage script to require direct questioning about ineffective breathing View source Failure to provide timely Category 2 ambulance responses during periods of high demand View source Failure of the MPDS algorithm to account for the cumulative effect of multiple symptoms 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
Martin Keith Sullivan · 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
Martin Keith Sullivan, aged 15, died on 24 November 2019 after experiencing a severe asthma attack. He was prioritised as Category 2 during two 999 calls, and his father was not asked about taking him directly to hospital; ambulance delays followed before Martin was taken to hospital, where resuscitation was unsuccessful. Concerns included whether the MPDS algorithm and call-handler script recognised the severity of his symptoms, whether Category 2 response times could be met, and whether direct transport to hospital should have been discussed.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of the asthma triage script to require direct questioning about ineffective breathing
Wider context from the report “2. Rule 6 of the MPDS Protocol recognises that asthma patients are generally very experienced in managing their disease. Noting that statements such as can’t breathe and unable to breathe or a similar description should be considered as ineffective breathing. Ineffective breathing eliciting a Category 1 response.
It is not clear whether this requires a direct question from the EMD or whether it falls into the volunteered category of factors. There was no direct question from the EMD in this case.
Given the significance of breathing problems in an asthma attack, and the inevitable progression without intervention, it is imperative in my view that the script seeks more detail and should not rely on information being ‘volunteered’.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 timely Category 2 ambulance responses during periods of high demand
Wider context from the report “3. This was clearly a busy shift for NWAS, notwithstanding that the service was at 97% of commissioned capacity. 111 ambulances instead of 112 – having increased from 67 circa one hour previously, and it is likely that this was probably building from the reduced numbers of ambulance over the earlier period.
The EA that eventually arrived was outside the 90ᵗʰ percentile target of 40mins.
There is a clear history of NWAS being unable to meet NHS Cat 2 target times, in particular during Qs 3 & 4.
NWAS Annual reports
2018/19
Yearly Category 2 targets: mean - 24.14mins and 90% - 52.31, with increased times for Qs 3&4.
The Category 1,3 &4 targets are generally well met.
2019/20
Yearly Category 2 targets: mean – 26 mins and 90% - 56.27 mins, with increased times for Qs 3&4.
The Category 1,3 &4 targets are generally well met.
I understand that resource funding was applied for in November 19 and has been utilised from February 2020.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 MPDS algorithm to account for the cumulative effect of multiple symptoms
Wider context from the report “1. The MPDS script and algorithm, it seems, were inadequate in this instance to recognise the life-threatening situation that Martin was in.
On the Paediatric evidence this acute attack was only going to end in one way without medical intervention. The evidence before me was that delay in treatment is the main cause of asthma deaths in children.
The algorithm does not account for the cumulative effect of more than one symptom. In this instance; difficulty breathing between sentences, clammy/sweaty and changes in colour.
The Paediatric evidence was that these symptoms in a well-controlled asthmatic whose home remedies are not working are indicative of a severe and life threatening condition.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold a learning event for ambulance services and triage-system providers to share best practice on safely identifying ineffective breathing.
Verbatim wording from the response “In order to ensure that the process of identifying ineffective breathing is embedded within all ambulance services NHS England and NHS Improvement will hold a learning event with all ambulance services, inviting the involvement of triage system providers, to share best practice and ensure ambulance services are enabled to utilise the triage systems safely and effectively.” Source location 2021-0056-Response-from-NHS-England-and-NHS-Improvement-Redacted
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 When used correctly, the MPDS algorithm identifies life-threatening asthma and results in a Category 1 response.
Verbatim wording from the response “It is not the case that the system is relying on the information being offered/volunteered but rather that the questions within Protocol 6 will elicit the information required. It is in response to both the open and closed questions that the EMD must recognise ineffective breathing in a patient with asthma. When applied correctly this is a very reliable method of determining life threatening respiratory distress including life threatening asthma. Any patient who is identified as ineffective breathing should receive a category 1 response. Acute severe asthma” Source location 2021-0056-Response-from-NHS-England-and-NHS-Improvement-Redacted
Open published response
11 Feb 2021 Jack Goodwin · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure of the call-handling script to support discussion of self-transport or provide a realistic ambulance-arrival timescale View source Lack of provision in the call-handling script to specify an acute hospital with an A and E department View source Failure of the call-handling script to emphasise further contact after deterioration for reassessment of urgency View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jack Goodwin · 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
Jack Goodwin experienced chest pains on 15 December 2017 and suffered a cardiac arrest after a delay in receiving emergency medical assistance, resulting in a hypoxic brain injury. He later developed significant cognitive impairment and died at home on 15 January 2020 from complications arising from the cardiac arrest and prolonged downtime. Concerns related to ambulance call-handling scripts, including the lack of guidance about self-transport, the need for an acute hospital, and reassessment if the patient deteriorated.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of the call-handling script to support discussion of self-transport or provide a realistic ambulance-arrival timescale
Wider context from the report “1. The inquest heard that at the time of the calls to NWAS on 15th December 2017 they were very busy. The script used by the call handler allowed them to indicate that they were busy. However it did not allow for any suggestion or discussion about whether he would be better to make his own way there or allow for the provision by the call handler of a realistic timescale for the ambulance arriving . As a consequence it was difficult for the call maker to make an assessment of the best course of action to ensure that Mr Goodwin received medical attention at the earliest opportunity.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 provision in the call-handling script to specify an acute hospital with an A and E department
Wider context from the report “2. When a decision was made to take Mr Goodwin direct to the hospital and NWAS were told. There was no provision within the script to emphasise that the hospital would need to be an acute hospital with an A and E department .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 call-handling script to emphasise further contact after deterioration for reassessment of urgency
Wider context from the report “3. There was an indication that given that if Mr Goodwin deteriorated then a further call should be made to NWAS. The evidence before the inquest was that this was not emphasised in such a way within the script to ensure there could be a further assessment of urgency .
” 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 Explore adding advice to ambulance call scripts to direct callers to the nearest hospital with an emergency department when appropriate.
Verbatim wording from the response “999 calls to the ambulance service can be answered anywhere in the country so we cannot rely on local knowledge; call handlers do not have immediate access to which is the nearest emergency department in those situations where a caller advises that the patient would make their own way to hospital. In appropriate circumstances, NHS E/I consider that advising the caller that they should make their way to the nearest emergency department, noting that not all hospitals have emergency departments, would be a useful addition to the script callers receive. This will be explored through the Ambulance Transformation Forum.” Source location 2021-0036-Response-from-NHS-England_Published
Open published response
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Providing an accurate ambulance arrival time is impracticable because lower-priority responses may be diverted to higher-priority incidents.
Verbatim wording from the response “All ambulance services are responsible for having in place scripts and procedures for dealing with delays in responding when under operational pressure. It is not possible in practice to offer an accurate arrival time for any given patient, but ambulance services will know an approximate current waiting time for that category of patient. NHS E/I support a position that callers should be provided with sufficient information to make informed decisions if an ambulance has not been despatched to the patient.” Source location 2021-0036-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 Case exit scripts already routinely instruct callers to call 999 again if the patient's condition changes or deteriorates.
Verbatim wording from the response “Instructions on worsening conditions, including specifically to call back on 999 should the patient’s condition change or deteriorate, are standard components of the case exit script. If this was not provided in a clear and easy to interpret manner this is a matter for ambulance services to resolve locally as a training issue for call handlers.” Source location 2021-0036-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 Ambulance services must resolve unclear deterioration instructions locally through call-handler training.
Verbatim wording from the response “Instructions on worsening conditions, including specifically to call back on 999 should the patient’s condition change or deteriorate, are standard components of the case exit script. If this was not provided in a clear and easy to interpret manner this is a matter for ambulance services to resolve locally as a training issue for call handlers.” Source location 2021-0036-Response-from-NHS-England_Published
Open published response
15 Jan 2021 Kevin John LOVATT · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 2 Insufficient provision of Advanced Life Support-trained staff in the prison estate View source Lack of guidance and training on safe use of force for resistant prisoners with items in their mouths View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Kevin John LOVATT · 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
Kevin John LOVATT was a serving prisoner at HMP Dovegate who died at the prison on 22 December 2017 after swallowing a package of illicit drugs and choking. The report identified concerns about communication, the response to choking, confusion at the scene, access to Advanced Life Support-trained staff and training on managing prisoners with items in their mouths that could compromise breathing.
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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 Insufficient provision of Advanced Life Support-trained staff in the prison estate
Wider context from the report “During evidence at the inquest I heard that nursing staff at HMP Dovegate (and throughout the prison estate) are trained to an Intermediate Life Support level . I realise it would be impractical for all nursing staff at prisons to be trained to an Advanced Life Support level however I was informed that at some stage there was at least one paramedic employed at HMP Dovegate who was trained to ALS level . I wonder if there might be some limited provision of ALS trained staff in the prison estate and if this could be part of the appropriate commissioning arrangements.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 and training on safe use of force for resistant prisoners with items in their mouths
Wider context from the report “Following the investigation by the Prisons and Probation Ombudsman a recommendation was made that you should ensure that there is clear guidance and training on the safe use of force when resistant prisoners have items in their mouth which might compromise their breathing . In evidence at the inquest I heard that suitable training on this topic did not appear to have been delivered and that it would be appreciated by prison staff. I wonder therefore if the national training you provide could include control and restraint for prisoners with items in their mouths.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Advanced Life Support training is not appropriate for prison healthcare professionals because it may require procedures outside their registered clinical competencies.
Verbatim wording from the response “The Resuscitation Council UK, who provide the recognised guidelines, including training, for England, outline that Advanced Life Support is appropriate for healthcare professionals who would undertake advanced life support as part of their clinical duties. This includes doctors, paramedics and nurses working in acute care areas (e.g. Emergency Departments, Coronary Care Units, Intensive Care Units, high dependency units, operating theatres, acute medical admissions units) or on resuscitation/medical emergency Critical Care outreach Teams. Advanced Life Support also involves some specialist clinical procedures which, to be clinically effective and cause no harm, must be performed as a regular part of clinical duties.” Source location 2021-0012-Response-from-NHS-England-and-NHS-Improvement_Published
Open published response
4 Jan 2021 Pardeep Singh PLAHE · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Failure of the EMIS consultation-list mitigation to reliably ensure practitioner logout and re-login View source Failure of EMIS consultation lists to update reliably View source Failure to ensure that all EMIS-using GP surgeries are alerted to the consultation-list error 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
Pardeep Singh PLAHE · 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
Pardeep Singh Plahe died at Queen Elizabeth Hospital on 12 August 2020 after inflicting a catastrophic injury to his neck with a decorative samurai sword. He had been increasingly concerned about a physical health complaint and had a scheduled GP telephone consultation that was missed because of a technical problem with the EMIS system. The report raised concerns that consultation lists could fail to update, creating a risk that urgent telephone consultations might be missed, and that the identified mitigation depended on practitioners remembering to log out and back in to the 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 of the EMIS consultation-list mitigation to reliably ensure practitioner logout and re-login
Wider context from the report “1. On the 10th August at 17:30, hours before he inflicted the fatal wound to his neck, Mr. Plahe had a telephone consultation scheduled with his GP at the Ashfield Surgery. The appointment had been booked by his sister that afternoon. Due to a technical issue with the EMIS system the consultation list of the GP due to speak to Mr. Plahe did not update so he did not realise the appointment had been added to his list and did not call Mr. Plahe. Practitioners at the surgery had realised that the system was intermittently not updating consultation lists on or around the 30th July 2020 and had raised the issue with EMIS on the 4th August 2020. To date a solution to correct this intermittent problem has not been identified. Evidence was given at inquest that it does not just affect the Ashfield Surgery but has occurred at other surgeries across the country.
2. Particularly for telephone consultations (where there will not be a patient physically present in the surgery to query why they have not been seen), the fact that the consultation lists do not always update creates a risk to life as a consultation could be missed for a patient with a medical emergency.
3. It is not known whether all GP Surgeries using EMIS have raised an alert that this error can occur.
4. To mitigate the risk of missing appointments the Ashfield Surgery has identified that if practitioners log out of the EMIS system and then log back on the consultation list will update . Therefore, all practitioners are advised to log out and log back in before completing their consultation lists. However, on one occasion since Mr. Plahe's death a locum GP carrying out a list at the surgery did not know to do this and missed an appointment .
5. The methods of mitigating this risk are vulnerable to human error if the practitioner is unaware of the need to log out of EMIS and log back in or if they forget to do so.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 EMIS consultation lists to update reliably
Wider context from the report “1. On the 10th August at 17:30, hours before he inflicted the fatal wound to his neck, Mr. Plahe had a telephone consultation scheduled with his GP at the Ashfield Surgery. The appointment had been booked by his sister that afternoon. Due to a technical issue with the EMIS system the consultation list of the GP due to speak to Mr. Plahe did not update so he did not realise the appointment had been added to his list and did not call Mr. Plahe. Practitioners at the surgery had realised that the system was intermittently not updating consultation lists on or around the 30th July 2020 and had raised the issue with EMIS on the 4th August 2020. To date a solution to correct this intermittent problem has not been identified . Evidence was given at inquest that it does not just affect the Ashfield Surgery but has occurred at other surgeries across the country.
2. Particularly for telephone consultations (where there will not be a patient physically present in the surgery to query why they have not been seen), the fact that the consultation lists do not always update creates a risk to life as a consultation could be missed for a patient with a medical emergency .
3. It is not known whether all GP Surgeries using EMIS have raised an alert that this error can occur.
4. To mitigate the risk of missing appointments the Ashfield Surgery has identified that if practitioners log out of the EMIS system and then log back on the consultation list will update. Therefore, all practitioners are advised to log out and log back in before completing their consultation lists. However, on one occasion since Mr. Plahe's death a locum GP carrying out a list at the surgery did not know to do this and missed an appointment.
5. The methods of mitigating this risk are vulnerable to human error if the practitioner is unaware of the need to log out of EMIS and log back in or if they forget to do so.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that all EMIS-using GP surgeries are alerted to the consultation-list error
Wider context from the report “1. On the 10th August at 17:30, hours before he inflicted the fatal wound to his neck, Mr. Plahe had a telephone consultation scheduled with his GP at the Ashfield Surgery. The appointment had been booked by his sister that afternoon. Due to a technical issue with the EMIS system the consultation list of the GP due to speak to Mr. Plahe did not update so he did not realise the appointment had been added to his list and did not call Mr. Plahe. Practitioners at the surgery had realised that the system was intermittently not updating consultation lists on or around the 30th July 2020 and had raised the issue with EMIS on the 4th August 2020. To date a solution to correct this intermittent problem has not been identified. Evidence was given at inquest that it does not just affect the Ashfield Surgery but has occurred at other surgeries across the country.
2. Particularly for telephone consultations (where there will not be a patient physically present in the surgery to query why they have not been seen), the fact that the consultation lists do not always update creates a risk to life as a consultation could be missed for a patient with a medical emergency.
3. It is not known whether all GP Surgeries using EMIS have raised an alert that this error can occur.
4. To mitigate the risk of missing appointments the Ashfield Surgery has identified that if practitioners log out of the EMIS system and then log back on the consultation list will update. Therefore, all practitioners are advised to log out and log back in before completing their consultation lists. However, on one occasion since Mr. Plahe's death a locum GP carrying out a list at the surgery did not know to do this and missed an appointment.
5. The methods of mitigating this risk are vulnerable to human error if the practitioner is unaware of the need to log out of EMIS and log back in or if they forget to do so.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a Safety Advisory Notice to GP practices and clinical services setting out required actions and further information.
Verbatim wording from the response “• A Safety Advisory Notice (SAN) was sent out to all GP Practices and Clinical Services on 3 February 2021, advising organisations and users of the issue, the actions that need to be completed, and a link to direct them to further information if required.” Source location 2021-0061-Response-from-NHS-England-and-NHS-Improvement-Redacted
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 EMIS actions addressing the appointment-list issue mean no further action is considered necessary from NHSE/I at this time.
Verbatim wording from the response “Given the action already being taken by EMIS, my Primary Care colleagues consider that there is no further action for NHSE/I to take at this time.” Source location 2021-0061-Response-from-NHS-England-and-NHS-Improvement-Redacted
Open published response
Concerns raised 1 Lack of national guidance on engaging the families of mental health patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Steven Clive Cooke · 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 Clive Cooke died at his home on 9 July 2019 after hanging himself by a ligature fashioned from a grey wiring cable. The principal concern was the absence of national guidance on engaging with the families of mental health patients to obtain as full a picture as possible.
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 on engaging the families of mental health patients
Wider context from the report “(1) That there is no national guidance regarding engagement with the family of a Mental Health patient to gain as full a picture as possible .
” Open source report
18 Dec 2020 Kalila Elizabeth Griffiths · Prevention of Future Deaths report East London
View report summary
Concerns raised 7 Failure to arrange follow-up after asthma-attack attendance at emergency or out-of-hours services View source Lack of electronic primary-care surveillance of preventer-inhaler prescribing View source Insufficient asthma-care training for GPs and emergency departments View source Failure to refer eligible asthma patients to a specialist asthma service View source Unclear guidance on which guidelines to use for acute asthma attacks View source Failure to arrange secondary-care follow-up after recurrent asthma-attack emergency attendances View source Conflicting asthma-care guidelines hindering clinical care View source See 4 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
Kalila Elizabeth Griffiths · 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
Kalila Elizabeth Griffiths, who had complex medical conditions including asthma, developed worsening breathing problems in January 2019 and died on 1 February 2019 from a pulmonary embolism, with asthma contributing to her death. The report states that she was discharged from hospital on 19 January despite severe respiratory deterioration and required observation and respiratory physician assessment. Concerns included the management of asthma patients nationally, inconsistent clinical guidelines, uncertainty over which guidelines should be used for acute asthma attacks, and insufficient training.
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 arrange follow-up after asthma-attack attendance at emergency or out-of-hours services
Wider context from the report “(1) Factual and expert witnesses gave evidence that there are concerns about the management of asthma patients within the NHS as a whole. The National Review of Asthma Deaths (“NRAD”), was published in 2014. This was five years before the care provided to Kalila and six years before the Inquest. Notwithstanding the length of time that has passed, the Inquest heard that eighteen of the nineteen recommendations set out in the NRAD report have not been implemented . The recommendations of importance in this case were:
• Patients with asthma must be referred to a specialist asthma service if they have required more than two courses of systemic corticosteroids in the previous twelve months.
• Follow-up arrangements must be made after every attendance at an emergency department or out of hours’ service for an asthma attack.
• Secondary care follow-up should be arranged after patients have attended the emergency department two or more times with an asthma attack in the previous twelve months.
• Electronic surveillance of prescribing in primary care should be in place to pick up too many or too few preventer inhalers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 electronic primary-care surveillance of preventer-inhaler prescribing
Wider context from the report “(1) Factual and expert witnesses gave evidence that there are concerns about the management of asthma patients within the NHS as a whole. The National Review of Asthma Deaths (“NRAD”), was published in 2014. This was five years before the care provided to Kalila and six years before the Inquest. Notwithstanding the length of time that has passed, the Inquest heard that eighteen of the nineteen recommendations set out in the NRAD report have not been implemented . The recommendations of importance in this case were:
• Patients with asthma must be referred to a specialist asthma service if they have required more than two courses of systemic corticosteroids in the previous twelve months.
• Follow-up arrangements must be made after every attendance at an emergency department or out of hours’ service for an asthma attack.
• Secondary care follow-up should be arranged after patients have attended the emergency department two or more times with an asthma attack in the previous twelve months.
• Electronic surveillance of prescribing in primary care should be in place to pick up too many or too few preventer inhalers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 asthma-care training for GPs and emergency departments
Wider context from the report “(4) The evidence revealed that further training is required for GPs and emergency departments in providing safe asthma 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 refer eligible asthma patients to a specialist asthma service
Wider context from the report “(1) Factual and expert witnesses gave evidence that there are concerns about the management of asthma patients within the NHS as a whole. The National Review of Asthma Deaths (“NRAD”), was published in 2014. This was five years before the care provided to Kalila and six years before the Inquest. Notwithstanding the length of time that has passed, the Inquest heard that eighteen of the nineteen recommendations set out in the NRAD report have not been implemented . The recommendations of importance in this case were:
• Patients with asthma must be referred to a specialist asthma service if they have required more than two courses of systemic corticosteroids in the previous twelve months.
• Follow-up arrangements must be made after every attendance at an emergency department or out of hours’ service for an asthma attack.
• Secondary care follow-up should be arranged after patients have attended the emergency department two or more times with an asthma attack in the previous twelve months.
• Electronic surveillance of prescribing in primary care should be in place to pick up too many or too few preventer inhalers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unclear guidance on which guidelines to use for acute asthma attacks
Wider context from the report “(3) It was noted that it is not clear to healthcare professionals which guidelines should be used for the management of acute asthma attacks . Many clinicians consider that the NICE guidelines can be used for the management of an acute asthma flare-up. The Inquest heard that this is incorrect and that the BTS/SIGN guidelines should be used.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 arrange secondary-care follow-up after recurrent asthma-attack emergency attendances
Wider context from the report “(1) Factual and expert witnesses gave evidence that there are concerns about the management of asthma patients within the NHS as a whole. The National Review of Asthma Deaths (“NRAD”), was published in 2014. This was five years before the care provided to Kalila and six years before the Inquest. Notwithstanding the length of time that has passed, the Inquest heard that eighteen of the nineteen recommendations set out in the NRAD report have not been implemented . The recommendations of importance in this case were:
• Patients with asthma must be referred to a specialist asthma service if they have required more than two courses of systemic corticosteroids in the previous twelve months.
• Follow-up arrangements must be made after every attendance at an emergency department or out of hours’ service for an asthma attack.
• Secondary care follow-up should be arranged after patients have attended the emergency department two or more times with an asthma attack in the previous twelve months.
• Electronic surveillance of prescribing in primary care should be in place to pick up too many or too few preventer inhalers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Conflicting asthma-care guidelines hindering clinical care
Wider context from the report “(2) Clinicians raised concerns in relation to the number of different guidelines relating to asthma (NICE Guidelines, BTS/SIGN Guidelines and GINA Guidelines). It was noted that there are discrepancies between the guidelines . This makes it difficult for those general practitioners and emergency care practitioners who are providing care to patients.
” Open source report
18 Dec 2020 Jennifer Sarah Myfanwy SPENCER · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 1 Lack of Mental Health Professionals’ awareness of “Shamanic” hallucinogenic drugs and their propensity to cause or exacerbate psychosis View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jennifer Sarah Myfanwy SPENCER · 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
Jennifer Sarah Myfanwy Spencer's mental health deteriorated after she ingested Shamanic hallucinogenic drugs and practised Kundalini Yoga, before she deliberately fell from Beachy Head on 16 November 2019 intending to end her life. The report identifies a lack of awareness among mental health professionals about Shamanic hallucinogens and their potential to cause or exacerbate psychosis, resulting in sub-optimal assessment, treatment and care.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of Mental Health Professionals’ awareness of “Shamanic” hallucinogenic drugs and their propensity to cause or exacerbate psychosis
Wider context from the report “There is a lack of awareness amongst Mental Health Professionals about “Shamanic” hallucinogenic drugs and their propensity to cause or exacerbate psychosis. This results in sub-optimal assessment, treatment and care. Ayahuasca, DMT and similar “Shamanic” hallucinogens are becoming more commonplace in the UK. Greater learning about them is required by Mental Health Professionals. Ref – Therapeutic Advances in Psychopharmacology 2017, Vol. 7(4) 141-157, dos Santos, Hallak, Mouso.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest in psychological therapies for people with severe mental illness through the community mental-health transformation programme.
Verbatim wording from the response “In addition to this, as part of the NHS Long Term Plan’s commitment to transform community mental health services, we are investing £181M in psychological therapies for severe mental illness (SMI). This includes the roll-out of ‘understanding psychosis and bipolar disorder’ training, which will be rolled out across staff working in community mental health teams over the next three years. The aim of this training is to ensure those working with people presenting with psychosis recognise the diverse bio-psychosocial factors (including substance use) that can impact upon a person's mental health.” 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 Deliver a national suicide-reduction support programme helping local partnerships improve safety planning, substance-misuse assessment and joint working with substance-misuse services.
Verbatim wording from the response “package with the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) and National Collaborating Centre for Mental Health (NCCMH) working together to support STPs in their quality improvement plans, as part of the national suicide prevention programme.” 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 Roll out understanding-psychosis-and-bipolar-disorder training to staff working in community mental-health teams.
Verbatim wording from the response “In addition to this, as part of the NHS Long Term Plan’s commitment to transform community mental health services, we are investing £181M in psychological therapies for severe mental illness (SMI). This includes the roll-out of ‘understanding psychosis and bipolar disorder’ training, which will be rolled out across staff working in community mental health teams over the next three years. The aim of this training is to ensure those working with people presenting with psychosis recognise the diverse bio-psychosocial factors (including substance use) that can impact upon a person's mental health.” 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 Raise awareness of shamanic hallucinogenic drugs and escalate related concerns through relevant forums.
Verbatim wording from the response “Key components of this support programme include supporting services with safety planning, using resources such as The National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) ‘Safer services: A toolkit for specialist mental health services and primary care’, which includes guidance for mental health services to work jointly with local substance misuse services and having specific training in place for staff on substance misuse assessment. I know that the South East region suicide prevention lead is working to raise awareness and escalate concerns regarding ‘shamanic hallucinogenic drugs’ via relevant forums to increase awareness and understanding of this risk factor.” 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 Public Health England is better placed to consider shamanic hallucinogens in its illicit drugs and medicines guidance.
Verbatim wording from the response “Your concerns around the lack of awareness of Shamanic hallucinogens are noted. It would be relevant that colleagues at Public Health England are better placed to consider this in their work on “Misuse of illicit drugs and medicines guidance”. I have shared your report and our response with my colleague Yvonne Doyle.” Source location Response from NHS England
Open published response
Concerns raised 5 Failure of EPR records to accurately reflect information given to patients View source Failure to accurately transfer EPR information to patient information leaflets View source Failure to provide written follow-up of advice from virtual consultations View source Failure to assess patients’ understanding of advice during virtual consultations View source Failure to use a standard set of initial questions during clinical triage View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Thomas Rawnsley · 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
Thomas Rawnsley, a residential nursing home resident, developed a chest infection, later collapsed at the home and died in hospital on 4 February 2015. Concerns included the quality of safety-netting advice, the risks of telephone consultations and incomplete information during clinical triage, and inaccuracies or omissions when paramedic advice was transferred to patient information leaflets.
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 EPR records to accurately reflect information given to patients
Wider context from the report “(3) The information which appears on the EPR is not accurately recorded on the patient information leaflet where pressures of time mean that paramedics are rushing to summarise the instructions on the EPR on the patient information leaflet. This could lead to incorrect information being provided to patients or incomplete information being provided to patients along with the EPR not properly reflecting the information which has actually been given to the patient .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately transfer EPR information to patient information leaflets
Wider context from the report “(3) The information which appears on the EPR is not accurately recorded on the patient information leaflet where pressures of time mean that paramedics are rushing to summarise the instructions on the EPR on the patient information leaflet. This could lead to incorrect information being provided to patients or incomplete information being provided to patients along with the EPR not properly reflecting the information which has actually been given to the patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide written follow-up of advice from virtual consultations
Wider context from the report “(1) Primary care are undertaking more and more virtual consultations with patients and the advice that is provided is inherently more risky over the phone with GPs not being in a strong position to assess the patients understanding of the advice that has been given in the same way as they can when the patient is sitting in front of them in the practice. This advice is not followed up in writing and therefore it may be misinterpreted or incorrectly passed from one care team to another in the event of someone, like Thomas, is having his care delivered by professional carers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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’ understanding of advice during virtual consultations
Wider context from the report “(1) Primary care are undertaking more and more virtual consultations with patients and the advice that is provided is inherently more risky over the phone with GPs not being in a strong position to assess the patients understanding of the advice that has been given in the same way as they can when the patient is sitting in front of them in the practice. This advice is not followed up in writing and therefore it may be misinterpreted or incorrectly passed from one care team to another in the event of someone, like Thomas, is having his care delivered by professional carers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to use a standard set of initial questions during clinical triage
Wider context from the report “(2) There is a standard set of questions asked by the call handler on a 111 or 999 call which is not then replicated for clinicians who subsequently triage a patient . Without a standard set of initial questions asked it is entirely possible that clinicians will provide advice in isolation of other important matters . This could be as simple as current medications that the patient routinely takes or current diagnosis the patient has which impact upon the advice to be provided. This may lead to incomplete or worse, inappropriate advice being given to patients during a clinical triage.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Routine written follow-up after every remote primary-care consultation is considered disproportionate; follow-up should be based on clinical judgment.
Verbatim wording from the response “In light of the above we consider it would be disproportionate to routinely require the provision of written follow up information following any and every remote consultation in primary care but that this should be based on any clinical judgement.” Source location 2020-0283-Response-from-NHS-National-Medical-Director-Redacted
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 Replicating NHS 111’s standard questions for subsequent clinicians is considered unnecessary because the existing assessment and information-sharing process is sufficient.
Verbatim wording from the response “In light of this, we consider that replicating the standard set of questions asked by 111 call handlers to clinicians subsequently involved, would not improve the process which is in place, as described above.” Source location 2020-0283-Response-from-NHS-National-Medical-Director-Redacted
Open published response
9 Dec 2020 Leslie Harris · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Failure to provide clear and consistent guidance on movement of patients to wards where other patients are in isolation from Covid View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Leslie Harris · 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
Leslie Harris was admitted to Stepping Hill Hospital after an accidental fall, underwent surgery for a fractured hip, and later died after testing positive for Covid-19. The principal concern was that interpretation of Public Health England guidance led to his movement to a ward where patients were isolating from Covid-19, potentially exposing vulnerable inpatients to infection; the trust subsequently changed its policy.
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 clear and consistent guidance on movement of patients to wards where other patients are in isolation from Covid
Wider context from the report “The inquest heard that he was moved to a ward where other patients were in isolation from Covid due to the interpretation of Public Health England guidance about management in these circumstances. As a result of reflection and concerns about interpreting the guidance in this way the trust have changed their policy and such movement no longer takes place. However, the guidance from PHE has not been amended and it was unknown how other trusts were choosing to interpret the guidance and as such putting potentially vulnerable patients at risk of developing Covid 19 whilst an in-patient .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implementation of national infection-control guidance and related risk assessments is assigned to healthcare providers at local level.
Verbatim wording from the response “The principles in the guidance apply to all health and care settings. Its implementation should be underpinned at provider level by risk assessments that take into consideration the patient, environment, procedure and task being undertaken by any member of health care staff, and through safe systems of working: administrative, environmental and engineering measures/controls that need to be adopted to reduce the risk of transmission, including: personal protective equipment, hand hygiene, social distancing, cleanliness/decontamination of the environment and equipment, ventilation and separation and segregation of patient and staff within the high, medium and low risk pathways.” Source location 2020-0280-Response-from-NHS-England-and-NHS-Improvement-Redacted
Open published response
Concerns raised 1 Failure to notify the existing GP when the Personal Demographics service is updated or amended View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ronald Richard TILLEY · 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
Ronald Richard Tilley presented to hospital on 16 October 2019 with a right ischaemic leg after anticoagulation had been stopped because of concerns about his capacity to manage medication. An assessment of his memory and capacity was completed, but the GP did not receive the communications because another surgery had amended the GP and correspondence address on the Personal Demographic Service; the principal concern was that such amendments do not notify the existing GP.
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 notify the existing GP when the Personal Demographics service is updated or amended
Wider context from the report “(1) When the Personal Demographics service is updated or amended there is no notification sent to the existing GP noted on the system
” 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 Rationalise and streamline systems and data flows for managing primary care registration.
Verbatim wording from the response “Whilst statistics may reflect positively on the system as a whole, I recognise that the key element of a quality service is the experience of individual patients and NHS Digital will take steps within its power to further reduce the risk of such untoward events. A programme of work is running which is in the process of rationalising and streamlining the systems and data flows in the management of primary care registration. The circumstances surrounding Mr Tilley's death will be brought to the attention of this programme so that improvements may be considered through appropriate consultation with system users and stakeholders.” Source location 2020-0278-Response-from-NHS-Digital-Redacted
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 GMS registration changes notify the old GP practice, while ‘Other’ services registrations do not update PDS or require such notification.
Verbatim wording from the response “In either case, Primary Care Support England (‘PCSE’), who have responsibility for managing primary care registration on behalf of NHS England, will validate and complete the registration by updating PDS with the GP practice code, depending on the chosen pathway, and apply a geographic administrative indicator known as an NHAIS cipher. In completing this action, a series of notifications is triggered from PDS to inform the old GP practice of the transfer and deduct the patient from the practice’s patient list and, separately, to initiate the transfer of the patient’s paper medical record envelope, which is often referred to as “the Lloyd George”.” Source location 2020-0278-Response-from-NHS-Digital-Redacted
Open published response
1 Dec 2020 Anthony Slack · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Failure to maintain staff clarity about PPE requirements View source Limited documentation of care home staff observations View source Failure to share and implement changes to PPE guidance View source Lack of risk assessment for admission of new residents View source Failure to undertake observations of sufficient quality View source Insufficient ambulance availability for timely transport to an acute setting View source See 3 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
Anthony Slack · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Anthony Slack, who had underlying health issues including asbestos-related pulmonary fibrosis, suffered an unwitnessed fall at a care home and waited over four hours for an ambulance. He later deteriorated, was transferred to hospital, and died on 13 April 2020. Concerns included limited care-home documentation and observations, unclear Covid-19 admission risk assessment and PPE arrangements, and ambulance delays linked to pandemic-related capacity pressures.
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 maintain staff clarity about PPE requirements
Wider context from the report “4. Staff were unclear as to the PPE requirements as a result of changes to the guidance that were occurring on a regular basis and it was unclear how changes were being shared with staff and implemented.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 documentation of care home staff observations
Wider context from the report “1. The documentation available at the inquest from the home was limited in detail . As a result, it was difficult to understand what observations had been undertaken by care home staff were monitoring him.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to share and implement changes to PPE guidance
Wider context from the report “4. Staff were unclear as to the PPE requirements as a result of changes to the guidance that were occurring on a regular basis and it was unclear how changes were being shared with staff and implemented .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 risk assessment for admission of new residents
Wider context from the report “3. The inquest heard that after the home went into lockdown Covid 19 was found in residents within the home. At the inquest the home were unclear if staff had brought it into the home or if the admission of residents from the community who were not tested for Covid 19 before admission were the cause of the entering the home. There was no risk assessment in place relating to admission of new residents.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 observations of sufficient quality
Wider context from the report “2. The evidence given at the inquest was that the observations were of limited quality notwithstanding the diagnosis of Covid 19 and his vulnerability.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 ambulance availability for timely transport to an acute setting
Wider context from the report “5. The inquest heard that the ambulance was delayed due to shortages of available ambulances . The inquest was told this was driven by a number of factors. This included staff absences due to the need to self-isolate awaiting testing and the increased cleaning needs in relation to ambulances required by Covid 19. The inquest was told that at some points in the day and in some acute trusts, ambulance crews were being supported by on-site cleaning crews. This meant quicker turnaround times and increased capacity. This was not consistent and not on a 24/7 basis. As a result, ambulances were struggling to reach vulnerable and unwell members of the public and transport them to an acute setting .
” Open source report
Concerns raised 2 Failure to document received specialist advice and confirm understanding View source Failure to confirm and record specialist advice 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
Peter James Michael Unsworth · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter James Michael Unsworth had a history of deep vein thromboses and was taking long-term anticoagulant medication before a right hip replacement. After developing an infected hip and undergoing surgery, his anticoagulant dose was reduced following haematological advice that was not recorded in writing; he subsequently developed pulmonary emboli and died at home on 29 July 2018. The principal concern was that the lack of written records may have led to a misunderstanding of the advice given and its significance.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to document received specialist advice and confirm understanding
Wider context from the report “The evidence showed that:
1. The advice provided by the Consultant Haematologist related to a very complex medical situation. It was not recorded in writing. The Consultant Orthopaedic surgeon did not record it in the patient’s records nor email his understanding of the advice to the Consultant Haematologist for confirmation of what he understood the advice to be.
2. The Consultant Haematologist did not confirm her advice in writing or make any record of the advice given.
3. As a consequence, there may have been a misunderstanding of the basis on which the advice was sought and/or given, and of the import of the 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 Failure to confirm and record specialist advice
Wider context from the report “The evidence showed that:
1. The advice provided by the Consultant Haematologist related to a very complex medical situation. It was not recorded in writing. The Consultant Orthopaedic surgeon did not record it in the patient’s records nor email his understanding of the advice to the Consultant Haematologist for confirmation of what he understood the advice to be.
2. The Consultant Haematologist did not confirm her advice in writing or make any record of the advice given.
3. As a consequence, there may have been a misunderstanding of the basis on which the advice was sought and/or given, and of the import of the advice.
” Open source report
Concerns raised 2 Lack of shared patient care records across health care departments View source Failure of health care departments to communicate crucial patient information View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Ball · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Ball was found deceased at home on 30 June 2019 after taking methadone and venlafaxine with the intention of taking his own life following delusions and paranoia. His discharge care plan was not fully implemented, including the planned community support. Concerns included poor communication between healthcare departments with separate patient records, and no process to ensure that emails were received or acted upon.
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 shared patient care records across health care departments
Wider context from the report “Different health care departments have different patient care records and the departments did not communicate with one another. Evidence was heard that healthcare professionals would have to rely on professional curiosity to ascertain crucial information regarding their patients. The examples used within the Inquest of David Ball were that the Hospital, Social Care and Derbyshire Healthcare all had different patient care records .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 health care departments to communicate crucial patient information
Wider context from the report “Different health care departments have different patient care records and the departments did not communicate with one another . Evidence was heard that healthcare professionals would have to rely on professional curiosity to ascertain crucial information regarding their patients . The examples used within the Inquest of David Ball were that the Hospital, Social Care and Derbyshire Healthcare all had different patient care records.
” 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 Task the Learning from Deaths Forum with considering system improvements alongside the move to a shared care record.
Verbatim wording from the response “The Forum will be tasked with considering system improvements complimentary to the move to a Shared Care Record and any recommendations will be escalated nationally through NHS E/I’s Executive Quality Group and associated sub-group which considers learning and improvement from these matters.” Source location 2020-0251-Response-from-NHS-England-and-NHS-Improvement-Redacted.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 a shared care record for Derby and Derbyshire to address information-sharing problems across multiple healthcare providers.
Verbatim wording from the response “- Shared Care Record: A clear plan is in place to bring together a shared care record for Derby and Derbyshire plans to address the problems where there are multiple healthcare providers involved in a person’s care. This work is unlikely to be completed until 2024. In the meantime, there are systems in place to facilitate shared care conversations which include a Mental Health Liaison Team who will share relevant details on request and where appropriate in line with data protection regulations and a Mental Health Risk Triage Assessment Form, in use at Chesterfield Royal Hospital (CRH). This triage assessment form is designed to prompt the professional completing it to contact the Mental Health Liaison Team where a risk is identified.” Source location 2020-0251-Response-from-NHS-England-and-NHS-Improvement-Redacted.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 Use interim shared-care communication systems, including Mental Health Liaison Team information-sharing and a mental health risk triage assessment form.
Verbatim wording from the response “- Shared Care Record: A clear plan is in place to bring together a shared care record for Derby and Derbyshire plans to address the problems where there are multiple healthcare providers involved in a person’s care. This work is unlikely to be completed until 2024. In the meantime, there are systems in place to facilitate shared care conversations which include a Mental Health Liaison Team who will share relevant details on request and where appropriate in line with data protection regulations and a Mental Health Risk Triage Assessment Form, in use at Chesterfield Royal Hospital (CRH). This triage assessment form is designed to prompt the professional completing it to contact the Mental Health Liaison Team where a risk is identified.” Source location 2020-0251-Response-from-NHS-England-and-NHS-Improvement-Redacted.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 Coordination and management of discharge care plans fall outside NHS Digital’s area of responsibility.
Verbatim wording from the response “We understand from the request that the discharge care plan was not followed, and this was not recognised. This is an issue of health and social care coordination and management.” Source location 2020-0251-Response-from-NHS-Digital-Redacted.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 A system is unlikely to replace professional curiosity and clinical judgement, which are supported by existing medical and nursing training.
Verbatim wording from the response “- Learning from Deaths: in the Midlands a Learning from Deaths Forum has been established which brings together Acute, Community and Mental Health Trusts as well as the Regional Medical Examiner. A suitably anonymised case study of Mr Ball’s experience has been taken to this forum for consideration, shared awareness and learning. It is accepted that “professional curiosity” or clinical judgement plays a major part in determining health risks and it is unlikely that a system can replace such decision-making which is supported by the significant training medical and nursing staff undertake to carry out their roles.” Source location 2020-0251-Response-from-NHS-England-and-NHS-Improvement-Redacted.pdf
Open published response
Concerns raised 4 Lack of NHS Trust requirements for internal UVC policies and procedures to comply with BAPM guidance View source Lack of NICE guidance on the use of UVCs View source Lack of NHS Trust requirements for clinicians to be familiar with BAPM guidance View source Failure of BAPM guidance to identify a key risk factor for mal-positioned UVCs View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Master Yo Li · 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
Yo Li was born extremely prematurely on 11 January 2019 and died on 15 January 2019 after an umbilical venous catheter was mal-positioned, resulting in total parenteral nutrition extravasation. Concerns included gaps in professional guidance about a risk factor for mal-positioned catheters, clinicians’ lack of familiarity with updated guidance, and the absence of NICE guidance or a requirement for NHS Trusts to follow the relevant guidance.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of NHS Trust requirements for internal UVC policies and procedures to comply with BAPM guidance
Wider context from the report “2. There is no NICE guidance on the use of UVCs and there is no requirement on NHS Trusts to ensure that their clinicians are familiar with the BAPM guidance or to ensure that their internal policies and procedures are in accordance with it . Consideration ought to be given by NHSI to introducing some NICE guidance to cover this issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 on the use of UVCs
Wider context from the report “2. There is no NICE guidance on the use of UVCs and there is no requirement on NHS Trusts to ensure that their clinicians are familiar with the BAPM guidance or to ensure that their internal policies and procedures are in accordance with it. Consideration ought to be given by NHSI to introducing some NICE guidance to cover this issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 NHS Trust requirements for clinicians to be familiar with BAPM guidance
Wider context from the report “2. There is no NICE guidance on the use of UVCs and there is no requirement on NHS Trusts to ensure that their clinicians are familiar with the BAPM guidance or to ensure that their internal policies and procedures are in accordance with it. Consideration ought to be given by NHSI to introducing some NICE guidance to cover this issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 BAPM guidance to identify a key risk factor for mal-positioned UVCs
Wider context from the report “1. The BAPM guidance on ‘Use of Central Venous Catheters in Neonates – A Framework for Practice’ does not identify a key risk factor for a mal-positioned UVC . Consideration ought to be given by BAPM to updating the guidance to include reference to this risk factor.
” Open source report
Concerns raised 4 Fitting or adjustment of bed levers in the absence of the patient View source Lack of a policy for reporting bed-lever risk-assessment concerns to the Occupational Therapy Team View source Failure to ensure prescribed bed levers are fitted by trained Occupational Therapy staff View source Failure to ensure bed levers fitted to Divan beds use a strap View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jean Williams · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jean Williams, aged 80, died at Thornton House Care Home between 6.30 a.m. and 8.27 a.m. on 19 November 2017 after her head became trapped between her bed and a chest of drawers, with her neck resting on a bed lever. The report found that the bed lever’s securing strap had not been used. Concerns included bed levers being fitted or adjusted without the patient present, insufficient reporting and training arrangements, and the possible supply or fitting of bed levers without the required strap.
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 Fitting or adjustment of bed levers in the absence of the patient
Wider context from the report “The supplier of the Bed Lever (Mobility 2000), Occupational Therapy staff at the Trust and Lancashire County Council Staff (including Care Assistants) working at Thornton House now fit or adjust Bed Levers if – on assessment – there is identified to be a problem. This raised concerns due to the following:
(a) Mobility 2000 and Lancashire County Council staff are fitting Bed Levers and/or adjusting Bed Levers in the absence of the patient (and therefore not taking into account important individual patient factors such as patient height, when fitting the Lever).
(b) Lancashire County Council do not currently have in place a policy that any concerns/issues raised on their risk assessments of bed levers at the premises should be reported to the Occupational Therapy Team at the Trust.
(c) The Occupational Therapy Team at the Trust, who are now correctly trained to fit and assess a patient for the use of the Bed Lever, are not – at present – routinely fitting the bed levers at Thornton House. In fact, there has been a miscommunication that Bed Levers are no longer to be used at Thornton House. Occupational Therapists prescribe bed levers due to the medical need of the patient and are now trained to fit them properly following full assessment of the patient.
I am concerned that the above raises a risk of future deaths in that bed levers are being fitted in the absence of the patient and not by the fully trained experts who have prescribed them.
In addition, the following matters in respect of Mobility 2000 specifically caused concern:
(a) Mobility 2000 did and do continue to fit bed levers in the absence of the patient at various different locations (not just at Thornton House)
(b) I found that Mobility 2000 did not routinely use the strap when fitting bed levers in 2017 and it is unclear whether staff now have training that they should always use a strap on a Divan bed
(c) The evidence from the Director of Mobility 2000 was that no Bed Levers had been supplied without a strap (to his knowledge). It was clear on the evidence that Mobility 2000 had purchased Bed Levers without a strap from Drive DeVilbiss Healthcare Limited (“Drive”), which should only be used with a specialist bed (and not a Divan bed, which always requires a strap). There is a risk that Mobility 2000 are supplying or fitting these bed levers (Model 130) without a strap to Divan beds.
I have also addressed this report to NHS England, as it was unclear on the evidence whether there may be similar instances of not using straps for Bed Levers (on Divan Beds) by Occupational Therapy Teams at other NHS Trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 policy for reporting bed-lever risk-assessment concerns to the Occupational Therapy Team
Wider context from the report “The supplier of the Bed Lever (Mobility 2000), Occupational Therapy staff at the Trust and Lancashire County Council Staff (including Care Assistants) working at Thornton House now fit or adjust Bed Levers if – on assessment – there is identified to be a problem. This raised concerns due to the following:
(a) Mobility 2000 and Lancashire County Council staff are fitting Bed Levers and/or adjusting Bed Levers in the absence of the patient (and therefore not taking into account important individual patient factors such as patient height, when fitting the Lever).
(b) Lancashire County Council do not currently have in place a policy that any concerns/issues raised on their risk assessments of bed levers at the premises should be reported to the Occupational Therapy Team at the Trust.
(c) The Occupational Therapy Team at the Trust, who are now correctly trained to fit and assess a patient for the use of the Bed Lever, are not – at present – routinely fitting the bed levers at Thornton House. In fact, there has been a miscommunication that Bed Levers are no longer to be used at Thornton House. Occupational Therapists prescribe bed levers due to the medical need of the patient and are now trained to fit them properly following full assessment of the patient.
I am concerned that the above raises a risk of future deaths in that bed levers are being fitted in the absence of the patient and not by the fully trained experts who have prescribed them.
In addition, the following matters in respect of Mobility 2000 specifically caused concern:
(a) Mobility 2000 did and do continue to fit bed levers in the absence of the patient at various different locations (not just at Thornton House)
(b) I found that Mobility 2000 did not routinely use the strap when fitting bed levers in 2017 and it is unclear whether staff now have training that they should always use a strap on a Divan bed
(c) The evidence from the Director of Mobility 2000 was that no Bed Levers had been supplied without a strap (to his knowledge). It was clear on the evidence that Mobility 2000 had purchased Bed Levers without a strap from Drive DeVilbiss Healthcare Limited (“Drive”), which should only be used with a specialist bed (and not a Divan bed, which always requires a strap). There is a risk that Mobility 2000 are supplying or fitting these bed levers (Model 130) without a strap to Divan beds.
I have also addressed this report to NHS England, as it was unclear on the evidence whether there may be similar instances of not using straps for Bed Levers (on Divan Beds) by Occupational Therapy Teams at other NHS Trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 prescribed bed levers are fitted by trained Occupational Therapy staff
Wider context from the report “The supplier of the Bed Lever (Mobility 2000), Occupational Therapy staff at the Trust and Lancashire County Council Staff (including Care Assistants) working at Thornton House now fit or adjust Bed Levers if – on assessment – there is identified to be a problem. This raised concerns due to the following:
(a) Mobility 2000 and Lancashire County Council staff are fitting Bed Levers and/or adjusting Bed Levers in the absence of the patient (and therefore not taking into account important individual patient factors such as patient height, when fitting the Lever).
(b) Lancashire County Council do not currently have in place a policy that any concerns/issues raised on their risk assessments of bed levers at the premises should be reported to the Occupational Therapy Team at the Trust.
(c) The Occupational Therapy Team at the Trust, who are now correctly trained to fit and assess a patient for the use of the Bed Lever, are not – at present – routinely fitting the bed levers at Thornton House. In fact, there has been a miscommunication that Bed Levers are no longer to be used at Thornton House . Occupational Therapists prescribe bed levers due to the medical need of the patient and are now trained to fit them properly following full assessment of the patient.
I am concerned that the above raises a risk of future deaths in that bed levers are being fitted in the absence of the patient and not by the fully trained experts who have prescribed them .
In addition, the following matters in respect of Mobility 2000 specifically caused concern:
(a) Mobility 2000 did and do continue to fit bed levers in the absence of the patient at various different locations (not just at Thornton House)
(b) I found that Mobility 2000 did not routinely use the strap when fitting bed levers in 2017 and it is unclear whether staff now have training that they should always use a strap on a Divan bed
(c) The evidence from the Director of Mobility 2000 was that no Bed Levers had been supplied without a strap (to his knowledge). It was clear on the evidence that Mobility 2000 had purchased Bed Levers without a strap from Drive DeVilbiss Healthcare Limited (“Drive”), which should only be used with a specialist bed (and not a Divan bed, which always requires a strap). There is a risk that Mobility 2000 are supplying or fitting these bed levers (Model 130) without a strap to Divan beds.
I have also addressed this report to NHS England, as it was unclear on the evidence whether there may be similar instances of not using straps for Bed Levers (on Divan Beds) by Occupational Therapy Teams at other NHS Trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 bed levers fitted to Divan beds use a strap
Wider context from the report “The supplier of the Bed Lever (Mobility 2000), Occupational Therapy staff at the Trust and Lancashire County Council Staff (including Care Assistants) working at Thornton House now fit or adjust Bed Levers if – on assessment – there is identified to be a problem. This raised concerns due to the following:
(a) Mobility 2000 and Lancashire County Council staff are fitting Bed Levers and/or adjusting Bed Levers in the absence of the patient (and therefore not taking into account important individual patient factors such as patient height, when fitting the Lever).
(b) Lancashire County Council do not currently have in place a policy that any concerns/issues raised on their risk assessments of bed levers at the premises should be reported to the Occupational Therapy Team at the Trust.
(c) The Occupational Therapy Team at the Trust, who are now correctly trained to fit and assess a patient for the use of the Bed Lever, are not – at present – routinely fitting the bed levers at Thornton House. In fact, there has been a miscommunication that Bed Levers are no longer to be used at Thornton House. Occupational Therapists prescribe bed levers due to the medical need of the patient and are now trained to fit them properly following full assessment of the patient.
I am concerned that the above raises a risk of future deaths in that bed levers are being fitted in the absence of the patient and not by the fully trained experts who have prescribed them.
In addition, the following matters in respect of Mobility 2000 specifically caused concern:
(a) Mobility 2000 did and do continue to fit bed levers in the absence of the patient at various different locations (not just at Thornton House)
(b) I found that Mobility 2000 did not routinely use the strap when fitting bed levers in 2017 and it is unclear whether staff now have training that they should always use a strap on a Divan bed
(c) The evidence from the Director of Mobility 2000 was that no Bed Levers had been supplied without a strap (to his knowledge). It was clear on the evidence that Mobility 2000 had purchased Bed Levers without a strap from Drive DeVilbiss Healthcare Limited (“Drive”), which should only be used with a specialist bed (and not a Divan bed, which always requires a strap). There is a risk that Mobility 2000 are supplying or fitting these bed levers (Model 130) without a strap to Divan beds.
I have also addressed this report to NHS England, as it was unclear on the evidence whether there may be similar instances of not using straps for Bed Levers (on Divan Beds) by Occupational Therapy Teams at other NHS Trusts.
” Open source report
14 Oct 2020 Mr Edward Cowey · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 5 Failure to ensure doctors are aware of relevant Trust local policies View source Falls form failing to direct doctors to relevant head injury guidance View source Failure to keep patient transfer information on one database View source Head injury treatment policies failing to align with NICE Guidelines View source Anticoagulation guidance failing to cover preventative anticoagulation View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Edward Cowey · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Edward Cowey was admitted to Royal Derby Hospital on 22 January 2020, suffered a fall with a head injury on 23 January, and died on 28 January 2020 from a subdural haematoma, with anticoagulation recorded as a contributing factor. Concerns included fragmented patient information across electronic and paper systems, inconsistent local and national guidance on head injuries, gaps in anticoagulation guidance, and a falls form that did not direct doctors to relevant head-injury guidance.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure doctors are aware of relevant Trust local policies
Wider context from the report “2. Trust local policy regarding treatment for head injuries is not consistent with NICE Guidelines and doctors cannot be expected to be aware of all trust local policies ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Falls form failing to direct doctors to relevant head injury guidance
Wider context from the report “4. The Trusts local falls form does not direct doctors to the relevant guidance regarding head injuries simply asks if a CT head scans indicated
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 keep patient transfer information on one database
Wider context from the report “1. That patient electronic and paper based transfer information is not kept on one database . Mr Coweys’ handover notes were kept on extra Med, his neurological observations on Patient Track and the falls form on his hard copy notes ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Head injury treatment policies failing to align with NICE Guidelines
Wider context from the report “2. Trust local policy regarding treatment for head injuries is not consistent with NICE Guidelines and doctors cannot be expected to be aware of all trust local policies;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Anticoagulation guidance failing to cover preventative anticoagulation
Wider context from the report “3. Anticoagulation guideless do not cover a situation where anticoagulation is being given as a preventative measure as opposed to a treatment ; and
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NICE guidance already covers prophylactic low-molecular-weight heparin after head injury, contrary to the concern that guidance excludes prophylactic anticoagulation.
Verbatim wording from the response “• Dr ████████, The Trusts Medical Director (Quality and Safety) Consultant in Emergency Medicine has contacted NICE to clarify the aspect of the guidance that refers to patients receiving anticoagulation. NICE are clear that any patient whether receiving low-molecular weight heparin for prophylactic or therapeutic reasons are included in this guidance. Consequently, the Trust will be explicit about this in the UHBD guidance. The Trusts Medical Director has also suggested to NICE that CG176 is updated to reflect this advice.” Source location 2020-0205-Response-from-NHS-England-and-NHS-Improvement-Redacted.pdf
Open published response
Concerns raised 7 Lack of documentation checks confirming bed brakes are on View source Failure to maintain a culture in which staff can speak up about errors and poor practice View source Lack of a minimum-information standard for cross-hospital specialist advice communication View source Lack of guidance for identifying, securing and gathering evidence in clinical incident investigations View source Failure of the Statutory Notification process to require timely submission of relevant evidence about deaths View source Unavailability of medical records across Trust hospital sites View source Lack of documentation checks confirming bed-rails are in the appropriate position View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr William Ivan McKibbin · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr William Ivan McKibbin died at Trafford General Hospital on 20 August 2018 following complications of a traumatic brain injury sustained in an unwitnessed fall in hospital. The report raised concerns about bed-rail and bed-brake checks, the culture of openness and candour, communication between specialists and hospital sites, incident investigations, and the process for learning from 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 documentation checks confirming bed brakes are on
Wider context from the report “2. It is a matter of concern that NHS nursing documentation, such as Intentional Rounding Checklists, in use at the Trust and in other hospitals, currently do not include ‘tick-box’ checks to confirm bed-rails are in the appropriate position, and the bed brakes are on .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a culture in which staff can speak up about errors and poor practice
Wider context from the report “1. The evidence heard at this inquest left me with residual concerns as to the prevailing culture at the Trust, and by extension, within the NHS .
It was clear from the evidence that by the time of Mr McKibbin’s death, Managers from the Trust were aware at the very least that the brakes simply cannot have been applied to his bed at the time he sustained the fall which led to his death.
Despite this, no confirmation of this fact was made to Mr McKibbin’s family, or in the report of his death to the Coroner. Similarly, this conclusion was not drawn by a number of internal investigations undertaken by the Trust, or indeed in evidence given to the court by Professor ████████, Chief Nurse and a member of the Trust’s board.
For a duty of candour to have meaning, it is essential the prevailing culture of an organisation is one where staff have freedom to speak out. For the reasons set out by Sir ████████ QC in his PFD Report into events at Mid Staffordshire NHS Foundation Trust, unless staff of all levels feel able to speak up about their own errors, and to point out to highlight poor practice of others, a significant risk of future deaths will remain .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 minimum-information standard for cross-hospital specialist advice communication
Wider context from the report “3. Given the operating model of the Trust, whereby different specialists provide services at different hospitals, it is a matter of concern that no proforma documentation / communication paradigm exists which sets out the minimum standard of information expected to be conveyed when a clinician seeks advice from a specialist based at another hospital .
The risk of death in this regard is currently compounded by the fact that medical records from one hospital are not necessarily accessible from another site within the Trust group.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for identifying, securing and gathering evidence in clinical incident investigations
Wider context from the report “4. In view of the importance of robust and reliable investigations into clinical incidents to reducing the risk of future deaths, it is a matter of concern that no guidance currently exists for on-call managers and investigators as to quickly identifying, securing and gathering relevant evidence .
Improvements in gathering evidence would assist the Trust in reliably identifying the underlying cause or causes of incidents, which in turn would better inform actions to be taken with a view to reducing the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of the Statutory Notification process to require timely submission of relevant evidence about deaths
Wider context from the report “5. In order to enhance learning from deaths, consideration should be given to modifying the Statutory Notification process following death of a service-user so as to require Registered Providers to lodge specified relevant evidence as to how the death occurred within a defined period .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 medical records across Trust hospital sites
Wider context from the report “3. Given the operating model of the Trust, whereby different specialists provide services at different hospitals, it is a matter of concern that no proforma documentation / communication paradigm exists which sets out the minimum standard of information expected to be conveyed when a clinician seeks advice from a specialist based at another hospital.
The risk of death in this regard is currently compounded by the fact that medical records from one hospital are not necessarily accessible from another site within the Trust group .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 documentation checks confirming bed-rails are in the appropriate position
Wider context from the report “2. It is a matter of concern that NHS nursing documentation, such as Intentional Rounding Checklists, in use at the Trust and in other hospitals, currently do not include ‘tick-box’ checks to confirm bed-rails are in the appropriate position , and the bed brakes are on.
” 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 Promote and encourage NHS employers to complete Just and Learning Culture training and accredited learning packages.
Verbatim wording from the response “I have been sighted on the Trust’s comprehensive response and that as part of our commitments in the People Plan, NHS England and NHS Improvement is promoting and encouraging NHS employers to complete the free online Just and Learning Culture training and accredited learning packages to help them become fair, open and learning organisations where colleagues feel they can speak up.” Source location 2020-0185-Response-from-NHS-England-and-NHS-Improvement-Redacted.pdf
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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