29 Jun 2018 Lindsey Tyrrell · Prevention of Future Deaths report Manchester City
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Concerns raised 1 Failure to routinely test for toxoplasmosis in allogeneic stem cell transplant patients presenting with signs of infection 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.
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AI-generated summary
Lindsey Tyrrell · 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
Lindsey Tyrrell, who had undergone an allogeneic stem cell transplant and was immunosuppressed, developed an infection and deteriorated before dying on 3 July 2017. Toxoplasmosis was identified retrospectively in blood and cerebrospinal fluid; the principal concern was that testing for toxoplasmosis was not routinely carried out at the Christie Hospital in comparable transplant patients presenting with signs of infection, and that learning from the incident should be shared nationally.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely test for toxoplasmosis in allogeneic stem cell transplant patients presenting with signs of infection
Wider context from the report “I heard evidence at the Inquest that toxoplasmosis is carried by about 30% of the population, however, prior to Mrs Tyrell's death testing for this infection was not routinely carried out at the Christie Hospital on patients who had received an allogeneic stem cell transplant and who had subsequently presented with signs of infection I heard evidence that, following Mrs Tyrell's death, testing for toxoplasmosis is now undertaken at the Christie Hospital when stem cell transplant patients present in similar circumstances However, there was no evidence before me as to the practice of other specialist blood cancer care units or hospitals in similar circumstances It seems appropriate that the learning from this incident at a local level should be shared on a nationwide basis
” Open source report
25 Jun 2018 Marjorie McMahon · Prevention of Future Deaths report Manchester South
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Concerns raised 1 Delays in ambulance and paramedic attendance for level 2 priority calls 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.
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AI-generated summary
Marjorie McMahon · 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
Marjorie McMahon became increasingly unwell at Cherry Tree House and was taken to hospital on 7 March 2018, where she received treatment before dying on 8 March 2018. The principal concern was the delay in ambulance and paramedic attendance despite her being categorised as a level 2 priority, with an 8-minute guideline response time.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance and paramedic attendance for level 2 priority calls
Wider context from the report “Mrs McMahon was correctly categorised as a level 2 priority at 1.30 pm on the 7th March 2018 when the North West Ambulance Service were first contacted in respect of her deteriorating condition. Despite this, due to high demand on the service and available resources, she was not attended to for nearly 1 ½ hours (in respect of the paramedic) and 2 hours (in respect of attendance of the ambulance). The guideline response time was confirmed to be 8 minutes.
” Open source report
25 Jun 2018 Lauren Amelia Rose SANDELL · Prevention of Future Deaths report London (East)
View report summary
Concerns raised 4 Unclear responsibility for capturing children unvaccinated through the school programme View source Lack of audit of GP practices’ systems for identifying and protecting children unvaccinated through the school programme View source Lack of systems to identify children not captured by the school vaccination programme View source Failure to put measures in place to protect children not captured by the school vaccination programme View source See 1 more concern
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Lauren Amelia Rose SANDELL · 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
Lauren Sandell became unwell with headaches, vomiting, aches and pains on 29 September 2016 and became unresponsive at home on 2 October 2016, when her life was pronounced extinct by paramedics. The inquest concluded that she died from meningococcal sepsis (serogroup W135) and fell within the cohort requiring MenACWY vaccination. Concerns included confusion over responsibility for vaccinating children not covered by the school programme, uncertainty about GP responsibilities, and the lack of auditing of systems to identify and protect unvaccinated children before university.
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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 Unclear responsibility for capturing children unvaccinated through the school programme
Wider context from the report “(1) There would appear to be on-going confusion about who is responsible for ensuring that those children who are not (for whatever reason), vaccinated at school, should be vaccinated before attending university. The evidence indicated that 70% to 80% of children receive the vaccination at school. This would leave 20% to 30% of children unvaccinated. The evidence indicated that GPs should primarily provide the safety net for unvaccinated children.
(2)The provision of the vaccination against MenW appears to fall under an enhanced service for GPs. As this is an optional addition to the GMS contract, it is unclear whether all GP surgeries have a responsibility to capture unvaccinated children .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 audit of GP practices’ systems for identifying and protecting children unvaccinated through the school programme
Wider context from the report “(3) It does not appear that there is any form of audit to ensure that GP practices have in place systems to identify those children who are not captured by the school programme and to put in place measures to protect children, particularly before commencing university.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of systems to identify children not captured by the school vaccination programme
Wider context from the report “(3) It does not appear that there is any form of audit to ensure that GP practices have in place systems to identify those children who are not captured by the school programme and to put in place measures to protect children, particularly before commencing university.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 put measures in place to protect children not captured by the school vaccination programme
Wider context from the report “(3) It does not appear that there is any form of audit to ensure that GP practices have in place systems to identify those children who are not captured by the school programme and to put in place measures to protect children , particularly before commencing university.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide regular CHIS process reports to the national NHS England oversight group.
Verbatim wording from the response “The Child Health Information Service (CHIS) service is the key organisation locally that records whether or not a child/ young person has received a vaccine or other public health interventions, and acts to support the process of capturing information, including transferring information it receives from school based services to a GP practice, who then have the responsibility to act on the information received. Each region has an established system in place to ensure that GP providers are made aware of vaccinations administered by school aged vaccination providers, with regular reports on the process within CHIS coming to a national NHS England oversight group on a quarterly basis.” Source location 2018-0205-Response-by-NHS-England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit regional vaccination call-and-recall systems and research factors affecting Men ACWY uptake.
Verbatim wording from the response “The NHS England London Immunisations webpage has been amended to include reference to the specific guidance. In addition, the London team, as part of their general drive to improve the quality of services, undertook a region wide audit of call/recall systems for vaccinations in 2016, and a research study looking at factors affecting uptake of Men ACWY in general practice. The outcome of the audit and research project has informed the local action plan to improve services and has informed commissioning. NHS England immunisation commissioners are working with NHS Clinical Commissioning Groups (CCG) to ensure call recall systems are embedded in practice systems. In 2017, the London CHIS services launched a new service providing electronic record of a” Source location 2018-0205-Response-by-NHS-England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work nationally to ensure eligible people are offered Men ACWY vaccination through schools or GP practices.
Verbatim wording from the response “NHS England is working to ensure that all those eligible for vaccinations should be offered the vaccine either in school or by a GP practice. Those who may have missed the opportunity to be vaccinated, remain eligible until they are 25 years of age.” Source location 2018-0205-Response-by-NHS-England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with clinical commissioning groups to embed vaccination call-and-recall systems in GP practice systems.
Verbatim wording from the response “The NHS England London Immunisations webpage has been amended to include reference to the specific guidance. In addition, the London team, as part of their general drive to improve the quality of services, undertook a region wide audit of call/recall systems for vaccinations in 2016, and a research study looking at factors affecting uptake of Men ACWY in general practice. The outcome of the audit and research project has informed the local action plan to improve services and has informed commissioning. NHS England immunisation commissioners are working with NHS Clinical Commissioning Groups (CCG) to ensure call recall systems are embedded in practice systems. In 2017, the London CHIS services launched a new service providing electronic record of a” Source location 2018-0205-Response-by-NHS-England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the adolescent vaccination guidance algorithm with relevant services.
Verbatim wording from the response “Public Health England (PHE) and NHS England Public Health Commissioning teams have the responsibility to monitor the uptake of Men ACWY, as part of NHS England’s accountabilities as the commissioner of immunisation services. In turn the local commissioning team alert practices to any poor uptake of immunisation programmes. As outlined in our previous correspondence the CHIS service is a key organisation locally that records whether or not a child/young person has received a vaccine or other public health interventions. In London the specific activities to improve services include sharing the guidance algorithm “Pathway for Administration of HPV, Men ACWY and Teenage 3-in-1 Booster (Td/IPV)”. The document outlines when and where adolescent vaccinations are offered and when general practice is to offer the vaccination.” Source location 2018-0205-Response-by-NHS-England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch an electronic record of children’s public health interventions across London, replacing separate local record systems.
Verbatim wording from the response “The NHS England London Immunisations webpage has been amended to include reference to the specific guidance. In addition, the London team, as part of their general drive to improve the quality of services, undertook a region wide audit of call/recall systems for vaccinations in 2016, and a research study looking at factors affecting uptake of Men ACWY in general practice. The outcome of the audit and research project has informed the local action plan to improve services and has informed commissioning. NHS England immunisation commissioners are working with NHS Clinical Commissioning Groups (CCG) to ensure call recall systems are embedded in practice systems. In 2017, the London CHIS services launched a new service providing electronic record of a” Source location 2018-0205-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work directly with the GP practice to prevent recurrence of the vaccination-programme failure.
Verbatim wording from the response “I accept the narrative conclusion of the inquest being that Lauren’s death was avoidable, as a result of the GP practice not implementing the Men ACWY immunisation programme to all of the requirements of the enhanced service specification.” Source location 2018-0205-Response-by-NHS-England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation GP practices are responsible for administrative systems and acting on vaccination information received from Child Health Information Services.
Verbatim wording from the response “All GP practices have the responsibility to ensure administrative processes are in place for service delivery. The process by which a GP practice offers the vaccine to all eligible children, involves working with the Child Health Information Services (CHIS). CHIS have a role to transfer information about public health interventions, transferring this to and from school based services and GP practice, for those providers to act on and deliver their services to patients. CHIS services and the ‘failsafe’ they provide are being improved as part of the NHS strategy for IT, improving the paperless flow of information across organisations by 2021.” Source location 2018-0205-Response-by-NHS-England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing service specifications clearly allocate responsibility for delivering school-based and GP-based vaccination services.
Verbatim wording from the response “1. There would appear to be on-going confusion about who is responsible for ensuring that those children who are not (for whatever reason), vaccinated at school, should be vaccinated before attending university. The evidence indicated that 70% to 80% of children receive the vaccination at school. This would leave 20% to 30% of children unvaccinated. The evidence indicated that GPs should primarily provide the safety net for unvaccinated children.” Source location 2018-0205-Response-by-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 GPs must provide eligible registered patients with Men ACWY vaccination or notify NHS England so an alternative primary care provider can do so.
Verbatim wording from the response “2. The provision of the vaccination against Men ACWY appears to fall under an enhanced service for GPs. As this is an optional addition to the GMS contract, it is unclear whether all GP surgeries have a responsibility to capture unvaccinated children.” Source location 2018-0205-Response-by-NHS-England
Open published response
Concerns raised 2 Confusable drug vial appearances for Fungizone and Ambisone View source Failure to conduct active nursing checks 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.
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AI-generated summary
Sneh Lata Chaudhry · 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
Sneh Lata Chaudhry underwent high-risk coronary artery bypass surgery and developed a systemic candida infection requiring amphotericin. The wrong intravenous preparation, Fungizone rather than Ambisone, was obtained and administered, and the inquest concluded that she died from immediate complications of this incorrect formulation. Concerns included the similar appearance of the drug vials and nursing checks being passive rather than active.
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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 Confusable drug vial appearances for Fungizone and Ambisone
Wider context from the report “(1) Fungizone and Ambisone have a similar drug vial appearance and can be confused. Fungizone is typically used as aerosol and Ambisone as an intravenous preparation. Fungizone has a smaller therapeutic window and is more toxic and may lead to a fatal hyperkalaemia as in this case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct active nursing checks
Wider context from the report “(2) The nursing checks were described as passive rather than active
” Open source report
29 May 2018 Brian Leonard Bicat · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 6 Unavailability of verbal fire-risk warnings from healthcare professionals for retail and online purchases View source Lack of accurate national data on fire incidents involving paraffin-based skin products View source Inconsistent fire-risk alerts and warnings across NHS prescribing systems View source Lack of healthcare professional awareness of the fire hazard from low-paraffin emollient creams View source Failure to display fire-risk warnings on all product packaging View source Fire hazard from paraffin-based ointments and low-paraffin emollient creams 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.
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AI-generated summary
Brian Leonard Bicat · 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
Brian Leonard Bicat sustained severe burns at home on 22 September 2017 when his dressing gown caught fire while he was smoking a cigarette. He died later that day from his extensive cutaneous burns, with evidence indicating that paraffin-based emollient creams and ointments increased the speed and intensity of the fire. The principal concerns were that low-paraffin emollients may pose a fire hazard, that warnings were not displayed consistently on packaging or communicated by healthcare professionals, and that related prescribing alerts and incident data were inconsistent or incomplete.
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 verbal fire-risk warnings from healthcare professionals for retail and online purchases
Wider context from the report “Members of the public are able to purchase such products in retail outlets and online where verbal warnings from healthcare professionals are not given
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of accurate national data on fire incidents involving paraffin-based skin products
Wider context from the report “Consider a review of the current effectiveness of obtaining fire incident reports involving paraffin based skin products since there is currently a lack of accurate national data involving paraffin based skin products
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inconsistent fire-risk alerts and warnings across NHS prescribing systems
Wider context from the report “The NHS prescribing systems (system One and Optimise) appear to be updated by individual CCG’s resulting inconsistent alerts and warnings .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of healthcare professional awareness of the fire hazard from low-paraffin emollient creams
Wider context from the report “Health care professionals in both hospital and community setting may not be aware of the potential fire hazard poised by emollient creams which contain a low level of paraffin
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 display fire-risk warnings on all product packaging
Wider context from the report “Warnings of such risks are not displayed on all product packaging
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Fire hazard from paraffin-based ointments and low-paraffin emollient creams
Wider context from the report “Paraffin based ointments and emollient creams which contain a low level of paraffin pose a potential fire hazard risk
” Open source report
Concerns raised 1 Failure to standardise PEWS scoring systems and escalation processes across trusts 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.
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AI-generated summary
Alfie Scambler-Holt · 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
Alfie Scambler-Holt, who had cerebral palsy and complex health needs, became seriously unwell at home and was admitted to Stepping Hill Hospital with suspected sepsis. He died after suddenly stopping breathing during treatment. The report identified concerns about differing PEWS scoring systems and escalation processes between trusts because there was no national system.
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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 standardise PEWS scoring systems and escalation processes across trusts
Wider context from the report “The inquest heard that since the death of Alfie Scambler -Holt the Trust had done a significant amount of work looking at PEWS scores and escalation processes. The Clinical Lead for Paediatrics told the inquest that one of the challenges was that there was no national PEWS scoring system . As a result there were different PEWS scoring systems in operation in different trusts . This meant that staff dealing with children and moving/rotating between Trusts would not necessarily be dealing with the same system and escalation processes .
” Open source report
Concerns raised 3 Lack of systems ensuring early paediatrician review of very young children in out-of-hours emergency department care View source Failure of emergency department on-call arrangements to trigger consultant attendance after long waits View source Failure to meet Manchester triage time targets 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
Novia Emilia Delima · 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
Novia Emilia Delima was brought to hospital on 25 July 2016 after blood was seen in her nappies, and she was not seen by a doctor until several hours after triage. She was subsequently diagnosed with sepsis, deteriorated despite treatment, and died later that day from neonatal herpes simplex and E. coli septicaemia. The concerns included delays in emergency assessment, the need for early paediatric input for very young babies, and consultant call-out arrangements that did not require attendance solely because of long waits.
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 systems ensuring early paediatrician review of very young children in out-of-hours emergency department care
Wider context from the report “2. The inquest heard that very young babies present significant challenges in diagnosis and early clinical input by a clinician experienced in dealing with young children was important. The trust had brought in significant changes to how it dealt with paediatric cases in ED since the death of Novia. This includes early clinical involvement of a paediatric clinician for babies between 0- 6 months due to their recognition of challenges of diagnosis in very young children. The inquest heard that not all trusts, nationally, have systems that ensure very young children are seen by a paediatrician at an early stage particularly in an OOH situation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 emergency department on-call arrangements to trigger consultant attendance after long waits
Wider context from the report “3.on the night in question the inquest heard that a consultant was on call for ED but was not called in despite the significant delays in ED. The inquest heard that the ED on call consultant arrangements meant that long wait times would not in themselves trigger on call consultants being asked to attend the hospital .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to meet Manchester triage time targets
Wider context from the report “1. The Trust had adopted the Manchester triage system but due to demand on the ED the time identified through the triage system could not be met . The Manchester triage tool is widely used but the inquest heard that often across EDs the targets set by the triage tool are not met ;
” Open source report
Concerns raised 4 Lack of a clear system for joined-up discharge planning between primary and secondary mental health services View source Failure of the Lorenzo electronic booking and triage system to capture key information about police conveyance View source Unavailability of identified mental health support services because they were not commissioned View source Failure to use one Trust-wide IT system for information sharing between professionals involved in care View source See 1 more concern
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
Adrian Jennings · 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
Adrian Jennings had a history of mental health issues and self-harm attempts and died on 10 December 2016 after taking a fatal cocktail of drugs and alcohol. The principal concerns included poor communication and inadequate discharge support planning between mental health services, failures to record key information when he arrived at hospital, and a policy gap concerning the reporting of high-risk absconding before triage.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear system for joined-up discharge planning between primary and secondary mental health services
Wider context from the report “2.there was no clear system for the primary and secondary mental health services of the mental health trust ,Pennine Care, to develop a joined up discharge plan following a stay on the mental health ward ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of the Lorenzo electronic booking and triage system to capture key information about police conveyance
Wider context from the report “4. Tameside Hospital cannot change their electronic booking in/triage system to allow them to include drop down boxes for key information such as the fact that Police Officers have brought an individual to the Hospital because it is a national IT system. Any trust operating the Lorenzo system will struggle to capture this information at booking in
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 identified mental health support services because they were not commissioned
Wider context from the report “3. a need for a type of mental health support service had been identified by the mental health trust Pennine Care but it could not be delivered because the Trust had not been commissioned to deliver the service ; and
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 one Trust-wide IT system for information sharing between professionals involved in care
Wider context from the report “1. The inquest heard evidence that the Mental Health Trust had not introduced one IT system across the Trust , which impacted on information sharing between professionals involved in his care ;
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish best-practice information on coordinated mental-health discharge planning and transition support.
Verbatim wording from the response “I note your second concern regarding the ability of primary and secondary mental health services to provide a joined up discharge plan. NHS England believes that strong communication, between health care professionals, with individuals receiving care, and with their families and carers is crucial to delivering safe, effective acute mental health care pathways. This communication is particularly important when individuals are transitioning between teams or services and for ensuring a robust discharge plan is in place.” Source location 2018-0111-Response-by-NHS-England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with Local Health and Care Record Exemplars to establish local longitudinal records enabling authorised staff to access permitted patient information.
Verbatim wording from the response “In addition, and building on this provider digitisation is the specific focus on enabling access to pertinent information from across venues of care. There has been progress made on this within the service with around 60 local information sharing initiatives that aim to share information across GP, Acute and Social Care settings. Building on this, NHS England will be working with a number of Local Health and Care Record Exemplars that will focus on establishing a local longitudinal record available in their areas to enable authorised staff to access permitted information about a patient’s history of contact with the NHS and related care services in order to support the provision of safe, integrated care.” Source location 2018-0111-Response-by-NHS-England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a framework for Community Mental Health Services setting out improved joint working between primary and secondary mental-health services.
Verbatim wording from the response “NHS England is also developing a framework in 2018/19 for Community Mental Health Services which will articulate models of improved joint working between primary and secondary mental health services. This will support teams to work together to plan” Source location 2018-0111-Response-by-NHS-England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Lead the Global Digital Exemplar programme to digitise and connect health systems and improve secure information sharing.
Verbatim wording from the response “In relation to your first concern, we recognise that there are challenges across the service in enabling secure record sharing and there are a number of steps being taken, led by NHS England.” Source location 2018-0111-Response-by-NHS-England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The current Lorenzo Emergency Department module provides mandated fields to record police transport and attendance source.
Verbatim wording from the response “I have consulted with NHS Digital in relation to your concern about the trust being unable to capture that an individual had been brought in by police officers because they were operating Lorenzo, a national system. This function was not available in 2016 but the Emergency Department (ED) module has recently been updated and includes mandatory data collection to fulfil the Emergency Care Data Set (ECDS) requirements (please see https://www.england.nhs.uk/ourwork/ts/ec-dataset/).” Source location 2018-0111-Response-by-NHS-England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The mental health trust is responsible for addressing the concern that mental health support services were not commissioned.
Verbatim wording from the response “Following the inquest you raised concerns in your Report to NHS England regarding disparate IT systems impacting on information sharing, the ability of primary and secondary mental health services to provide a joined up discharge plan, mental health support services not being commissioned, and the inability to capture that police officers had brought an individual into the hospital as they are operating a national IT system. I have noted that your Regulation 28 letter has also been sent to the mental health trust directly involved in Mr Jennings’s case, and will leave it to the trust to address your concern regarding mental health support services not being commissioned. I will only address the other three concerns in this letter.” Source location 2018-0111-Response-by-NHS-England
Open published response
29 Mar 2018 Ross REEVES · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 1 Failure to provide adequate information during transfer of patients between GP practices 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.
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AI-generated summary
Ross REEVES · 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
Ross REEVES died after taking more than one week’s worth of Gabapentin, Zomorph and Mirtazapine, which caused profound stupor and respiratory depression; he subsequently developed lobar pneumonia. The principal concern was that his transfer to a new GP was likely unsafe and that better handover information might have led to different prescribing arrangements.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate information during transfer of patients between GP practices
Wider context from the report “(1) The transfer of this patient to his new GP was likely ‘unsafe’.
I am particularly concerned because in Brighton and Hove we have an extremely high rate of drug related deaths.
It seems to me that there were clues to this man’s death and if there had been more information available to the new GP it is highly likely that they would have taken different action with regard to him . In particular, they may well have prescribed his medications weekly rather than monthly.
At the Inquest it was clear that only he had access to the medications that he collected on the 3rd October, 2017 and that with regard to Gabapentin, Zomorph and Mirtazapine he took over one week’s worth of each. This caused his sudden collapse, his state of profound stupor and his ultimate death due to a lobar pneumonia which developed during the time he was in such a state of profound respiratory depression due to the drugs that he had been able to take.
I would like it made clear that the Inquest is not a vehicle for apportioning blame however lessons must be learned and it was clear that better hand over of patients from one practice to another would provide a better chance for the manipulative patient who lies to his new GP to be picked up and dealt with adequately , hopefully preventing his death.
” Open source report
Concerns raised 1 Lack of a national framework governing private providers’ response times to referrals for locked rehabilitation units 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
Thomas Edward Curtin · 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 Edward Curtin, who was detained under the Mental Health Act on an acute mental health ward, absconded during escorted leave and later died in hospital on 20 August 2016 from heroin intoxication. The report raised concern that private locked rehabilitation providers were not subject to a national response-time framework, potentially leaving patients on wards inappropriate for their needs while awaiting placement.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a national framework governing private providers’ response times to referrals for locked rehabilitation units
Wider context from the report “At the hearing witnesses from the treating Mental Health Trust advised the court that Mr Curtin was identified as requiring a placement on a locked rehabilitation ward to treat the chronic nature of his illness namely of schizophrenia, with ADHD with harmful misuse of alcohol and drugs and psychoactive substances and to prevent relapse. The majority of such facilities are provided by the private sector. Evidence at inquest revealed that public entities of low and medium security facilities were subject to a National NHS England framework concerning the timing of their response to referrals for specialist units. The evidence at inquest was that private providers of “Locked Rehabilitation Units” were not subject to such a National NHS England framework . This may lead to the risk of future deaths as patients are left on a ward which is inappropriate for their needs while awaiting the private provider’s response to a referral .
” 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 Require NHS England-commissioned specialist mental health providers, public and private, to respond to referrals within specified timeframes through standardised contracts.
Verbatim wording from the response “Following the inquest, you raised a concern in your Report to NHS England regarding the requirement for specialist mental health providers to respond to referrals within a given timeframe. Evidence presented at the inquest suggested that this requirement only applies to public providers of low and medium security facilities and not to private providers of ‘Locked Rehabilitation Units’.” Source location 2018-0076-Response-by-NHS-England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation For specialist rehabilitation services commissioned by Clinical Commissioning Groups, referral response-time requirements are determined locally by the relevant commissioning CCG.
Verbatim wording from the response “Some specialist mental health services, including specialist mental health rehabilitation services, are the commissioning responsibility of local Clinical Commissioning Groups (“CCG”) and therefore are not subject to similar national frameworks requiring set response times. This enables services to be commissioned in response to local population need, local priorities and plans. As such, the contractual requirement to respond to referrals within a given time would be determined by the commissioning CCG and therefore subject to local variation.” Source location 2018-0076-Response-by-NHS-England
Open published response
Concerns raised 11 Lack of national reinforcement of paediatric assessment for young children View source Lack of understanding of button-battery risks among people responsible for small children View source Failure of NHS information-sharing systems to share detailed illness histories beyond the OOH GP service View source Failure to sustain and nationally reinforce the button-battery safety alert View source Failure to follow the policy for children under 5 View source Failure to complete or fully document child assessments View source Lack of POAU audit systems for detecting noncompliance View source Lack of understanding of the risks of subjective assessments in young children View source Failure to follow the POAU system View source Failure to value-check subjective assessments in young children View source Lack of child-resistant safety features for button batteries in commonly used household devices View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Venkata Naga Lakshyasi KAGGA · 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
Venkata Naga Lakshyasi KAGGA died on 9 July 2017 after a button battery lodged in her oesophagus and caused an oesophageal arterial fistula. Before her death, she was seen by doctors and ambulance staff, but the battery was not identified. Concerns included failures to examine and assess her, non-compliance with ambulance policy for children under five, inadequate information sharing, and limited understanding of the risks posed by button batteries.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of national reinforcement of paediatric assessment for young children
Wider context from the report “3. NWAS had a policy in place in relation to children under 5 that was not followed. Work had been carried out within NWAS subsequent to the death to reinforce the importance of young children been seen by paediatricians. Similar work had not occurred nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of button-battery risks among people responsible for small children
Wider context from the report “1. The button battery was likely to have come from a remote control. Button batteries once ingested can lead to catastrophic consequences for a child. They are used with increasing frequency in every day household devices which are often easily accessible by children. The remote control had no safety feature to prevent a child having easy access to the battery without the parents knowledge. Risks of button batteries to small children are not widely understood. Whilst there are precautions in place for children’s toys similar precautions are not in place for commonly used household devices, which can easily be accessed by small children.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 NHS information-sharing systems to share detailed illness histories beyond the OOH GP service
Wider context from the report “7. The 111 service obtained detailed accounts of the history of illness. However systems for sharing information across the NHS are such that this information was not shared beyond the OOH GP service .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 sustain and nationally reinforce the button-battery safety alert
Wider context from the report “2. NHS England issued a safety alert across the NHS in December 2014 relating to button batteries. During the inquest it was clear that the impact of that alert had lessened over time across the Trusts involved . The Trusts involved in the inquest had taken steps to highlight and reinforce the safety alert amongst their workforce but no such national work had taken place .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the policy for children under 5
Wider context from the report “3. NWAS had a policy in place in relation to children under 5 that was not followed. Work had been carried out within NWAS subsequent to the death to reinforce the importance of young children been seen by paediatricians. Similar work had not occurred nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to complete or fully document child assessments
Wider context from the report “5. The importance of carrying out a full assessment of a child or documenting fully why it was not carried out on 6ᵗʰ July was not recognised by the medical staff involved .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 POAU audit systems for detecting noncompliance
Wider context from the report “4. The Hospital’s POAU did not follow their system on 6th July and the Doctor on 6ᵗʰ July did not undertake an examination. This was not picked up by the Trust until an internal investigation post death. There was not at the time an audit system in place to ensure that systems in the POAU were being complied with. It is unclear if other POAUs will have audit systems to allow them to pick up on noncompliance with a recognised system .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of the risks of subjective assessments in young children
Wider context from the report “6. NWAS staff partly based decision making on 9ᵗʰ July on subjective assessment, which was not value checked with those who knew Venkata. The risks around subjective assessments particularly with young children with no basis on which to make a value comparison did not appear to be fully understood.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the POAU system
Wider context from the report “4. The Hospital’s POAU did not follow their system on 6th July and the Doctor on 6ᵗʰ July did not undertake an examination. This was not picked up by the Trust until an internal investigation post death. There was not at the time an audit system in place to ensure that systems in the POAU were being complied with. It is unclear if other POAUs will have audit systems to allow them to pick up on noncompliance with a recognised system.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to value-check subjective assessments in young children
Wider context from the report “6. NWAS staff partly based decision making on 9ᵗʰ July on subjective assessment, which was not value checked with those who knew Venkata . The risks around subjective assessments particularly with young children with no basis on which to make a value comparison did not appear to be fully understood.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 child-resistant safety features for button batteries in commonly used household devices
Wider context from the report “1. The button battery was likely to have come from a remote control. Button batteries once ingested can lead to catastrophic consequences for a child. They are used with increasing frequency in every day household devices which are often easily accessible by children. The remote control had no safety feature to prevent a child having easy access to the battery without the parents knowledge. Risks of button batteries to small children are not widely understood. Whilst there are precautions in place for children’s toys similar precautions are not in place for commonly used household devices, which can easily be accessed by small children.
” Open source report
Concerns raised 3 Failure to invite people over 65 at screening programme introduction for abdominal aortic aneurysm screening View source Patients may not appreciate the benefits of opting into screening for asymptomatic abdominal aortic aneurysms View source High mortality associated with ruptured abdominal aortic aneurysms 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
William John Abrahams · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
William John Abrahams presented to hospital with a ruptured abdominal aortic aneurysm and died there on 28 August 2017 during attempted endovascular repair. The substantive concerns included that he was not invited for aneurysm screening because he was over 65 when the screening programme was introduced, and that the benefits of opting into screening may not be apparent because aneurysms are asymptomatic until they leak.
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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 invite people over 65 at screening programme introduction for abdominal aortic aneurysm screening
Wider context from the report “(1) Mr Abrahams was not invited for screening to check whether he had an Abdominal Aortic Aneurysm , as he was over 65 at the time that the screening programme was introduced .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Patients may not appreciate the benefits of opting into screening for asymptomatic abdominal aortic aneurysms
Wider context from the report “(3) As Abdominal Aortic Aneurysms are asymptomatic until they begin to leak , the benefits of “opting in” to the screening programme may not be apparent to patients .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation High mortality associated with ruptured abdominal aortic aneurysms
Wider context from the report “(2) Only about 20% of people that have a ruptured Abdominal Aortic Aneurysm survive
” 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 Deliver targeted outreach through GPs, health providers, media, community events, patient groups, social media and the programme website to promote AAA screening access.
Verbatim wording from the response “In 2018-19 NHS England London Region Public Health Commissioners will continue to support London AAA screening programme providers to ensure that programmes work to improve men’s awareness of their options to attend screening. A local quality standard implemented by NHS England London ensures that programmes record the numbers of men in each local Clinical Commissioning Group over 65 who Self-Refer to the screening programme. This is monitored by local and informs screening programme communication strategies with the local population. In 2018-19 this will include:” Source location 2018-0074-Response-by-NHS-England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue supporting London AAA screening providers to improve men’s awareness of screening options.
Verbatim wording from the response “In 2018-19 NHS England London Region Public Health Commissioners will continue to support London AAA screening programme providers to ensure that programmes work to improve men’s awareness of their options to attend screening. A local quality standard implemented by NHS England London ensures that programmes record the numbers of men in each local Clinical Commissioning Group over 65 who Self-Refer to the screening programme. This is monitored by local and informs screening programme communication strategies with the local population. In 2018-19 this will include:” Source location 2018-0074-Response-by-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 Implement a local quality standard requiring programmes to record older men’s self-referrals to AAA screening.
Verbatim wording from the response “In 2018-19 NHS England London Region Public Health Commissioners will continue to support London AAA screening programme providers to ensure that programmes work to improve men’s awareness of their options to attend screening. A local quality standard implemented by NHS England London ensures that programmes record the numbers of men in each local Clinical Commissioning Group over 65 who Self-Refer to the screening programme. This is monitored by local and informs screening programme communication strategies with the local population. In 2018-19 this will include:” Source location 2018-0074-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing self-referral arrangements and communications are considered sufficient to enable men over 65 to access AAA screening and understand their options.
Verbatim wording from the response “The North East London NAAASP began in April 2013. At this time Mr Abrahams was 81 years and would therefore not have received an invitation to have AAA screening. However he would have received screening had he asked for an appointment.” Source location 2018-0074-Response-by-NHS-England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The UK National Screening Committee determines eligible screening ages and reviews new evidence that might justify changing those recommendations.
Verbatim wording from the response “With regards to point 1, men are currently invited to NHS Abdominal Aortic Aneurysm Screening Programme (“NAAASP”) in the year they are 65. The programme was introduced in England in 2009 on the recommendations of the UK National Screening Committee (“UKNSC”) following review of research evidence and data from existing local screening programmes against specific criteria.¹ This evidence showed a reduction in deaths from aneurysms when men were offered screening in their 65th year. Subsequently the UKNSC concluded that the ultrasound screening should be offered to men in their 65th year with men over 65 being able to self-refer or ‘opt in’ and request screening.²” Source location 2018-0074-Response-by-NHS-England
Open published response
26 Jan 2018 Vanessa Ferkova · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 5 Difference in commissioned services between primary and secondary care settings for similar unscreened patient populations View source Failure to include clinical observations in walk-in centre triage View source Confusion among the public about the roles of walk-in centres, urgent care centres and GP services attached to Emergency Departments View source Failure to maintain equivalent triage systems for unscreened patients across walk-in centres and emergency departments View source Unavailability of timely clinical triage including assessment of clinical observations at walk-in centre services View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Vanessa Ferkova · 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
Vanessa Ferkova, aged 2, attended a GP walk-in centre with fever and vomiting and later developed a rash. She was subsequently recognised as very unwell and likely suffering from meningococcal septicaemia, went into cardiac arrest in an ambulance, and died after unsuccessful resuscitation. The principal concern was that the walk-in centre did not provide clinical triage or a required timeframe for initial assessment, despite concerns that earlier observations could have identified and treated shock.
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 Difference in commissioned services between primary and secondary care settings for similar unscreened patient populations
Wider context from the report “I am concerned that there is a difference in the services commissioned between primary and secondary care settings, where the potential population of patients is similar; that being unscreened members of the public, including children .
I heard evidence that there is a confusion amongst the general public as to the roles of walk-in centres, urgent care centres and GP services attached to Emergency Departments. In this case it was likely that, had Vanessa presented to a GP service attached to an Emergency Department, she would have had a clinical triage within 15 minutes of arriving (including an assessment of clinical observations) and that she would not have died from septicaemia. I am concerned that she did not receive this care because of the service from which her parents (understandably) sought treatment.
The walk-in centre provider is currently investigating whether it should/could provide a triage service which includes an assessment of clinical observations. I am to be provided the outcome of this investigation at the end of February 2018. As such, I have not written a prevention of future deaths report to this provider but I am concerned that this is a nationwide issue which warrants consideration by NHS England as the commissioner of primary care services.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to include clinical observations in walk-in centre triage
Wider context from the report “I heard evidence from the CQC that the walk-in centre had been inspected for the first time in the June following Vanessa’s death. It was judged to have ‘triage process whereby patients were assessed so they were seen according to clinical need...’ but also that ‘Patients arriving at the service were seen generally according to arrival time’. The report also states that ‘Screening, prioritising and navigation of patients was completed by an appropriate clinician’. These conclusions were based on the process of receptionists documenting the presence/absence of ‘red flags’ and clinicians reviewing the waiting list when considering which patient was next to be seen.
I am concerned that the CQC judged the centre to have a triage process that was based on clinical need when that assessment does not include taking clinical observations which, in secondary care hospitals, was stated to be a vital patient safety tool . Given that walk-in centres and emergency departments both accept ‘unscreened’ patients, it is concerning that such differing triage systems should be in place; a situation which is seeming accepted by the regulator. I heard evidence that, should this circumstance repeat itself, then it is likely that the same outcome would occur. As such, my duty to raise these concerns is engaged.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Confusion among the public about the roles of walk-in centres, urgent care centres and GP services attached to Emergency Departments
Wider context from the report “I am concerned that there is a difference in the services commissioned between primary and secondary care settings, where the potential population of patients is similar; that being unscreened members of the public, including children.
I heard evidence that there is a confusion amongst the general public as to the roles of walk-in centres, urgent care centres and GP services attached to Emergency Departments . In this case it was likely that, had Vanessa presented to a GP service attached to an Emergency Department, she would have had a clinical triage within 15 minutes of arriving (including an assessment of clinical observations) and that she would not have died from septicaemia. I am concerned that she did not receive this care because of the service from which her parents (understandably) sought treatment.
The walk-in centre provider is currently investigating whether it should/could provide a triage service which includes an assessment of clinical observations. I am to be provided the outcome of this investigation at the end of February 2018. As such, I have not written a prevention of future deaths report to this provider but I am concerned that this is a nationwide issue which warrants consideration by NHS England as the commissioner of primary care services.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain equivalent triage systems for unscreened patients across walk-in centres and emergency departments
Wider context from the report “I heard evidence from the CQC that the walk-in centre had been inspected for the first time in the June following Vanessa’s death. It was judged to have ‘triage process whereby patients were assessed so they were seen according to clinical need...’ but also that ‘Patients arriving at the service were seen generally according to arrival time’. The report also states that ‘Screening, prioritising and navigation of patients was completed by an appropriate clinician’. These conclusions were based on the process of receptionists documenting the presence/absence of ‘red flags’ and clinicians reviewing the waiting list when considering which patient was next to be seen.
I am concerned that the CQC judged the centre to have a triage process that was based on clinical need when that assessment does not include taking clinical observations which, in secondary care hospitals, was stated to be a vital patient safety tool. Given that walk-in centres and emergency departments both accept ‘unscreened’ patients, it is concerning that such differing triage systems should be in place ; a situation which is seeming accepted by the regulator . I heard evidence that, should this circumstance repeat itself, then it is likely that the same outcome would occur. As such, my duty to raise these concerns is engaged.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unavailability of timely clinical triage including assessment of clinical observations at walk-in centre services
Wider context from the report “I am concerned that there is a difference in the services commissioned between primary and secondary care settings, where the potential population of patients is similar; that being unscreened members of the public, including children.
I heard evidence that there is a confusion amongst the general public as to the roles of walk-in centres, urgent care centres and GP services attached to Emergency Departments. In this case it was likely that, had Vanessa presented to a GP service attached to an Emergency Department, she would have had a clinical triage within 15 minutes of arriving (including an assessment of clinical observations) and that she would not have died from septicaemia. I am concerned that she did not receive this care because of the service from which her parents (understandably) sought treatment.
The walk-in centre provider is currently investigating whether it should/could provide a triage service which includes an assessment of clinical observations. I am to be provided the outcome of this investigation at the end of February 2018. As such, I have not written a prevention of future deaths report to this provider but I am concerned that this is a nationwide issue which warrants consideration by NHS England as the commissioner of primary care services.
” Open source report
25 Jan 2018 David Squire · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 3 Failure of smoke-free hospital guidance to permit staged Section 17 leave for smoking patients refusing nicotine replacement medication View source Failure of guidance to account for differing safety needs across hospital types View source Lack of a tool to depart from smoke-free hospital guidance where necessary 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
David Squire · 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 Squire, a detained patient at The Priory Lakeside View Care Home, took his own life by hanging in Fibbersley Nature Reserve on 25 July 2018 after leaving escorted off-ground leave for a cigarette and not returning. Concerns were raised that smoke-free hospital guidance required smoking patients who refused nicotine replacement to begin leave off grounds, without the staged observation process used for non-smoking patients, and that the guidance did not adequately account for risks in mental health hospitals.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of smoke-free hospital guidance to permit staged Section 17 leave for smoking patients refusing nicotine replacement medication
Wider context from the report “1. This guidance does not permit the proper use of Section 17 leave. The Priory is a smoke free hospital in accordance with NHS England guidance and cannot have a smoking area on the hospital grounds. To allow patients to smoke, Section 17 leave is utilised outside of The Priory’s grounds. Section 17 leave should be used for many purposes, including patent observation and interaction and to assess whether they are a risk of absconding. Given that purpose, the process of leave is staged. Patients start with escorted leave within the grounds, then unescorted, then escorted leave off grounds and then unescorted. Patients, who refuse nicotine replacement medication, and continue to smoke, must start the staged leave at escorted “off grounds.” This is so The Priory can comply with the NHS England guidance. Smoking patients therefore start leave at “off grounds” without the staged process and level of observation that non-smoking patients would be offered.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 guidance to account for differing safety needs across hospital types
Wider context from the report “2. The guidance fails to account for the differing needs regarding the different type of hospital that the policy spans. The application of the guidance to a standard NHS hospital creates far less of a risk than it does to a mental health hospital where it is accepted there is a frequency of patients who are at risk of absconding, self-harm and harm to others. The guidance leaves mental health hospitals, when detained patients smoke and refuse nicotine replacement therapy, to take detained patients off grounds in undesirable circumstances. The guidance, as it stands, with no tool to depart from the guidance, where necessary, leaves a significant risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a tool to depart from smoke-free hospital guidance where necessary
Wider context from the report “2. The guidance fails to account for the differing needs regarding the different type of hospital that the policy spans. The application of the guidance to a standard NHS hospital creates far less of a risk than it does to a mental health hospital where it is accepted there is a frequency of patients who are at risk of absconding, self-harm and harm to others. The guidance leaves mental health hospitals, when detained patients smoke and refuse nicotine replacement therapy, to take detained patients off grounds in undesirable circumstances. The guidance, as it stands, with no tool to depart from the guidance, where necessary, leaves a significant risk.
” 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 Suggest that smoking and section 17 leave be considered in future revisions to the Mental Health Act Code of Practice.
Verbatim wording from the response “In response to your request for further consideration I can confirm NHS England will raise the complexity of this issue with the Department of Health & Social Care as part of its contributions to the government-led response to the Independent Review of the Mental Health Act that reported to the Prime Minister in December 2018. The government has signalled its intention to legislate in response to the review, and NHS England will suggest that the issue of smoking and use of section 17 leave should also be considered as part of future revisions to the Code of Practice.” Source location 2019-0062-Response-by-NHS-England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise the complexity of smoking and section 17 leave with the Department of Health and Social Care through the government-led Mental Health Act review response.
Verbatim wording from the response “In response to your request for further consideration I can confirm NHS England will raise the complexity of this issue with the Department of Health & Social Care as part of its contributions to the government-led response to the Independent Review of the Mental Health Act that reported to the Prime Minister in December 2018. The government has signalled its intention to legislate in response to the review, and NHS England will suggest that the issue of smoking and use of section 17 leave should also be considered as part of future revisions to the Code of Practice.” Source location 2019-0062-Response-by-NHS-England
Open published response
19 Jan 2018 William Myers · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 8 Failure to circulate important clinical risk information to treating clinicians View source Failure to undertake multidisciplinary case conference reassessment by a forensic psychiatrist View source Inconsistent continuity of psychiatric care across teams and wards View source Failure to act on recommendations to consider Mental Health Act assessment View source Gaps in clinical record keeping hindering treatment coordination and discharge accountability View source Failure to identify complex cases early and assign them to an appropriately qualified psychiatrist View source Failure of psychiatric consultants to confer sufficiently on a clear management plan View source Insufficient availability of inpatient psychiatric beds for complex individuals View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
William Myers · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
William Myers, aged 79, was unlawfully killed; the medical cause of death was multiple stab wounds. The principal concerns related to inconsistent and inappropriate community care of his attacker, including failures to coordinate treatment, recognise warning signs, share relevant information, act on recommendations for Mental Health Act assessment, and maintain adequate records.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to circulate important clinical risk information to treating clinicians
Wider context from the report “(3) Valuable background information was not circulated to those involved in his treatment with the result that they were deprived of the crucially important medical history of the potential risks (particularly the attacker was no longer taking the medication which controlled his behaviour and was once again resorted to using illicit drugs). An example of this concerns a 20 page discharge report prepared by a Consultant Forensic Psychiatrist at the time the attacker was being prepared to leave Ashworth High Security Hospital. This report not seem to have been material to the Care Coordinator, the GP nor the Consultant Psychiatrist who undertook treatment on two different psychiatric wards and in the community.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake multidisciplinary case conference reassessment by a forensic psychiatrist
Wider context from the report “(2) A variety of incidents should have alerted the clinicians and others involved in his management to the need for a multi-disciplinary case conference reassessment by the Forensic Psychiatrist . Neither of these took place and in consequence warning signs of impending or actual violence were not recognised . Examples include being found by the Police in a public place in possession of a bladed article when under the influence of some illicit substance and admitting he was hearing voices commanding him to kill people.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inconsistent continuity of psychiatric care across teams and wards
Wider context from the report “(1) The care and treatment provided to Mr Lound's attacker ('the attacker') in 2015/16 whilst in the community was inconsistent and/or inappropriate management strategy . Instead of being treated by the same team of psychiatric clinicians, he was admitted to four different psychiatric wards during 2015 . The consultants involved in his treatment did not confer sufficiently to produce a clear management plan.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to act on recommendations to consider Mental Health Act assessment
Wider context from the report “(4) On three occasions during 2015 other clinicians who encountered the attacker recommended that a Mental Health Act assessment be considered with a view to him being detained . These recommendations were not acted upon . Judgements made by Consultant psychiatrists were not acted upon, preferably by a second opinion in the least, but preferably by a Forensic Psychiatrist, as this has been verified by the benefit of hindsight, the attacker's propensity to violent conduct may well have been triggers by a Mental Health Act assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Gaps in clinical record keeping hindering treatment coordination and discharge accountability
Wider context from the report “(5) Gaps in record keeping hindered the coordination of treatment . Examples included a void in the medical notes to explain why the number of letters had been transferred from one psychiatric ward to another (with a different consultant and clinical team), a discharge in his absence (taking place in October 2015) without any record of the assessment having been produced by the same team as to how the risk followed up and why he was to be benefited, nor an explanation as to who had authorised the discharge and the discharge was made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to identify complex cases early and assign them to an appropriately qualified psychiatrist
Wider context from the report “Overall, the lingering concern is complex such as this are not identified early enough and managed by an identified and appropriately qualified psychiatrist . There should be a clear delineation of all the clinicians and agencies involved, by way of periodic case conferences with reasons and decisions made being recorded and circulated. The scarcity of inpatient psychiatric beds fuels the concern that complex individuals are being treated in the community rather than controlling the risks they present by having them remain in hospital until such crimes as their condition has been shown to have stabilised.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 psychiatric consultants to confer sufficiently on a clear management plan
Wider context from the report “(1) The care and treatment provided to Mr Lound's attacker ('the attacker') in 2015/16 whilst in the community was inconsistent and/or inappropriate management strategy. Instead of being treated by the same team of psychiatric clinicians, he was admitted to four different psychiatric wards during 2015. The consultants involved in his treatment did not confer sufficiently to produce a clear management plan .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of inpatient psychiatric beds for complex individuals
Wider context from the report “Overall, the lingering concern is complex such as this are not identified early enough and managed by an identified and appropriately qualified psychiatrist. There should be a clear delineation of all the clinicians and agencies involved, by way of periodic case conferences with reasons and decisions made being recorded and circulated. The scarcity of inpatient psychiatric beds fuels the concern that complex individuals are being treated in the community rather than controlling the risks they present by having them remain in hospital until such crimes as their condition has been shown to have stabilised.
” Open source report
Concerns raised 3 Failure to communicate relevant patient information between GP and mental health services View source Lack of access to relevant records across healthcare providers View source Lack of clarity about crisis response pathways and service roles View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David John Buttriss · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David John Buttriss died at home on 9 May 2016 after cutting himself during a mental health crisis, despite medical assistance and resuscitation. The report identified communication problems between the GP and mental health services, separate healthcare record systems that limited access to relevant information, and a lack of clarity about the appropriate crisis-response pathway and the roles of different mental health teams.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate relevant patient information between GP and mental health services
Wider context from the report “1. Mr Buttriss had contact with a number of health agencies in the weeks prior to his death including the Community Mental Health, Home Treatment team, GP, Out of Hours GP and Paramedics. It was clear from the evidence at the inquest that
• There were Communication issues between the GP and mental health service. The mental health services had requested a patient profile from the GP on 14.5.16 which was not received. The Patient’s GP did not advise mental health services that Mr Buttriss had a mental health history pre-2009 when spoken to following his first self-referral on 14.5.16. It was not known whether this may have affected the decisions the mental health professionals took but it did and meant that his mental health issues were not known to the Cornwall Mental Health Service when they were contacted at the time of crisis
• The health care records for the GP and the Mental Health services are held on different health care record systems held by the different healthcare providers. This meant that the GP did not have access to the mental health service records at the time of the consultation on by ████████ on 25th April nor did the mental health workers have information about the appointment with ████████ nor were they aware of the medication issues. The Out of Hours GP, ████████ did not have access to either the mental health or GP records and was in a difficult position when deciding how to deal with Mr Buttriss especially with regards to prescribing and sign posting to mental health professionals when she saw him in acute crisis on the 7th May.
• It was clear from the evidence of the Paramedic and ████████ and the parents that there was lack of clarity of the appropriate method or pathway to deal with Mr Butriss on the night of 7th May when he was in crisis. The paramedic did speak to the Home Treatment Team for advice but as Mr Buttriss was reluctant to engage no intervention was made. There appeared to be confusions between the role of the Community Mental Health Service and the Home Treatment Team and the Home Treatment Team Out of Hours provision.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 access to relevant records across healthcare providers
Wider context from the report “1. Mr Buttriss had contact with a number of health agencies in the weeks prior to his death including the Community Mental Health, Home Treatment team, GP, Out of Hours GP and Paramedics. It was clear from the evidence at the inquest that
• There were Communication issues between the GP and mental health service. The mental health services had requested a patient profile from the GP on 14.5.16 which was not received. The Patient’s GP did not advise mental health services that Mr Buttriss had a mental health history pre-2009 when spoken to following his first self-referral on 14.5.16. It was not known whether this may have affected the decisions the mental health professionals took but it did and meant that his mental health issues were not known to the Cornwall Mental Health Service when they were contacted at the time of crisis
• The health care records for the GP and the Mental Health services are held on different health care record systems held by the different healthcare providers. This meant that the GP did not have access to the mental health service records at the time of the consultation on by ████████ on 25th April nor did the mental health workers have information about the appointment with ████████ nor were they aware of the medication issues. The Out of Hours GP, ████████ did not have access to either the mental health or GP records and was in a difficult position when deciding how to deal with Mr Buttriss especially with regards to prescribing and sign posting to mental health professionals when she saw him in acute crisis on the 7th May.
• It was clear from the evidence of the Paramedic and ████████ and the parents that there was lack of clarity of the appropriate method or pathway to deal with Mr Butriss on the night of 7th May when he was in crisis. The paramedic did speak to the Home Treatment Team for advice but as Mr Buttriss was reluctant to engage no intervention was made. There appeared to be confusions between the role of the Community Mental Health Service and the Home Treatment Team and the Home Treatment Team Out of Hours provision.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about crisis response pathways and service roles
Wider context from the report “1. Mr Buttriss had contact with a number of health agencies in the weeks prior to his death including the Community Mental Health, Home Treatment team, GP, Out of Hours GP and Paramedics. It was clear from the evidence at the inquest that
• There were Communication issues between the GP and mental health service. The mental health services had requested a patient profile from the GP on 14.5.16 which was not received. The Patient’s GP did not advise mental health services that Mr Buttriss had a mental health history pre-2009 when spoken to following his first self-referral on 14.5.16. It was not known whether this may have affected the decisions the mental health professionals took but it did and meant that his mental health issues were not known to the Cornwall Mental Health Service when they were contacted at the time of crisis
• The health care records for the GP and the Mental Health services are held on different health care record systems held by the different healthcare providers. This meant that the GP did not have access to the mental health service records at the time of the consultation on by ████████ on 25th April nor did the mental health workers have information about the appointment with ████████ nor were they aware of the medication issues. The Out of Hours GP, ████████ did not have access to either the mental health or GP records and was in a difficult position when deciding how to deal with Mr Buttriss especially with regards to prescribing and sign posting to mental health professionals when she saw him in acute crisis on the 7th May.
• It was clear from the evidence of the Paramedic and ████████ and the parents that there was lack of clarity of the appropriate method or pathway to deal with Mr Butriss on the night of 7th May when he was in crisis . The paramedic did speak to the Home Treatment Team for advice but as Mr Buttriss was reluctant to engage no intervention was made. There appeared to be confusions between the role of the Community Mental Health Service and the Home Treatment Team and the Home Treatment Team Out of Hours provision.
” 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 Support Local Health and Care Record Exemplars to establish safe, integrated access to permitted patient information across health and care organisations.
Verbatim wording from the response “In addition, NHS England is working with a number of Local Health and Care Record Exemplars to support the provision of safe integrated care across health and care settings. The aim will be to establish a local record for authorised staff in different organisations to access permitted information about a patient’s history of contact with the NHS and related care services. This may include information from ‘physical health checks’ for people with serious mental illness which NHS England is encouraging a greater take up of. We have made progress on this with around 60 local information sharing initiatives underway, each aiming to share information across organisations – such as GP, Acute and Social Care settings – and across geographies as the patient moves.” Source location 2018-0010-Response-by-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 Lead the Global Digital Exemplar programme to improve electronic record sharing and disseminate digital information-sharing learning across NHS trusts.
Verbatim wording from the response “We recognise that there are many challenges across the NHS to support secure data and record sharing, and we are actively leading a number of initiatives to address this. For example, the Global Digital Exemplar (“GDE”) programme, led” Source location 2018-0010-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the National Data Guardian to encourage appropriate information sharing by health and care practitioners.
Verbatim wording from the response “NHS England is committed to working with the National Data Guardian to encourage health and care practitioners to share information in the interests of patients. There are clear guidelines that encourage information sharing such as the principles and recommendations published in the 2013 review of information governance in the health and care system (“To Share or Not to Share”¹). This report was conducted by Dame Fiona Caldicott who has since been appointed to be the National Data Guardian.” Source location 2018-0010-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish guidelines clarifying community pathways for urgent, emergency and acute mental health services in 2018/19.
Verbatim wording from the response “NHS England has already published guidelines on the provision of urgent and emergency mental health provision in A&E / general hospitals, and intends to publish guidelines in 2018/19 to clarify the pathways of care for urgent, emergency and acute mental health services in the community. This includes ensuring that anyone, including health professionals, police, family members are able to access timely, 24/7 specialist care for people with emergency mental health needs.” Source location 2018-0010-Response-by-NHS-England
Open published response
Concerns raised 3 Failure to complete quarterly kidney function and lithium-level monitoring View source Failure to review and act on specialist medication advice View source Failure of clinical alert processes to reflect applicable lithium monitoring guidelines View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Pauline May Pryor · 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
Pauline May Pryor, a resident of Trevornor Nursing Home receiving lithium treatment, was found unwell on 9 July 2015 and died in hospital on 13 July 2015. The report identified concerns that required quarterly blood tests were not carried out because of unclear communication between the nursing home and GP surgery, and that psychiatric advice to reduce and stop lithium was not seen or followed up.
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 complete quarterly kidney function and lithium-level monitoring
Wider context from the report “• Mrs Pryor suffered from bipolar affective disorder and was on Lithium treatment which had been successful for many years in controlling her mood. Patients on Lithium are required to have quarterly blood tests to check kidney function and lithium levels. This was not carried out for a number of reasons do to with unclear communication between the Nursing Home and GP surgery . The practice did have in place a computer system to highlight test/reviews for certain groups of patients based on “Quality Outcome Framework Targets” (QOF) guidelines and were unaware these did not necessarily mirror the NICE Guidelines or Local Prescribing /Care Guidelines such as in the case of Lithium Toxicity
• A blood test on 29th April 2015 showed Mrs Pryor’s kidney function dropped (eGFR 25) despite a lithium test being requested by Nursing Home and GP it did not occurred . As a result of the kidney function test result the GP wrote to Mrs Pryor’s Consultant Psychiatrist for advice on medication. The Psychiatrist replied by e-mail on the 15.6.15 and advised the GP to reduce and stop the Lithium medication. The E-mail was sent to the GP Practice e-mail but was not seen by the GP for reasons unknown nor was the reply chased up
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to review and act on specialist medication advice
Wider context from the report “• Mrs Pryor suffered from bipolar affective disorder and was on Lithium treatment which had been successful for many years in controlling her mood. Patients on Lithium are required to have quarterly blood tests to check kidney function and lithium levels. This was not carried out for a number of reasons do to with unclear communication between the Nursing Home and GP surgery. The practice did have in place a computer system to highlight test/reviews for certain groups of patients based on “Quality Outcome Framework Targets” (QOF) guidelines and were unaware these did not necessarily mirror the NICE Guidelines or Local Prescribing /Care Guidelines such as in the case of Lithium Toxicity
• A blood test on 29th April 2015 showed Mrs Pryor’s kidney function dropped (eGFR 25) despite a lithium test being requested by Nursing Home and GP it did not occurred. As a result of the kidney function test result the GP wrote to Mrs Pryor’s Consultant Psychiatrist for advice on medication. The Psychiatrist replied by e-mail on the 15.6.15 and advised the GP to reduce and stop the Lithium medication. The E-mail was sent to the GP Practice e-mail but was not seen by the GP for reasons unknown nor was the reply chased up
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of clinical alert processes to reflect applicable lithium monitoring guidelines
Wider context from the report “• Mrs Pryor suffered from bipolar affective disorder and was on Lithium treatment which had been successful for many years in controlling her mood. Patients on Lithium are required to have quarterly blood tests to check kidney function and lithium levels. This was not carried out for a number of reasons do to with unclear communication between the Nursing Home and GP surgery. The practice did have in place a computer system to highlight test/reviews for certain groups of patients based on “Quality Outcome Framework Targets” (QOF) guidelines and were unaware these did not necessarily mirror the NICE Guidelines or Local Prescribing /Care Guidelines such as in the case of Lithium Toxicity
• A blood test on 29th April 2015 showed Mrs Pryor’s kidney function dropped (eGFR 25) despite a lithium test being requested by Nursing Home and GP it did not occurred. As a result of the kidney function test result the GP wrote to Mrs Pryor’s Consultant Psychiatrist for advice on medication. The Psychiatrist replied by e-mail on the 15.6.15 and advised the GP to reduce and stop the Lithium medication. The E-mail was sent to the GP Practice e-mail but was not seen by the GP for reasons unknown nor was the reply chased up
” 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 Highlight lithium monitoring requirements to GPs and practices and remind them that current BNF and local CCG prescribing guidance is available.
Verbatim wording from the response “2. Lithium monitoring. Thank you for pointing out that the QOF framework which is designed to reward GPs for quality, is not the mirror of lithium monitoring guidelines. We will ensure that this is highlighted to GPs and practices and a reminder that up to date guidance is available from the latest BNF, and also local CCG prescribing guidelines.” Source location 2018-0008-Response-by-NHS-England
Open published response
13 Dec 2017 Rebecca Jay ROMERO · Prevention of Future Deaths report Avon
View report summary
Concerns raised 6 Lack of training or guidance for staff communicating with young persons by text or social media View source Lack of a clear documented process for in-patient transfers View source Lack of guidance for managing children returning to their local area after out-of-area psychiatric inpatient care View source Lack of guidance for managing children receiving out-of-area psychiatric inpatient care View source Inconsistent terminology and grading in risk assessment View source Failure of care plans to specify dates for meetings and task completion 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
Rebecca Jay ROMERO · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Rebecca Romero died at home on 19 July 2017 after being found with a ligature around her neck, five days after discharge from a psychiatric unit and while under community team care. The report raised concerns about gaps in post-discharge contact and medical review, unclear and inconsistent care planning and risk terminology, communication by text, and arrangements for transferring children between out-of-area and local psychiatric services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of training or guidance for staff communicating with young persons by text or social media
Wider context from the report “(4) That consideration should be given to training and/or guidance issued for staff communicating with young persons by text or any means of social media .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear documented process for in-patient transfers
Wider context from the report “(1) In this case there was confusion as to whether on an in-patient transfer there should be a Form 2 to go alongside the Form 1 procedure . As well as clarifying this process with all providers concerned consideration should be given that a clear documented process is put in place for in-patient transfers so that all those involved understand clearly the situation and the decision made in relation 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 Lack of guidance for managing children returning to their local area after out-of-area psychiatric inpatient care
Wider context from the report “(5) Consideration should be given to reviewing whether there ought to be guidance issued when managing children who go out of area for psychiatric in patient care and further guidance issued in the management of children when returning to their local area when they have been an in-patient of out area . Whether certain steps should be taken to ensure best practice and a consistent approach e.g. risk assessing; face to face meetings; robust care planning; parental involvement; how best to re-integrate back into the local area/team .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for managing children receiving out-of-area psychiatric inpatient care
Wider context from the report “(5) Consideration should be given to reviewing whether there ought to be guidance issued when managing children who go out of area for psychiatric in patient care and further guidance issued in the management of children when returning to their local area when they have been an in-patient of out area. Whether certain steps should be taken to ensure best practice and a consistent approach e.g. risk assessing; face to face meetings; robust care planning; parental involvement; how best to re-integrate back into the local area/team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inconsistent terminology and grading in risk assessment
Wider context from the report “(3) That the issue of inconsistent terminology when assessing risk is reviewed to ensure a consistent approach. In this case there were a number of different phrases and grading's used to determine the deceased's risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of care plans to specify dates for meetings and task completion
Wider context from the report “(2) Consideration should be given to ensuring that all care plans are time specific so that dates of meetings or dates for tasks to be completed are set at the time of the meeting so agreeing expectations are managed to everyone knows exactly what the plan is and when actions will occur.
” Open source report
Concerns raised 1 Failure to account for the totality and synergistic effects of prescribed central nervous system and respiratory-depressant medication 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
Stuart Andrew WALLS · 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
Stuart Andrew WALLS was found dead in his room on 12 March 2017 after being last seen alive the previous morning. The inquest concluded that he died from drug poisoning caused by the combined effects of prescribed medication, with concern that multiple central-nervous-system medicines could have a synergistic effect on respiration even when taken at prescribed doses.
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 account for the totality and synergistic effects of prescribed central nervous system and respiratory-depressant medication
Wider context from the report “Stuart died as a result of drug poisoning. However, there was no evidence of illicit drug use (other than cannabis which the Consultant Histopathologist confirmed had not played a part in the death). All prescribed drugs in his blood were within the therapeutic range.
The Consultant Histopathologist explained that the prescribed drugs had combined in a synergistic effect, acting together to poison Stuart.
My concern is that in the prescription of medication, particularly those that act on the central nervous system and affect respiration control, full account should be taken of the totality of drugs prescribed and their potential synergistic effect.
The reasons for my concern are:
Four prescription drugs namely Diazepam, Pregabalin, Amitriptyline and Promethazine were all found at a level consistent with therapeutic use. Each of these alone was at a level not expected to kill however each can exacerbate the effect of the other. I understood from the evidence that each of the drugs have a direct effect on the central nervous system. In particular a depressive effect on respiration. The Consultant Histopathologist confirmed this to be the case.
In addition to those prescribed drugs, methadone was also prescribed at 60 mg daily. That is well within normal prescription range. It was found at a level of 507ng/mL in blood. Methadone also has an effect on the central nervous system and is another respiratory depressor. The toxicology report said:
“...the deceased was prescribed 60mg of methadone daily. It has been reported that in 20 long-term opiate addicts who were administered a mean oral dose of 60mg methadone (range 10-225mg), the peak blood methadone concentrations ranged between 124-1255 ng/mL. It has been reported that in a study of 18 patients maintained on methadone 7.5 to 130 mg daily for at least 2 months, peak plasma concentrations of 69-698 ng/mL (pre-dose concentrations: 44-614 ng/mL) were achieved in 3 hours. The blood methadone level in the deceased was 507 ng/mL which may, therefore, reflect therapeutic use”.
It is of course, not known how much methadone Stuart had taken or when. However, properly taking the prescribed dose could still achieve the recorded level.
To put the amount of methadone into context, the toxicology evidence indicated a therapeutic range of 75 – 1100 ng/ml in blood; a toxic range of 200 – 2000 ng/ml and a fatal range of 400 – 2000 ng/mL. A level of tolerance builds with regular use.
Methadone is a potent opioid narcotic analgesic and would also have a synergistic effect together with the other four drugs mentioned above.
Therefore, even taking the properly prescribed medication as prescribed could have led to the situation that resulted in the death of Stuart WALLS. That is, drugs properly prescribed and properly taken could achieve a level, acting synergistically, that caused drug toxicity sufficient to cause death.
” Open source report
Concerns raised 3 Failure to oversee or verify ultrasonography reports by a Consultant Radiologist View source Ultrasound reports failing to carry appropriate recommendations to referring clinicians View source Lack of General Practitioner awareness that a supra-renal aortic aneurysm finding may indicate a larger thoracic aortic aneurysm requiring further investigation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mrs Violet Levine Nelson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Violet Nelson collapsed suddenly at home and died on 17 September 2016; a post-mortem examination identified a ruptured thoracic aortic aneurysm. The report raised concerns that earlier ultrasound findings were not overseen by a Consultant Radiologist and did not recommend referral to a Vascular Surgeon or CT examination, and that GPs may not have been aware of the significance of a suprarenal aortic aneurysm.
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 oversee or verify ultrasonography reports by a Consultant Radiologist
Wider context from the report “(1) If the reports of Ultrasonography in 2012, 2013 and 2014 had been overseen/verified by a Consultant Radiologist , it is likely that referral of Mrs Nelson to a Vascular Surgeon and CT examination of the chest would have prompted an appropriate response by the referring GP.
(2) It is more likely than not that General Practitioners are not aware of the fact that the Ultrasonography finding of an Aneurysm of the Supra-renal Aorta is likely to indicate the presence of a larger Thoracic Aortic Aneurysm and that, in consequence, CT examination of the chest should be performed or the patient should be referred to a Vascular Surgeon.
(3) Therefore, without an ultrasound report carrying an appropriate recommendation to the referring Clinician and if General Practitioners are not made aware of the fact the Ultrasonography finding of an Aneurysm of the Supra-renal Aorta is likely to indicate the presence of a large Thoracic Aortic Aneurysm requiring further investigation, similar deaths to that suffered by Mrs Nelson may occur 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 Ultrasound reports failing to carry appropriate recommendations to referring clinicians
Wider context from the report “(1) If the reports of Ultrasonography in 2012, 2013 and 2014 had been overseen/verified by a Consultant Radiologist, it is likely that referral of Mrs Nelson to a Vascular Surgeon and CT examination of the chest would have prompted an appropriate response by the referring GP.
(2) It is more likely than not that General Practitioners are not aware of the fact that the Ultrasonography finding of an Aneurysm of the Supra-renal Aorta is likely to indicate the presence of a larger Thoracic Aortic Aneurysm and that, in consequence, CT examination of the chest should be performed or the patient should be referred to a Vascular Surgeon.
(3) Therefore, without an ultrasound report carrying an appropriate recommendation to the referring Clinician and if General Practitioners are not made aware of the fact the Ultrasonography finding of an Aneurysm of the Supra-renal Aorta is likely to indicate the presence of a large Thoracic Aortic Aneurysm requiring further investigation, similar deaths to that suffered by Mrs Nelson may occur 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 General Practitioner awareness that a supra-renal aortic aneurysm finding may indicate a larger thoracic aortic aneurysm requiring further investigation
Wider context from the report “(1) If the reports of Ultrasonography in 2012, 2013 and 2014 had been overseen/verified by a Consultant Radiologist, it is likely that referral of Mrs Nelson to a Vascular Surgeon and CT examination of the chest would have prompted an appropriate response by the referring GP.
(2) It is more likely than not that General Practitioners are not aware of the fact that the Ultrasonography finding of an Aneurysm of the Supra-renal Aorta is likely to indicate the presence of a larger Thoracic Aortic Aneurysm and that, in consequence, CT examination of the chest should be performed or the patient should be referred to a Vascular Surgeon .
(3) Therefore, without an ultrasound report carrying an appropriate recommendation to the referring Clinician and if General Practitioners are not made aware of the fact the Ultrasonography finding of an Aneurysm of the Supra-renal Aorta is likely to indicate the presence of a large Thoracic Aortic Aneurysm requiring further investigation, similar deaths to that suffered by Mrs Nelson may occur in the future.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure the NICE lead for the abdominal aortic aneurysm guideline is aware of the Coroner’s concerns.
Verbatim wording from the response “NICE are developing new Clinical Guideline on “Abdominal aortic aneurysm: diagnosis and management”; the expected publication date is November 2018.¹ The guideline is intended for a wide audience, including patients and their families. It will also provide standards and thresholds for clinicians involved in the diagnosis and management of patients with AAs. This appears to be a timely opportunity for NHS England to inform the NICE AAA Committee of the concerns you raised and ask them to consider incorporating appropriate advice to all relevant clinical professions. Therefore, I will ensure that the NICE lead for this Guideline, Mr Andrew Bradbury, is aware of your Regulation 28 letter and the concerns raised by you.” Source location 2017-0356-Response-by-NHS-Engalnd
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Royal College of General Practitioners and Society of Radiographers may address the specific concerns about ultrasound report content.
Verbatim wording from the response “I note that your Report has been sent to The Royal College of General Practitioners and The Society of Radiographers who may be able to address your specific concerns as detailed in section 5 of your Report.” Source location 2017-0356-Response-by-NHS-Engalnd
Open published response
22 Nov 2017 Tomas Kelly · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 2 Lack of routine chicken pox vaccination offer for children with Downs Syndrome View source Failure to communicate the increased infection risks associated with Downs Syndrome to parents or carers 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
Tomas Kelly · 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
Tomas Kelly, aged 3, was admitted to hospital after choking and being diagnosed with aspiration pneumonia and a chest infection. After later developing chicken pox, he deteriorated rapidly at home and died in hospital on 22 November 2016; the cause of death was confluent bronchopneumonia. The principal concerns were that his parents may not have been informed about the increased infection risks associated with Down’s Syndrome, and whether children with Down’s Syndrome should routinely be offered chicken pox vaccination.
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 routine chicken pox vaccination offer for children with Downs Syndrome
Wider context from the report “2. Vaccination against chicken pox
a. The evidence confirmed that it is not the chicken pox per se which creates a risk. Rather it is the immunosupppressant effect of this – creating a risk of more serious infections as a result.
b. We heard from a community paediatrician that, as matters stand, there is no plan to vaccinate all children against chicken pox. This is limited to certain high risk groups only.
c. It is clear that children with Downs Syndrome are at increased risk – both of contracting infection and of the infections being more serious.
d. Careful consideration should be given to including children with Downs Syndrome to the category of children who will be routinely offered this vaccination .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the increased infection risks associated with Downs Syndrome to parents or carers
Wider context from the report “1. Talking to parents
a. I did not have concerns about the medical professionals being aware of the increased risks associated with infection in children with Downs Syndrome. I heard no evidence of the parents being made aware of this however – either when he was discharged from hospital on 22 October 2016 or when he was seen by his GP on 21 November 2016.
b. Tomas’ parents said they may have sought additional medical assistance if they had known about these risks.
c. Whilst this may be happening to some extent in community paediatrics, it is important for health professionals in acute settings (including primary care) to be advised to share these risks with parents/ carers, so that they can adopt an appropriate threshold for seeking medical assistance.
” Open source report
Concerns raised 4 Lack of widespread, regular, mandatory ongoing crisis-drill training for anaesthetists View source Failure to ensure sufficient understanding of capnography among clinical staff who may intubate patients View source Failure to ensure utilisation of capnography by clinical staff who may intubate patients View source Failure to observe capnography for up to 15 to 20 seconds after intubation View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter Saint · 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 Saint was admitted for routine elective knee replacement surgery and died after an endotracheal tube was placed in his oesophagus, resulting in approximately 38 minutes without effective lung ventilation and subsequent hypoxic brain damage. The principal concerns were inadequate understanding and interpretation of capnography, failure to follow the required confirmation procedure after intubation, and insufficient ongoing training for anaesthetists in crisis situations.
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 widespread, regular, mandatory ongoing crisis-drill training for anaesthetists
Wider context from the report “The evidence heard, including the expert evidence, confirmed that an integral part of the process of intubating a patient requires that the anaesthetist, following the placement of the intubation tube into the patient, observes the capnography for a period of up to 15 to 20 seconds to ensure that a “proper CO2 end tidal wave” can be detected; failure to do so would be a “fundamental and basic error” and a “serious error”. I am concerned that this procedure was not followed by either the lead consultant anaesthetist in this case or the anaesthetists who attended to assist him. The expert evidence indicated a lack of widespread, regular, mandatory on-going training for anaesthetists in drills dealing with crisis situations potentially facing an anaesthetic team particularly in relation to the issues of “task fixation” and “confirmatory bias” , and that such training would be beneficial.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 sufficient understanding of capnography among clinical staff who may intubate patients
Wider context from the report “I am concerned that the evidence in this case, including the expert evidence, established that notwithstanding the findings and recommendations of the 2011 NAP4 there is a continuing failure to ensure that capnography is sufficiently understood and utilised by all clinical staff who may intubate patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure utilisation of capnography by clinical staff who may intubate patients
Wider context from the report “I am concerned that the evidence in this case, including the expert evidence, established that notwithstanding the findings and recommendations of the 2011 NAP4 there is a continuing failure to ensure that capnography is sufficiently understood and utilised by all clinical staff who may intubate patients .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to observe capnography for up to 15 to 20 seconds after intubation
Wider context from the report “The evidence heard, including the expert evidence, confirmed that an integral part of the process of intubating a patient requires that the anaesthetist, following the placement of the intubation tube into the patient, observes the capnography for a period of up to 15 to 20 seconds to ensure that a “proper CO2 end tidal wave” can be detected; failure to do so would be a “fundamental and basic error” and a “serious error” . I am concerned that this procedure was not followed by either the lead consultant anaesthetist in this case or the anaesthetists who attended to assist him . The expert evidence indicated a lack of widespread, regular, mandatory on-going training for anaesthetists in drills dealing with crisis situations potentially facing an anaesthetic team particularly in relation to the issues of “task fixation” and “confirmatory bias”, and that such training would be beneficial.
” 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 Existing RCoA continuing professional development and mandatory consultant training address ongoing anaesthetic training concerns.
Verbatim wording from the response “In terms of training, the RCoA’s continuing professional development¹ (“CPD”) does include training on perioperative emergencies (including crisis training); emergency management and resuscitation; and human factors in anaesthetic practice. Consultants must undertake CPD training and this is used to assess revalidation, which every doctor practising medicine in the United Kingdom must do. We believe that the additional development of national guidance under the Never Events Framework will further support this.” Source location 2017-0404_Response-by-NHS-England
Open published response
16 Nov 2017 John Haines · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3 Delays in access to Healthy Minds due to long waiting times View source Lack of access to qualified psychological therapy for mental health in-patients View source Lack of access to qualified psychological therapy for patients under the care of the Home Treatment Team 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
John Haines · 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
John Haines was admitted to a mental health ward in March 2017 after his anxiety and depression deteriorated, and was discharged on 14 June 2017 with planned follow-up. He was found deceased at home on 17 June 2017 after failing to respond to contact. The report raised concerns about in-patients and Home Treatment Team patients being unable to access qualified psychological therapy, including delays in accessing Healthy Minds.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in access to Healthy Minds due to long waiting times
Wider context from the report “3. Timely access to Healthy Minds is also hindered by long waiting times .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 access to qualified psychological therapy for mental health in-patients
Wider context from the report “1. During the course of the evidence it became apparent that mental health in-patients still do not have access to therapy from a qualified Psychologist , despite the fact that this has been raised in previous Regulation 28 PFD Forms.
Notably, all clinicians were of the professional view that psychological therapy was critical to treatment, alongside psychiatric 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 Lack of access to qualified psychological therapy for patients under the care of the Home Treatment Team
Wider context from the report “2. Similarly, patients cannot access a qualified Psychologist whilst under the care of the Home Treatment Team (‘HTT’) etc. The only way for patients to get access to a Psychologist is through referral to ‘Healthy Minds’. Healthy Minds cannot provide access where the patient remains under the care of the HTT etc.
” Open source report
6 Nov 2017 RYAN JAMES VOUT · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Inability to pre-arrange ambulance attendance during execution of a s.135 (1) MHA Act 1983 warrant View source Failure to inform family before discharge View source Failure of hospital and community professionals to liaise before discharge View source Lack of a formal briefing or risk assessment before entry under a s.135 (1) MHA Act 1983 warrant 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
RYAN JAMES VOUT · 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
Ryan James Vout, who had paranoid schizophrenia and was apparently unmedicated, stabbed himself in the chest during an attempt by police officers to execute a section 135 warrant on 10 August 2016. He died despite emergency first aid and hospital treatment. The principal concerns were inadequate coordination before his discharge from psychiatric care, the inability to pre-arrange an ambulance for section 135 warrant attendances, and the lack of a formal briefing or risk assessment before officers entered the premises.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inability to pre-arrange ambulance attendance during execution of a s.135 (1) MHA Act 1983 warrant
Wider context from the report “(2) The inability to pre-arrange attendance of an ambulance when police officers exercise a s.135 (1) MHA Act 1983 warrant;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to inform family before discharge
Wider context from the report “(1) The lack of a co-ordinated discharge from in-patient psychiatric care into the community, in particular the failure of appropriate professionals from hospital and community to liaise and for family to be informed as a pre-requisite for discharge ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital and community professionals to liaise before discharge
Wider context from the report “(1) The lack of a co-ordinated discharge from in-patient psychiatric care into the community, in particular the failure of appropriate professionals from hospital and community to liaise and for family to be informed as a pre-requisite for discharge;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal briefing or risk assessment before entry under a s.135 (1) MHA Act 1983 warrant
Wider context from the report “(3) The lack of a formality to the ‘briefing’ or risk assessment exercise before officers enter premises with a view to exercising a s.135 (1) MHA Act 1983 warrant.
” Open source report
27 Oct 2017 Stephen George Coulson · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 5 Failure of the system for audit of controlled-drug processes View source Failure of the system for documentation of controlled drugs View source Lack of escalation for admission of patients requiring continued observation or review View source Failure of high-level investigations to identify lessons View source Failure of the system for administration of controlled drugs View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Stephen George Coulson · 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 George Coulson was discharged from Manchester Royal Infirmary after an increased Fentanyl patch was applied, with no record that the previous patch had been removed and despite confusion and agitation requiring further observation under hospital policy. He was found in cardiac arrest at home in the early hours of 1 January 2016 and died in intensive care later that day. The principal concerns were controlled-drug administration and documentation, failure to escalate the need for observation and review before discharge, and the Trust’s investigation failing to identify lessons.
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 system for audit of controlled-drug processes
Wider context from the report “1) Controlled drugs – the system in place for the administration, documentation and audit of processes associated with the use of controlled drugs
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of the system for documentation of controlled drugs
Wider context from the report “1) Controlled drugs – the system in place for the administration, documentation and audit of processes associated with the use of controlled drugs
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 escalation for admission of patients requiring continued observation or review
Wider context from the report “2) Observation policy – the lack of escalation of the need to admit patients for observation and review should they fulfil the criteria to require continued observation / review prior to discharge
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of high-level investigations to identify lessons
Wider context from the report “3) High Level Investigation – the witness did not accept that any lessons could be learnt from the investigation surrounding the death of the deceased.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of the system for administration of controlled drugs
Wider context from the report “1) Controlled drugs – the system in place for the administration , documentation and audit of processes associated with the use of controlled drugs
” Open source report
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