Concerns raised 1 Shortage of Cardiac Intensive Care Unit specialist nurses for post-operative patient care 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
Trevor Paul Hunking · 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
Trevor Paul Hunking had severe aortic stenosis and was transferred for planned aortic valve replacement and coronary artery bypass grafting after an acute deterioration. He underwent surgery but did not recover and died on 16 June 2015; the report raised a concern about a shortage of Cardiac Intensive Care Unit Specialist Nurses for post-operative patients.
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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 Shortage of Cardiac Intensive Care Unit specialist nurses for post-operative patient care
Wider context from the report “(1) A shortage of Cardiac Intensive Care Unit Specialist Nurses to deal with patients post-operatively .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue partnership work with Health Education England to explore and develop specialist critical-care nurse training, development and retention opportunities.
Verbatim wording from the response “There are other opportunities to work in collaboration with HEE to support the training, development and retention of specialist critical care nurses. They require further development but could include:” Source location 2016-0391-Response-by-NHS-Health-England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review NHS operational plans and workforce requirements to support safe, sustainable workforce models.
Verbatim wording from the response “We are currently reviewing the NHS operational plans including workforce for this year and into next to ensure that system demand is deliverable with safe and sustainable workforce models. This work is aligned with NHS England whom also have an important role in supporting the system on workforce such as nursing staff.” Source location 2016-0391-Response-by-NHS-Health-England
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review national registered-nurse supply and its impact on specialist intensive-care nurse recruitment and retention.
Verbatim wording from the response “Nationally, NHS Improvement is working with HEE to help address the concerns you raise regarding the availability of cardiac specialist nurses in a number of ways. Firstly, we are working in collaboration with both HEE and NHS England to review the wider national supply issues of Registered Nurses, and the longstanding impact this has had on recruitment and retention of qualified, specialist, cardiac, general and neuro intensive care nurses.” Source location 2016-0391-Response-by-NHS-Health-England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Employers are responsible for specialist nurse training and ongoing specialist cardiac intensive care workforce supply and retention, with support available from HEE.
Verbatim wording from the response “Since its establishment in 2013, Health Education England has been working to support an increase in the overall general nursing supply. Nurses often go on to train as specialists and it is employers who are responsible for this.” Source location 2016-0391-Response-by-NHS-Health-England
Open published response
25 Oct 2016 Jane Louise Reason · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Insufficient public education in the use of public access defibrillators View source Inadequate placement of public access defibrillators View source Insufficient availability of public access defibrillators in colleges and schools 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
Jane Louise Reason · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jane Louise Reason, a lecturer, collapsed at work on 28 April 2016 and was later declared deceased in hospital; the medical cause of death was recorded as hypertensive heart disease. The inquest highlighted the importance of early defibrillation and CPR and raised concern about the availability and public education surrounding public access defibrillators, particularly in colleges and schools.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient public education in the use of public access defibrillators
Wider context from the report “1. Evidence at the inquest confirmed that the greatest chance of survival following an arrhythmic out of cardiac arrest is with early defibrillation and CPR. I heard evidence that there was a need for more public access defibrillators particularly in colleges and school. Further consideration needs to be given to the placement of public access defibrillators and education of the public in their use .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequate placement of public access defibrillators
Wider context from the report “1. Evidence at the inquest confirmed that the greatest chance of survival following an arrhythmic out of cardiac arrest is with early defibrillation and CPR. I heard evidence that there was a need for more public access defibrillators particularly in colleges and school. Further consideration needs to be given to the placement of public access defibrillators and education of the public in their use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of public access defibrillators in colleges and schools
Wider context from the report “1. Evidence at the inquest confirmed that the greatest chance of survival following an arrhythmic out of cardiac arrest is with early defibrillation and CPR. I heard evidence that there was a need for more public access defibrillators particularly in colleges and school . Further consideration needs to be given to the placement of public access defibrillators and education of the public in their use.
” Open source report
Concerns raised 1 Failure to ensure accurate and complete discharge information is communicated to primary care teams 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
Margaret Mary Dempsie · 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
Margaret Mary Dempsie, who had advanced dementia and frailty, was admitted to hospital for treatment of infected leg ulcers, later deteriorated with sepsis, and died two days after discharge for end-of-life care. The discharge letter contained inaccurate and incomplete clinical information, including an incorrect reference to aspiration pneumonia and omission of pyelonephritis, raising concerns that vulnerable patients could receive inappropriate care based on incorrect discharge information.
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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 ensure accurate and complete discharge information is communicated to primary care teams
Wider context from the report “The discharge letter from the University Hospitals of Leicester NHS Trust addressed to the primary care team contained inaccuracies . It stated that Mrs Dempsie had been suffering from aspiration pneumonia when no pneumonia had been identified and did not mention pyelonephritis, which had been present. The Consultant who was looking after Mrs Dempsie was not surprised and admitted in the inquest that the Discharge Letters for patients were being completed with mistakes by the Junior Doctors , that this was something that happens and that GP's regularly have to phone the hospital to ascertain the correct facts . He said that sometimes the junior doctors who complete the discharge letters have never seen the patient. This situation was also confirmed by the General Practitioner who was also present at the inquest. I have concerns that the wrong information is being passed on to primary carers who are then, of course, obliged to act upon the information they are furnished with in the Discharge Letter and that this could lead to serious mistakes being made in the care of vulnerable patients newly discharged from hospital.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for commissioning services and providing assurance on mitigation actions rests with the Leicester City Clinical Commissioning Group.
Verbatim wording from the response “I have reviewed your report in detail and I have identified that the Leicester City Clinical Commissioning Group (“CCG”) is responsible for commissioning services from the University Hospitals of Leicester NHS Trust. I have therefore asked the CCG to respond and provide assurance regarding actions they have taken in order to mitigate the risk identified within your report. A copy of their response is enclosed with this letter.” Source location 2016-0374-Response-by-NHS-England
Open published response
Concerns raised 3 Failure to subject advanced nurse practitioners to stringent appraisal and revalidation processes View source Lack of direct employer responsibility and supervision for some advanced nurse practitioners View source Lack of regulatory oversight for advanced nurse practitioners View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Benjamin Orrill · 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
Benjamin Orrill died on 12 June 2016 following a fall from Lee Circle NCP car park, Leicester; the inquest concluded that the death was suicide. He had been reviewed by an advanced nurse practitioner after feeling suicidal, and the report identified concerns about the lack of a regulatory body and appraisal or revalidation processes for advanced nurse practitioners, with potential implications for patient safety.
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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 subject advanced nurse practitioners to stringent appraisal and revalidation processes
Wider context from the report “During the course of the Inquest it came to my attention that there is no regulatory body for advanced nurse practitioners. It would appear they are not subject to the same stringent appraisal and revalidation processes such that GPs currently are , despite the fact that they may perform similar duties and can have parallel roles.
I also became aware that some advance nurse practitioners may independently buy into a partnership and may not have an employer directly responsible for their appraisal. Therefore some may potentially be operating as independent practitioners without any supervision or regulation. I am concerned that this may have a significant impact on patient safety.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of direct employer responsibility and supervision for some advanced nurse practitioners
Wider context from the report “During the course of the Inquest it came to my attention that there is no regulatory body for advanced nurse practitioners. It would appear they are not subject to the same stringent appraisal and revalidation processes such that GPs currently are, despite the fact that they may perform similar duties and can have parallel roles.
I also became aware that some advance nurse practitioners may independently buy into a partnership and may not have an employer directly responsible for their appraisal . Therefore some may potentially be operating as independent practitioners without any supervision or regulation . I am concerned that this may have a significant impact on patient safety.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 regulatory oversight for advanced nurse practitioners
Wider context from the report “During the course of the Inquest it came to my attention that there is no regulatory body for advanced nurse practitioners . It would appear they are not subject to the same stringent appraisal and revalidation processes such that GPs currently are, despite the fact that they may perform similar duties and can have parallel roles.
I also became aware that some advance nurse practitioners may independently buy into a partnership and may not have an employer directly responsible for their appraisal. Therefore some may potentially be operating as independent practitioners without any supervision or regulation. I am concerned that this may have a significant impact on patient safety.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Nursing and Midwifery Council is responsible for nurses’ standards, registration, revalidation and professional regulation.
Verbatim wording from the response “1.0 There is no regulatory body for advanced nurse practitioners: NHS England has no jurisdiction over the regulation of nurses. The NMC is the body which sets standards of education, training, conduct and performance and ensures that nurses and midwives keep their skills and knowledge up to date and uphold professional standards. They have processes to investigate nurses and midwives who do not meet those requisite standards and maintain a register of nurses and midwives allowed to practice in the UK.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Supervision or regulation of registered nurses practising independently falls outside NHS England’s mandate.
Verbatim wording from the response “2.0 Advanced nurse practitioners may independently buy into a partnership and may not have an employer directly responsible for their appraisal; and therefore may be operating as independent practitioners without any supervision or regulation. Again NHS England has no mandate in relation to registered nurses who have chosen to practise independently. Those registrants remain accountable to the NMC as their regulatory body and through a process of professional revalidation are expected to maintain their registration.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Regulation of nurses, including advanced nurse practitioners, falls outside NHS England’s jurisdiction.
Verbatim wording from the response “1.0 There is no regulatory body for advanced nurse practitioners: NHS England has no jurisdiction over the regulation of nurses. The NMC is the body which sets standards of education, training, conduct and performance and ensures that nurses and midwives keep their skills and knowledge up to date and uphold professional standards. They have processes to investigate nurses and midwives who do not meet those requisite standards and maintain a register of nurses and midwives allowed to practice in the UK.” Source location Response from NHS England
Open published response
13 Oct 2016 Robert Arthur Davidson · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Failure to train care staff in basic emergency call processes View source Lack of objectively assessed basic training and competence standards for HCAs View source Failure to train care staff in CPR and choking procedures View source Failure to highlight essential patient information during transfers between care homes View source See 1 more concern
Responses linked to these concerns
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AI-generated summary
Robert Arthur Davidson · 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
Robert Arthur Davidson, who had dementia, Alzheimer’s disease and PICA, died after choking on a plastic glove at a care home on 27 January 2016. The report identified concerns about inadequate transfer of information about his PICA, insufficient staff training and failures in emergency procedures, including calling emergency services and initiating CPR.
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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 train care staff in basic emergency call processes
Wider context from the report “1. During the inquest I heard evidence that Health care staff had not been trained on basic process as follows:
• Making 999 calls – to obtain an outside line caller’s needed to first dial “9”. The HCA instructed to make the 999 call did not know this so the call was unsuccessful. The registered nurse looking after the patient whilst he was choking had to make the 999 call resulting in her leaving the patient.
• When to Start CPR. The RGN and HCA (Health Care Assistants) staff had received no training on the CPR and choking policy
The concern is that staff are not trained in basic processes and therefore not able to deal with emergency situations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of objectively assessed basic training and competence standards for HCAs
Wider context from the report “2. The two HCA’s had no experience or basic training before starting work as HCA’s. They had limited understanding of conditions and processes. Consideration needs to be given as to whether there should be mandatory training or minimum standards, which are objectively assessed, to ensure HCA’s have the necessary knowledge and understanding to undertake their role.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to train care staff in CPR and choking procedures
Wider context from the report “1. During the inquest I heard evidence that Health care staff had not been trained on basic process as follows:
• Making 999 calls – to obtain an outside line caller’s needed to first dial “9”. The HCA instructed to make the 999 call did not know this so the call was unsuccessful. The registered nurse looking after the patient whilst he was choking had to make the 999 call resulting in her leaving the patient.
• When to Start CPR. The RGN and HCA (Health Care Assistants) staff had received no training on the CPR and choking policy
The concern is that staff are not trained in basic processes and therefore not able to deal with emergency situations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to highlight essential patient information during transfers between care homes
Wider context from the report “3. The deceased PICA behaviour was not highlighted or identified on his transfer between care homes. Some process or direction from the governing body needs to be provided to care homes to ensure essential information is provided and highlighted when patients are transferred.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The commissioning organisation should ensure receiving care homes can meet transferred patients’ needs; the Care Quality Commission may comment on this.
Verbatim wording from the response “It is essential that information is communicated between organisations when a patient is transferred. In this case between Jubilee Gardens and Aran Court Care Centre. Had Aran Court Care Centre been aware of Mr Davidson’s condition they would have been aware of the need for additional, possibly 1:1, care. The commissioning organisation should be satisfied that the organisation to which Mr Davidson was being admitted were able to meet his care needs. The care home will be registered with and regulated by the Care Quality Commission, to whom this Regulation 28 report has also been sent, and they may wish to comment in respect of this issue.” Source location 2016-0363-Response-by-NHS-England
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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 Care homes are responsible for providing and maintaining staff training, including emergency telephone, CPR and choking procedures.
Verbatim wording from the response “Care organisations, including homes such as Aran Court Care Centre, are responsible for the induction and training of their staff. This should include the use of the telephone in emergency situations. Basic CPR training is a minimal expectation of those working in care settings. It is the responsibility of the care home to provide this training and ensuring that staff maintains their competence through regular updates. It may be necessary for the care home to access training in the NHS to meet these requirements.” Source location 2016-0363-Response-by-NHS-England
Open published response
Concerns raised 1 Failure to classify all identified ligature points as extreme risks requiring urgent elimination 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
Helen Louise MILLARD · 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
Helen Louise MILLARD hanged herself using bathroom taps at the Westlands Mental Health Unit, Hull, between 18:32 and 18:59 on 12 May 2015, and died at Hull Royal Infirmary at 01:28 on 13 May 2015. The principal concern was that the ligature-point classification system treated points one metre or less above the ground as amber, despite evidence that ligature risk was independent of height and that such points could cause death rapidly.
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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 classify all identified ligature points as extreme risks requiring urgent elimination
Wider context from the report “Evidence was heard that NHS England is undertaking an ongoing programme of work to eliminate ligature points in in-patient and other psychiatric facilities. It was established that a ‘traffic light’ system is in operation which prioritises the work once a ligature point has been identified in any particular facility. The Court heard that if a point is scored ‘red’ this equates with an extreme risk and mandates urgent elimination of the point. If, however, a risk is categorised as ‘amber’ this nevertheless represents a high risk. The classification according to this traffic light system is based upon the height of the ligature point from the ground. If a ligature point is one metre or less it is categorised as being ‘amber’, whereas if it is over one metre above the ground it is categorised as ‘red’.
Expert evidence was adduced from a number of expert witnesses and Consultant Psychiatrists that at least 50% of deaths due to hanging in inpatient psychiatric facilities occur from ligature points which are one metre or less in height above the ground. Patients merely need to learn forward and tighten the ligature around their neck under their body weight and they collapse into unconsciousness within ten to twenty seconds and death can occur in as little as two to three minutes. This evidence was backed up by peer reviewed literature which was also read out during the course of the Inquest.
My principal concern is that there is an obvious incongruity in the classification system as effectively all ligature points, no matter what their height, should be regarded as representing extreme risks . Evidence was heard that the risk is independent of height and consideration needs to be given to classifying all ligature points once identified as ‘red’ and their elimination tackled on an urgent basis .
” Open source report
15 Sep 2016 Philip Richard David BREATNACH · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 8 Excessive quantities of Dihydrocodeine prescribed View source Unrestricted online applications for medications View source Prescribing Dihydrocodeine for migraine View source Failure to prescribe safe Dihydrocodeine dosing instructions View source Failure to contact the patient’s GP to verify medication application answers View source Failure to account for the potential diversion of Dihydrocodeine View source Failure to thoroughly check online medication application forms View source Failure to assess a patient in person before prescribing Dihydrocodeine View source See 5 more concerns
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AI-generated summary
Philip Richard David BREATNACH · 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
Philip Richard David Breatnach's circumstances are referred to in the Record of Inquest. The concerns relate to online applications for medication, inadequate checking of answers and failure to contact his GP, and the prescribing of Dihydrocodeine by a prescriber who had not seen him, including concerns about the quantity, suitability for migraine, and dosing instructions. The inquest concluded with a finding of MISADVENTURE (DEPENDENCE ON DRUGS).
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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 Excessive quantities of Dihydrocodeine prescribed
Wider context from the report “(1) Mr Breatnach (and anybody else) is able to apply online for medications
(2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did.
(3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true.
(4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice.
(5) The amount of Dihydrocodeine prescribed appears to be excessive .
(6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication.
(7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed.
(8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did.
(9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unrestricted online applications for medications
Wider context from the report “(1) Mr Breatnach (and anybody else) is able to apply online for medications
(2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did.
(3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true.
(4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice.
(5) The amount of Dihydrocodeine prescribed appears to be excessive.
(6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication.
(7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed.
(8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did.
(9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Prescribing Dihydrocodeine for migraine
Wider context from the report “(1) Mr Breatnach (and anybody else) is able to apply online for medications
(2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did.
(3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true.
(4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice.
(5) The amount of Dihydrocodeine prescribed appears to be excessive.
(6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication.
(7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed.
(8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did.
(9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to prescribe safe Dihydrocodeine dosing instructions
Wider context from the report “(1) Mr Breatnach (and anybody else) is able to apply online for medications
(2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did.
(3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true.
(4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice.
(5) The amount of Dihydrocodeine prescribed appears to be excessive.
(6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication.
(7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required . The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed .
(8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did.
(9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to contact the patient’s GP to verify medication application answers
Wider context from the report “(1) Mr Breatnach (and anybody else) is able to apply online for medications
(2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did.
(3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true .
(4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice.
(5) The amount of Dihydrocodeine prescribed appears to be excessive.
(6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication.
(7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed.
(8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did.
(9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to account for the potential diversion of Dihydrocodeine
Wider context from the report “(1) Mr Breatnach (and anybody else) is able to apply online for medications
(2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did.
(3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true.
(4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice.
(5) The amount of Dihydrocodeine prescribed appears to be excessive.
(6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication.
(7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed.
(8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency . The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did.
(9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to thoroughly check online medication application forms
Wider context from the report “(1) Mr Breatnach (and anybody else) is able to apply online for medications
(2) That applying online, if the application form is not thoroughly checked , allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did.
(3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true.
(4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice.
(5) The amount of Dihydrocodeine prescribed appears to be excessive.
(6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication.
(7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed.
(8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did.
(9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to assess a patient in person before prescribing Dihydrocodeine
Wider context from the report “(1) Mr Breatnach (and anybody else) is able to apply online for medications
(2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did.
(3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true.
(4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice.
(5) The amount of Dihydrocodeine prescribed appears to be excessive.
(6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication.
(7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed.
(8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did.
(9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use.
” 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 Work with partner agencies to consolidate regulatory and professional guidance on online prescribing and medicine supply.
Verbatim wording from the response “The group agreed to work together to assimilate current regulatory and professional guidance into one place so there is greater clarity regarding good practice in respect of online prescribing and supply of medicines giving particular guidance on medicines such as controlled drugs and antibiotics.” Source location 2016-0330-Response-by-NHS-England
Open published response
Concerns raised 6 Lack of clear responsibility for care pending further mental health appointments View source Failure to provide medication risks and further-assistance contact information View source Failure of GPs to recognise their responsibility for prescribing and medication advice View source Failure to ensure patients know how to request discussion with a consultant psychiatrist View source Non-prescriber mental health staff advising GPs on medication View source Failure to ensure GPs know how to contact the duty psychiatrist 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
Edward Angus Mallen · 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
Edward Angus Mallen, who was suffering from depression and had disclosed suicidal thoughts, died after lying across a railway line and being struck by a train on 9 February 2015. The concerns included unclear responsibility for his care, advice from a non-prescriber about medication, lack of information about possible worsening symptoms and increased suicidal feelings, and inadequate awareness of routes to further psychiatric advice.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of clear responsibility for care pending further mental health appointments
Wider context from the report “3. Edward received no advice about the contraindications of the medication and critically that he may well feel worse before he felt better and may feel more suicidal. In either event he should have been told who to call to get further assistance.
4. The fact that Edward did not receive this information could be due to there being no clear sense of who would be responsible for his care pending further mental health team appointments .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 medication risks and further-assistance contact information
Wider context from the report “3. Edward received no advice about the contraindications of the medication and critically that he may well feel worse before he felt better and may feel more suicidal . In either event he should have been told who to call to get further assistance .
4. The fact that Edward did not receive this information could be due to there being no clear sense of who would be responsible for his care pending further mental health team appointments.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 GPs to recognise their responsibility for prescribing and medication advice
Wider context from the report “1. The GP, ████████ understood that he had been instructed by a member of the Assessment and Referral Team to prescribe citalopram. The member of staff with whom he spoke was a nurse with no prescriber status. The GP felt bound to follow the advice given seemingly without appreciating that prescribing was his responsibility and with it the obligation to advise the patient about the medication.
2. The trust acknowledges that it would be inappropriate for non psychiatrist members of staff to be advising GPs on medication and that this must be communicated to all staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 patients know how to request discussion with a consultant psychiatrist
Wider context from the report “5. ████████ did not appear to appreciate that he could ask to speak with a consultant psychiatrist if he had any concerns and wanted to discuss any aspect of care or treatment .
6. Apparently all GPs should have been made aware by the CCG that there is a duty psychiatrist with whom they can speak but according to the trust many GPs remain unaware of this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Non-prescriber mental health staff advising GPs on medication
Wider context from the report “1. The GP, ████████ understood that he had been instructed by a member of the Assessment and Referral Team to prescribe citalopram. The member of staff with whom he spoke was a nurse with no prescriber status . The GP felt bound to follow the advice given seemingly without appreciating that prescribing was his responsibility and with it the obligation to advise the patient about the medication.
2. The trust acknowledges that it would be inappropriate for non psychiatrist members of staff to be advising GPs on medication and that this must be communicated to all staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 GPs know how to contact the duty psychiatrist
Wider context from the report “5. ████████ did not appear to appreciate that he could ask to speak with a consultant psychiatrist if he had any concerns and wanted to discuss any aspect of care or treatment.
6. Apparently all GPs should have been made aware by the CCG that there is a duty psychiatrist with whom they can speak but according to the trust many GPs remain unaware of this .
” Open source report
Concerns raised 2 Lack of literature informing anticoagulant therapy patients about the steps to take in response to a brain bleed View source Lack of literature informing anticoagulant therapy patients about the symptoms of a brain bleed View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Wade · 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 Wade, who was receiving Warfarin therapy for atrial fibrillation, developed severe headaches, vomiting and collapse on 14 June 2016. A CT scan showed a non-survivable cerebellar haemorrhage; the report identified concern that there was no system for providing anticoagulant patients with information about brain-bleed symptoms and what action to take.
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 literature informing anticoagulant therapy patients about the steps to take in response to a brain bleed
Wider context from the report “Patients who are provided with anti-coagulant therapy are at an increased risk of the development of haemorrhagic strokes. There appears to be no system in place to provide patients with literature setting out the symptoms of a bleed on the brain and the steps that patients should take in response .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 literature informing anticoagulant therapy patients about the symptoms of a brain bleed
Wider context from the report “Patients who are provided with anti-coagulant therapy are at an increased risk of the development of haemorrhagic strokes. There appears to be no system in place to provide patients with literature setting out the symptoms of a bleed on the brain and the steps that patients should take in response.
” 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 anticoagulant information, including the Yellow OAT book, NHS Choices guidance and NICE support, addresses patients’ need for bleeding-symptom advice.
Verbatim wording from the response “In light of your concerns I would wish to bring to your attention the standard anticoagulant booklet (more commonly known as the “yellow book” – which is warfarin specific) given to patients as recommended by the former National Patient Safety Agency. A link to its content is below:
http://www.nrls.npsa.nhs.uk/resources/?EntryId45=61777” Source location david-wade-Response
Open published response
Concerns raised 1 Failure of vomiting pathways to ensure an appropriate response View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Harry Stuart Gill · 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
Harry Gill became unwell with vomiting, made five calls to NHS 111, and collapsed and died shortly after an ambulance was being arranged on 2 June 2016. The inquest concluded that he died from a heart attack brought on by vomiting caused by an intermittent bowel blockage, and that his death could probably have been prevented if his condition had been appropriately assessed. The principal concern was that only one of five calls received the appropriate response, indicating that the vomiting pathway was not sufficiently robust.
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 vomiting pathways to ensure an appropriate response
Wider context from the report “That on four out of five telephone conversations between Mr Gill and his wife and NHS 111 only one call elicited the appropriate response. It would therefore appear that the vomiting pathways is not sufficiently robust to ensure an appropriate response .
” 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 Enhance the site training package for managing vomiting during remote third-party telephone triage.
Verbatim wording from the response “This work has been concluded and will be issued to all NHS Pathways sites for the next release in the spring of next year. In addition we have further enhanced our site training package for the management of vomiting in recognition of the difficulties in identifying the nature of vomit remotely via third party telephone triage.” Source location 2016-0323-Response-by-NHS-Digital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue the amended vomiting-question content to all NHS Pathways sites in the next algorithm release.
Verbatim wording from the response “We have amended the question to be more specific and allow for a more focussed interrogation of the nature of the vomit, in particular the presence of coffee ground like matter in the vomit that can indicate a localised gastric bleed. The question that will be asked in the next release of the algorithms will be;” Source location 2016-0323-Response-by-NHS-Digital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce amended vomiting questions with separate prompts and supporting information for coffee-ground vomit, blood and faeces.
Verbatim wording from the response “We have amended the question to be more specific and allow for a more focussed interrogation of the nature of the vomit, in particular the presence of coffee ground like matter in the vomit that can indicate a localised gastric bleed. The question that will be asked in the next release of the algorithms will be;” Source location 2016-0323-Response-by-NHS-Digital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review vomiting pathways with NWAS input and identify improvements to the vomiting questions.
Verbatim wording from the response “The Coroner has requested that NHS Pathways review its management of the vomiting pathways and report on any improvements that have been made.” Source location 2016-0323-Response-by-NHS-Digital
Open published response
Concerns raised 2 Inadequate education on managing hyperglycaemia and its life-threatening progression View source Inadequate advice and guidance on insulin pump misuse dangers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James Michael HEDGE · 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
James Michael HEDGE, an 18-year-old type 1 insulin-dependent diabetic, was found deceased in his room at Cardiff University with an insulin pump connected to him. The pump’s insulin cartridge had been fitted incorrectly and leaked, and the inquest recorded diabetic ketoacidosis as the medical cause of death. Concerns included inadequate guidance about the dangers of insulin-pump misuse and insufficient education about the potentially rapid, life-threatening consequences of hyperglycaemia.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequate education on managing hyperglycaemia and its life-threatening progression
Wider context from the report “(2) The evidence showed that the education of diabetic patients does not adequately focus upon the potential consequences of failing to properly manage a hyperglycaemic state and in particular, how quickly such a state can become life threatening .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequate advice and guidance on insulin pump misuse dangers
Wider context from the report “(1) The evidence showed that the advice and guidance in relation to the use of the insulin pump, which is one of several on the market, does not adequately highlight the dangers of misuse and the potential consequences which may follow if the device is not used correctly – in this case, the incorrect insertion of the insulin cartridge leading to a leak and loss of insulin at a time when blood sugars were high.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review how to support greater uptake and consistency of structured education, including content on incorrect pump use and hyperglycaemia management.
Verbatim wording from the response “NHS England is currently reviewing how greater take-up and consistency of structured education can be supported and the issues of key content in relation to the risks from incorrect use of insulin pumps and the management of hyperglycaemia will be considered as part of this.” Source location 2016-0269-Response-by-NHS-England
Open published response
25 Jul 2016 Patricia Ann Cleghorn · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Unavailability of acute mental health inpatient beds View source Limited resources and care for vulnerable people in the community View source Failure to control access to available medication for a person at risk of overdose View source Failure to undertake a formal suicide and overdose risk assessment 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
Patricia Ann Cleghorn · 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
Patricia Ann Cleghorn, who had suicidal ideation and was awaiting an inpatient mental health bed, was found collapsed at home after receiving diazepam and was declared dead by paramedics on 14 December 2015. The concerns were the lack of an available inpatient bed, allowing her to self-medicate with potentially dangerous drugs despite repeated statements that she intended to overdose, and the absence of a formal risk assessment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unavailability of acute mental health inpatient beds
Wider context from the report “(1) The deceased could not be admitted to hospital as there were no inpatient beds available . I heard evidence at the inquest that had she been admitted it is unlikely she would have died when she did. The availability of acute mental health beds means the most vulnerable people are being cared for in the community with limited resources and care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Limited resources and care for vulnerable people in the community
Wider context from the report “(1) The deceased could not be admitted to hospital as there were no inpatient beds available. I heard evidence at the inquest that had she been admitted it is unlikely she would have died when she did. The availability of acute mental health beds means the most vulnerable people are being cared for in the community with limited resources and care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to control access to available medication for a person at risk of overdose
Wider context from the report “(2) The deceased had repeatedly stated that she would end her life by taking an overdose. Despite this she was left at home self-medicating drugs including amitriptyline, MST and oromorph . No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake a formal suicide and overdose risk assessment
Wider context from the report “(2) The deceased had repeatedly stated that she would end her life by taking an overdose. Despite this she was left at home self-medicating drugs including amitriptyline, MST and oromorph. No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her.
” 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 all areas have evidence-based, high-quality 24/7 Crisis Resolution Home Treatment Teams providing intensive home treatment and acute-bed gatekeeping by 2020/21.
Verbatim wording from the response “As noted in ████████ recent letter, we are aware that Crisis Resolution Home Treatment Teams are not always resourced to fully meet their core functions in” Source location 2016-0270-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 Develop evidence-based mental health treatment pathways and commissioning tools, including acute-care quality standards for inpatient and community services.
Verbatim wording from the response “Further, we are working with the National Collaborating Centre for Mental Health at the Royal College of Psychiatrists to develop a series of evidence-based treatment pathways for mental health care with accompanying commissioning support tools. This includes the development of an acute care pathway comprising a comprehensive set of quality standards, which is planned for completion within 2016/17. The work involves a range of multi-agency experts, including clinicians, social workers, service managers, service users and carers, and will focus on access to care, patient safety, patient experience and clinical outcomes. The scope of the pathway comprises both inpatient and community settings, reflecting the need to ensure services are commissioned and delivered in the context of a whole system approach based on clinical need and the safe management of patients.” Source location 2016-0270-Response-by-NHS-England
Open published response
15 Jul 2016 Sydney Mya Neil · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 5 Insufficient resuscitation expertise in GP practices View source Inadequate ventilation during resuscitation in GP practices View source Insufficient emergency equipment in GP practices View source Failure to provide oxygen during resuscitation in GP practices View source Failure to use suction during resuscitation in GP practices View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sydney Mya Neil · 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
Sydney Mya Neil suffered from severe brittle asthma and died at Birmingham Children's Hospital after collapsing at a GP surgery following breathing difficulties. The report raised concerns about inadequate ventilation, lack of suction and lack of oxygen during resuscitation, and whether GP practices have sufficient expertise and equipment for emergencies.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient resuscitation expertise in GP practices
Wider context from the report “Once Sydney collapsed in the GP surgery there was inadequate ventilation for 8 minutes. No suction was used nor was oxygen provided. I am concerned about the level of expertise in GP practices when resuscitation is required and whether they have sufficient equipment to deal with emergency situations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequate ventilation during resuscitation in GP practices
Wider context from the report “Once Sydney collapsed in the GP surgery there was inadequate ventilation for 8 minutes . No suction was used nor was oxygen provided. I am concerned about the level of expertise in GP practices when resuscitation is required and whether they have sufficient equipment to deal with emergency situations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient emergency equipment in GP practices
Wider context from the report “Once Sydney collapsed in the GP surgery there was inadequate ventilation for 8 minutes. No suction was used nor was oxygen provided. I am concerned about the level of expertise in GP practices when resuscitation is required and whether they have sufficient equipment to deal with emergency situations .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide oxygen during resuscitation in GP practices
Wider context from the report “Once Sydney collapsed in the GP surgery there was inadequate ventilation for 8 minutes. No suction was used nor was oxygen provided . I am concerned about the level of expertise in GP practices when resuscitation is required and whether they have sufficient equipment to deal with emergency situations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to use suction during resuscitation in GP practices
Wider context from the report “Once Sydney collapsed in the GP surgery there was inadequate ventilation for 8 minutes. No suction was used nor was oxygen provided. I am concerned about the level of expertise in GP practices when resuscitation is required and whether they have sufficient equipment to deal with emergency situations.
” 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 Ask the CQC to ensure inspections check that primary care services have equipment and skills to address respiratory emergencies.
Verbatim wording from the response “I have asked ████████ Head of Primary Care Commissioning, NHS” Source location 2016-0256-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 Suction facilities should not be mandated nationally because training should prioritise recognising emergencies rather than maintaining suction skills.
Verbatim wording from the response “In relation to the requirement for suction facilities to facilitate ventilator support, I have sought the views of NHS England’s National Clinical Directors. Whilst a number of practices will have some access to suction facilities, it was not felt that this should become a national requirement of primary care. BTS guidance highlights the risks associated with ventilatory support and non-invasive ventilation, (NIV) in severe asthma. It is the view of my Clinical Directors therefore better to target training in primary care on recognising an emerging emergency situation rather than to attempt to train and maintain skills in using suction equipment in challenging emergency situations. As a result, I do not feel it appropriate to mandate all general practices to purchase and maintain suction facilities which would necessarily include ensuring all relevant staff are appropriately trained.” Source location 2016-0256-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 Except in remote or inaccessible locations, practices may rely on rapid access to emergency services when determining appropriate equipment and training.
Verbatim wording from the response “The Care Quality Commission (CQC) as the regulator of general practice needs to be assured that practices are able to immediately respond to the needs of a person who becomes seriously ill. The CQC does not have explicit guidance around emergency equipment; however does state that if the practice does not have oxygen they are unlikely to be able to demonstrate they are equipped for dealing with emergencies.²” Source location 2016-0256-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 The CQC is responsible for using its inspection regime to ensure primary care services carry necessary equipment and skills for respiratory emergencies.
Verbatim wording from the response “The Care Quality Commission (CQC) as the regulator of general practice needs to be assured that practices are able to immediately respond to the needs of a person who becomes seriously ill. The CQC does not have explicit guidance around emergency equipment; however does state that if the practice does not have oxygen they are unlikely to be able to demonstrate they are equipped for dealing with emergencies.²” Source location 2016-0256-Response-by-NHS-England
Open published response
14 Jul 2016 Fred Whittaker · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Lack of recording of reasons, requests or decisions to stop prescribing a drug in clinical records View source Lack of standard directions for managing requests to restart a discontinued medication 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
Fred Whittaker · 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
Fred Whittaker, who had schizophrenia and was known to abuse drugs and alcohol, attended hospital with chest pains and drowsiness after taking codeine, alcohol and methadone, but self-discharged and went home. He was found dead in his flat the following morning; the inquest concluded that he died from developing bronchopneumonia and combined codeine, methadone and alcohol toxicity. A principal concern was that Clonazepam was restarted in error after his psychiatrist had requested that it be stopped, reflecting inadequate recording and procedures for discontinued prescriptions.
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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 recording of reasons, requests or decisions to stop prescribing a drug in clinical records
Wider context from the report “An important issue in the Inquest was the continued prescription of Clonazepam by the Heaton Moor Medical Centre despite the written request on 17th August 2015, from Mr Whittaker’s treating psychiatrist, ████████ that this medication be stopped.
The evidence given to me by ████████ a partner at the Heaton Moor Medical Centre, suggests that although the prescription was stopped it was started again in error.
████████ advised that,
a) On receipt of ████████ request the drug was moved from the Repeat Prescription list to the Past Prescription list, without any reference in the records of the reason as to why the Clonazepam was being stopped.
b) On or about the 19th August 2015 the pharmacy which administered Mr Whittaker’s medication requested a repeat prescription.
c) It was likely that upon receiving that request Clonazepam was simply moved back on to the repeat prescription by one of the doctors at the Practice on being advised by an administrator of the Pharmacy’s request.
This is clearly an unacceptable error.
I accept that, on this occasion, this error played no part in Mr Whittaker’s demise but it is not difficult to imagine a completely different set of circumstances where such an error would give rise to a risk of death.
████████ evidence was that there were no standard directions as to how to manage this as a situation and that other practices may adopt the same simple policy of transferring the drug from one list to another.
1. That Heaton Moor Medical Centre does not have a mechanism whereby the reasons or requests or decisions that a patient is no longer to be prescribed a particular drug are recorded in the clinical records.
2. That this poor practice may not be limited to Heaton Moor Medical Centre and is replicated in many GP practices in the Northwest and indeed, 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 standard directions for managing requests to restart a discontinued medication
Wider context from the report “An important issue in the Inquest was the continued prescription of Clonazepam by the Heaton Moor Medical Centre despite the written request on 17th August 2015, from Mr Whittaker’s treating psychiatrist, ████████ that this medication be stopped.
The evidence given to me by ████████ a partner at the Heaton Moor Medical Centre, suggests that although the prescription was stopped it was started again in error.
████████ advised that,
a) On receipt of ████████ request the drug was moved from the Repeat Prescription list to the Past Prescription list, without any reference in the records of the reason as to why the Clonazepam was being stopped.
b) On or about the 19th August 2015 the pharmacy which administered Mr Whittaker’s medication requested a repeat prescription.
c) It was likely that upon receiving that request Clonazepam was simply moved back on to the repeat prescription by one of the doctors at the Practice on being advised by an administrator of the Pharmacy’s request.
This is clearly an unacceptable error.
I accept that, on this occasion, this error played no part in Mr Whittaker’s demise but it is not difficult to imagine a completely different set of circumstances where such an error would give rise to a risk of death.
████████ evidence was that there were no standard directions as to how to manage this as a situation and that other practices may adopt the same simple policy of transferring the drug from one list to another.
1. That Heaton Moor Medical Centre does not have a mechanism whereby the reasons or requests or decisions that a patient is no longer to be prescribed a particular drug are recorded in the clinical records.
2. That this poor practice may not be limited to Heaton Moor Medical Centre and is replicated in many GP practices in the Northwest and indeed, nationally.
” 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 Legal responsibility for prescribing lies with the doctor who signs the prescription.
Verbatim wording from the response “In the guidance published by the Department of Health, Responsibility for prescribing between hospitals and GPs EL (91) 127, 1991 (enclosed) makes it clear that the legal responsibility for prescribing lies with the doctor who signs the prescription.
The issue of any prescription and the subsequent doctor’s signature is to assure the dispensing pharmacist that the doctor considers the medication to be appropriate and necessary to treat that patient, giving due regard to dose,” Source location 2016-0249-Response-by-NHS-England
Open published response
30 Jun 2016 Terence Henry Stilges · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2 Failure to ensure completion of outstanding tests before discharge View source Failure to document outstanding test results and required follow-up in discharge records 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
Terence Henry Stilges · 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
Terence Henry Stilges was admitted to hospital after collapsing, was discharged before an outstanding troponin result was available, and was readmitted with severe shortness of breath and chest pain. He was diagnosed with an acute myocardial infarction and died following a cardiac arrest; the principal concern was that advance preparation of discharge summaries and incorrect discharge instructions could lead to patients being discharged before tests were complete.
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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 ensure completion of outstanding tests before discharge
Wider context from the report “(1) A discharge summary was prepared several days in advance for this patient. This summary did not mention the need for a further troponin result before the patient was discharged home. In addition the medical records wrongly specified that he should be discharged home. Therefore the patient was incorrectly sent home before the second troponin result was available. I heard that there was a practice of writing discharge summaries in advance despite tests results being outstanding. I am concerned this could result in other patients being discharged before their tests are complete.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to document outstanding test results and required follow-up in discharge records
Wider context from the report “(1) A discharge summary was prepared several days in advance for this patient. This summary did not mention the need for a further troponin result before the patient was discharged home. In addition the medical records wrongly specified that he should be discharged home . Therefore the patient was incorrectly sent home before the second troponin result was available. I heard that there was a practice of writing discharge summaries in advance despite tests results being outstanding . I am concerned this could result in other patients being discharged before their tests are complete.
” Open source report
24 Jun 2016 Kirsty Childs · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 9 Failure to identify patients' previous contact with other healthcare agencies at the beginning of calls View source Failure to record conclusions and advice from earlier calls View source Failure of agencies to obtain information from previously involved agencies View source Absence of a lower threshold for recommending face-to-face medical review View source Remote diagnosis without face-to-face assessment View source Use of non-medically qualified personnel to select symptom questionnaires and care pathways View source Failure to peer review decisions to downgrade recommended advice outcomes View source Failure to establish whether patients have the means to attend advised emergency care View source Failure to review details of earlier calls when assessing subsequent calls View source See 6 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
Kirsty Childs · 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
Kirsty Childs, aged 20, developed severe abdominal symptoms and repeatedly sought advice from NHS Direct and other services between 31 December 2012 and 2 January 2013. She was not admitted to hospital and was later found dead at home; the inquest recorded septic shock caused by an undiagnosed and untreated mesenteric venous thrombosis. The principal concerns included incorrect telephone triage, failure to review earlier calls, medically unqualified staff selecting questionnaires, the ability to override recommended outcomes, and poor information-sharing between agencies.
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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 identify patients' previous contact with other healthcare agencies at the beginning of calls
Wider context from the report “1. There was no standard question asked at the beginning of the calls to identify whether the patient had previously contacted NHS Direct, or any other agency , with regard to the symptoms giving rise to the latest call.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to record conclusions and advice from earlier calls
Wider context from the report “5. It was not possible at the inquest to review what details were recorded. I was concerned that details of earlier calls may not contain the conclusion and advice given to the patient . This information may be of significant assistance to ensure that if the patient calls again, appropriate care and advice is given.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of agencies to obtain information from previously involved agencies
Wider context from the report “7. All the different agencies operated in isolation , and despite computerised systems and phone facilities being available, there was no attempt to gain information from previous agencies which they had been 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 Absence of a lower threshold for recommending face-to-face medical review
Wider context from the report “3. Nurse Advisers within NHS Direct were reaching a diagnosis in Kirsty's case, without having the opportunity to undertake a face to face assessment, and there did not appear to be a lower threshold of recommending a face to face medical review
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Remote diagnosis without face-to-face assessment
Wider context from the report “3. Nurse Advisers within NHS Direct were reaching a diagnosis in Kirsty's case, without having the opportunity to undertake a face to face assessment , and there did not appear to be a lower threshold of recommending a face to face medical review
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Use of non-medically qualified personnel to select symptom questionnaires and care pathways
Wider context from the report “2. Medical advisers in NHS Direct were not medically qualified, and emergency medical despatchers in West Yorkshire Ambulance service are not medically qualified. They were required to illicit details of the patient's symptoms, and proceed to identify the most significant symptom from the information gained to select the most appropriate questionnaire. I understand there are a significant number of questionnaires to select from. They repeatedly selected the incorrect questionnaire in Kirsty's case. This resulted in significantly different outcomes being followed. I am concerned that without medical training the likelihood of incorrect questionnaires being selected and as a consequence, incorrect pathways being followed will reoccur
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 peer review decisions to downgrade recommended advice outcomes
Wider context from the report “6. The Nurse Adviser was able to override the recommendation of the questionnaire programme to downgrade the recommended advice outcome. This led to a tragic outcome in Kirsty's case. If Kirsty had attended accident and emergency at an early stage rather than being diagnosed with a bug and to self- care, the evidence indicated she would have lived. There were no safeguards put in place for this decision to be peer reviewed if a decision is taken to downgrade the recommended advice outcome.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to establish whether patients have the means to attend advised emergency care
Wider context from the report “8. On the one occasion when NHS Direct advised Kirsty to attend her nearest accident and emergency service, no enquiry was made as to whether Kirsty had the means to attend .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 details of earlier calls when assessing subsequent calls
Wider context from the report “4.Within NHS direct there was a complete consistency of treating each call separately, there was no attempt to review details of earlier calls made .
” Open source report
13 Jun 2016 Kevin Dermott · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 8 Failure to provide specialist hospital treatment for serious mental illness View source Inadequacies in mental health care planning and communication View source Inadequate mental health staffing and psychiatric referral provision View source Failure to recognise relapse into depression View source Failure to properly observe ACCT procedures View source Lack of suitable psychiatric care facilities View source Failure to plan ongoing mental health care and relapse management View source Failure to complete psychiatric referral and therapeutic medication care planning View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Kevin Dermott · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kevin Dermott, who had bipolar affective disorder and was serving a prison sentence, suffered episodes of mental illness while held at several prisons and died by hanging in his cell at HMP Risley on 19 May 2014. The concerns included inadequate mental health and psychiatric care, failures in care planning and communication, and failure to follow ACCT procedures; the jury concluded that deficiencies in mental health care and observation partly contributed to his death.
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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 specialist hospital treatment for serious mental illness
Wider context from the report “The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment . The evidence showed that his illness was not properly addressed . At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequacies in mental health care planning and communication
Wider context from the report “The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison , the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequate mental health staffing and psychiatric referral provision
Wider context from the report “The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral . He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise relapse into depression
Wider context from the report “The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised . The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to properly observe ACCT procedures
Wider context from the report “The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 suitable psychiatric care facilities
Wider context from the report “The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 plan ongoing mental health care and relapse management
Wider context from the report “The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur . At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 psychiatric referral and therapeutic medication care planning
Wider context from the report “The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures.
” 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 Complete consultation and publish the updated guidance for transferring prisoners to and from secure mental-health hospitals.
Verbatim wording from the response “secure mental health hospitals. This guidance is due for final consultation in autumn 2016 prior to publication and until the Department of Health 2011 guidelines remain extant. The HJIPs data set also contains transfer timelines to mental health secure units.” Source location 2016-0220-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 Maintain nationally specified integrated stepped mental-health care, including consultant psychiatry, long-term care planning and continuity of care.
Verbatim wording from the response “Better integration of health care services within prisons has also been supported by the development of a national set of service specifications for primary care services (including GP and nursing services), mental health services and substance misuse services. The mental health service specification outlines the requirement for mental health services to provide an integrated stepped care model for mental health which enables patients to flow seamlessly between mild to moderate and severe and enduring stages based on clinical need and include the provision of a consultant psychiatrist. These service specifications were developed in December 2013 and set the outcomes and standards required from the services including long-term care planning and continuity of care.” Source location 2016-0220-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 Develop updated guidance for transferring prisoners to and from secure mental-health hospitals.
Verbatim wording from the response “NHS England Health and Justice and Specialised Commissioning teams have developed updated guidelines for the transfer of prisoners to and remission from” Source location 2016-0220-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 Roll out the revised Person Escort Record and provide training so operational staff transfer relevant health information throughout custody transitions.
Verbatim wording from the response “NHS England is supporting the National Offender Management Services (NOMS) with their review of the Person Escort Record (PER). This revised form ensures that all current and relevant information, including health information, is held in one document and transfers with the prisoner from police custody through to reception into prison and during any subsequent prison transfer or release. The roll out of the paper form pilot is still ongoing and work is being undertaken to ensure PER training will be available to all operational staff. This is expected to be launched by March 2017. The digital PER form is being piloted in a couple of prisons and NOMS are leading on this work.” Source location 2016-0220-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 specialised commissioning teams and partner organisations to address the shortage of secure psychiatric beds and delays transferring acutely unwell prisoners.
Verbatim wording from the response “NHS England recognises that there is a national issue regarding lack of secure psychiatric beds which impacts on the timely transfer of acutely unwell prisoners. The Health and Justice commissioning team are working with colleagues in the NHS England Specialised Commissioning teams, who are responsible for secure mental health provision, and other partners in Department of Health, National Offender Management Services and Ministry of Justice and Home Office to look at this issue and try to resolve it.” Source location 2016-0220-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 Specialised Commissioning teams are responsible for secure mental health provision, including addressing shortages affecting transfers of acutely unwell prisoners.
Verbatim wording from the response “NHS England recognises that there is a national issue regarding lack of secure psychiatric beds which impacts on the timely transfer of acutely unwell prisoners. The Health and Justice commissioning team are working with colleagues in the NHS England Specialised Commissioning teams, who are responsible for secure mental health provision, and other partners in Department of Health, National Offender Management Services and Ministry of Justice and Home Office to look at this issue and try to resolve it.” Source location 2016-0220-Response-by-NHS-England
Open published response
Concerns raised 14 Inappropriate RCHT SI and SOM View source Failure to identify red flag signs of neonatal sepsis View source Unavailability and non-use of standard physiological observation equipment for mothers and babies View source Failure to undertake and record routine physiological observations of mothers and babies View source Core midwifery paperwork failing to prompt routine physiological assessments View source Failure of neonatal infection guidelines to be known and consistent with NICE guidance View source Failure to formally record Maternity Helpline calls and outcomes View source Use of a single birth-weight threshold in hypoglycaemic guidance View source Failure to complete NEWS on all babies View source Delays in full assessment of labour progress View source Insufficient systemic, rigorous and regular neonatal sepsis training View source Maternity Helpline triage by unregistered, inadequately trained and unqualified staff View source Unavailability of centile charts in handheld maternity records View source Failure to undertake and record capillary refill time in suspected neonatal sepsis View source See 11 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
Charlie Mark Jermyn · 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
Charlie Jermyn was born at home on 9 May 2015 and developed sleepiness, feeding difficulty and possible respiratory distress. He stopped breathing during a routine visit the following day and died in hospital despite resuscitation attempts. The principal concerns were delayed recognition and referral for suspected sepsis, inadequate telephone triage and recording, insufficient observations, and wider shortcomings in midwifery guidance, equipment and training.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inappropriate RCHT SI and SOM
Wider context from the report “9. The Expert Midwife noted that RCHT SI and SOM were not appropriate and been identified in the most recent LSA report on the Trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 red flag signs of neonatal sepsis
Wider context from the report “8. The red flag signs for sepsis (in this case sleepy, possible respiratory distress (grunting) and difficulty in feeding) were overlooked resulting in a fatal delay in referral to specialist hospital support/treatment. Identification of sepsis in new born babies is difficult and the staff and Trust should have had in place a systemic, rigorous and regular training in this area. The Trust's own clinical guidelines for the Prevention, Diagnosis and Treatment of Early Onset Neonatal Bacterial Infection, were not known to the midwives at the inquest. The Expert Midwife gave the opinion that the RCHT Trust guidelines were not consistent with the NICE guidance or best practice on this matter (page 14). In particular it was noted that capillary re-fill time should be undertaken and recorded in cases of suspected sepsis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unavailability and non-use of standard physiological observation equipment for mothers and babies
Wider context from the report “4. All Community Midwives should be provided with standard equipment to include, ear thermometers, stethoscopes, blood sugar testing and SATS monitors and these should be used as routine practice to make routine observations on mother and baby .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 and record routine physiological observations of mothers and babies
Wider context from the report “2. Routine physiological observations of mother and baby were not undertaken and recorded by the Community Midwives . This practice is not in line with national practice. The accurate temperature, heart rate and other appropriate observations/ recording should be routine and formally recorded with stethoscope and thermometer etc (not just visual and touch). NEWS should be completed on all babies.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Core midwifery paperwork failing to prompt routine physiological assessments
Wider context from the report “3. The Royal Cornwall Hospital Trust core midwifery paperwork does not meet best practice or NICE guidelines and does not prompt midwives to undertake routine physiological assessments .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of neonatal infection guidelines to be known and consistent with NICE guidance
Wider context from the report “8. The red flag signs for sepsis (in this case sleepy, possible respiratory distress (grunting) and difficulty in feeding) were overlooked resulting in a fatal delay in referral to specialist hospital support/treatment. Identification of sepsis in new born babies is difficult and the staff and Trust should have had in place a systemic, rigorous and regular training in this area. The Trust's own clinical guidelines for the Prevention, Diagnosis and Treatment of Early Onset Neonatal Bacterial Infection, were not known to the midwives at the inquest. The Expert Midwife gave the opinion that the RCHT Trust guidelines were not consistent with the NICE guidance or best practice on this matter (page 14). In particular it was noted that capillary re-fill time should be undertaken and recorded in cases of suspected sepsis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 formally record Maternity Helpline calls and outcomes
Wider context from the report “7. The telephone Maternity Helpline was inappropriately triaged by unregistered inappropriately trained and qualified staff, who were unable to identify obvious and significant sepsis markers indicating the seriousness of the deterioration in Charlie’s health. No structured note taking or recording of the call was made for future referral. Nor was the call/caller recorded. Helpline triage is a complex task and should only be undertaken after specialist training by an appropriately qualified person and the outcome of the conversations should be recorded formally in line with best practice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Use of a single birth-weight threshold in hypoglycaemic guidance
Wider context from the report “6. The Expert Midwife advised that the use of a single birth weight in the Trusts hypoglycaemic guidance (at risk at 2.5 kg) was not best practice and suggested the use of three weights: pre term, term, and late weight.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 NEWS on all babies
Wider context from the report “2. Routine physiological observations of mother and baby were not undertaken and recorded by the Community Midwives. This practice is not in line with national practice. The accurate temperature, heart rate and other appropriate observations/ recording should be routine and formally recorded with stethoscope and thermometer etc (not just visual and touch). NEWS should be completed on all babies .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 full assessment of labour progress
Wider context from the report “1. The Delay of over 5 hours, in full assessment of ████████ labour progress in the Day Assessment Unit at Royal Cornwall Hospital on the 8th/9th May 2015 was unacceptable (systemic failing).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 systemic, rigorous and regular neonatal sepsis training
Wider context from the report “8. The red flag signs for sepsis (in this case sleepy, possible respiratory distress (grunting) and difficulty in feeding) were overlooked resulting in a fatal delay in referral to specialist hospital support/treatment. Identification of sepsis in new born babies is difficult and the staff and Trust should have had in place a systemic, rigorous and regular training in this area . The Trust's own clinical guidelines for the Prevention, Diagnosis and Treatment of Early Onset Neonatal Bacterial Infection, were not known to the midwives at the inquest. The Expert Midwife gave the opinion that the RCHT Trust guidelines were not consistent with the NICE guidance or best practice on this matter (page 14). In particular it was noted that capillary re-fill time should be undertaken and recorded in cases of suspected sepsis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Maternity Helpline triage by unregistered, inadequately trained and unqualified staff
Wider context from the report “7. The telephone Maternity Helpline was inappropriately triaged by unregistered inappropriately trained and qualified staff , who were unable to identify obvious and significant sepsis markers indicating the seriousness of the deterioration in Charlie’s health. No structured note taking or recording of the call was made for future referral. Nor was the call/caller recorded. Helpline triage is a complex task and should only be undertaken after specialist training by an appropriately qualified person and the outcome of the conversations should be recorded formally in line with best practice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 centile charts in handheld maternity records
Wider context from the report “5. There was a recommendation by the Midwife Consultant that centile charts for each baby should be available in all hand held maternity records to assist midwives identify babies who are potentially at 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 to undertake and record capillary refill time in suspected neonatal sepsis
Wider context from the report “8. The red flag signs for sepsis (in this case sleepy, possible respiratory distress (grunting) and difficulty in feeding) were overlooked resulting in a fatal delay in referral to specialist hospital support/treatment. Identification of sepsis in new born babies is difficult and the staff and Trust should have had in place a systemic, rigorous and regular training in this area. The Trust's own clinical guidelines for the Prevention, Diagnosis and Treatment of Early Onset Neonatal Bacterial Infection, were not known to the midwives at the inquest. The Expert Midwife gave the opinion that the RCHT Trust guidelines were not consistent with the NICE guidance or best practice on this matter (page 14). In particular it was noted that capillary re-fill time should be undertaken and recorded in cases of suspected sepsis .
” Open source report
Concerns raised 3 Lack of healthcare staff experience and knowledge for recognising malaria and tropical diseases View source Lack of healthcare staff experience and knowledge for recognising malaria and tropical diseases View source Failure to ensure transfer of medical records from previous custodial establishments 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
Adetokunbo Ohisaga Ajakaiye · 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
Adetokunbo Ohisaga Ajakaiye was arrested on 13 November 2010, transferred to HMP Doncaster, and later taken to hospital, where he died of malaria early on 25 November 2010. Concerns included healthcare staff’s lack of practical experience and knowledge concerning malaria and tropical diseases, and the failure of medical records from earlier custodial establishments to accompany him to HMP Doncaster.
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 healthcare staff experience and knowledge for recognising malaria and tropical diseases
Wider context from the report “2. It became apparent, from the evidence, that none of the healthcare staff who dealt with Mr Ajakaiye at HMP Doncaster, had, prior to November 2010, any practical experience of dealing with a patient suffering from malaria and that there was a lack of knowledge and understanding of the signs and symptoms of malaria and of tropical diseases generally in circumstances where, in an era of increased foreign travel and inward migration, the incidence of malaria is likely to increase.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of healthcare staff experience and knowledge for recognising malaria and tropical diseases
Wider context from the report “1. It became apparent, from the evidence, that none of the healthcare staff who dealt with Mr Ajakaiye at HMP Doncaster, had, prior to November 2010, any practical experience of dealing with a patient suffering from malaria and that there was a lack of knowledge and understanding of the signs and symptoms of malaria and of tropical diseases generally in circumstances where, in an era of increased foreign travel and inward migration, the incidence of malaria is likely to increase.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 transfer of medical records from previous custodial establishments
Wider context from the report “1. When Mr Ajakaiye arrived at HMP Doncaster on 15th November 2010 it appears that his medical records from Heathrow Airport Police Station and Lawcroft House Police Station did not accompany him . The doctor who saw Mr Ajakaiye, on 16th November 2010, stated, in her evidence, that it would have assisted her in her diagnosis had she had those medical records available to her at that appointment. The court heard that, whilst the medical records from previous custodial establishments sometimes accompanied the Prisoner Escort Records, it was not infrequently the case that they did not .
” Open source report
Concerns raised 3 Failure to recognise and act on paediatric respiratory red flag markers View source Failure to routinely use oxygen blood monitoring in paediatric medicine View source Failure to routinely use respiratory rate benchmarks in paediatric respiratory medicine 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
Esmee Shayla Polmear · 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
Esmee Polmear fell ill during a school trip on 1 July 2015, later collapsed and went into cardiac arrest, and was pronounced dead in hospital despite resuscitation attempts. She had pulmonary veno-occlusive disease that was not diagnosed or recognised before her death; concerns included the use of respiratory-rate benchmarks and oxygen monitoring, and recognition and action on red-flag symptoms.
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 recognise and act on paediatric respiratory red flag markers
Wider context from the report “At the inquest the Paediatric Expert, ████████ gave the opinion that
• The routine use of respiratory rate bench-markers in paediatric respiratory medicine
• The use of routine oxygen blood monitoring in paediatric medicine
• The recognition and action on red flag markers (which in this case were shortness of breath, chest pain and blue lips)
Would have assisted and improved the chances of diagnosis and treatment of Esmee and other children, with a view to preventing future deaths or providing appropriate treatment and palliative care in life limiting cases.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely use oxygen blood monitoring in paediatric medicine
Wider context from the report “At the inquest the Paediatric Expert, ████████ gave the opinion that
• The routine use of respiratory rate bench-markers in paediatric respiratory medicine
• The use of routine oxygen blood monitoring in paediatric medicine
• The recognition and action on red flag markers (which in this case were shortness of breath, chest pain and blue lips)
Would have assisted and improved the chances of diagnosis and treatment of Esmee and other children, with a view to preventing future deaths or providing appropriate treatment and palliative care in life limiting cases.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely use respiratory rate benchmarks in paediatric respiratory medicine
Wider context from the report “At the inquest the Paediatric Expert, ████████ gave the opinion that
• The routine use of respiratory rate bench-markers in paediatric respiratory medicine
• The use of routine oxygen blood monitoring in paediatric medicine
• The recognition and action on red flag markers (which in this case were shortness of breath, chest pain and blue lips)
Would have assisted and improved the chances of diagnosis and treatment of Esmee and other children, with a view to preventing future deaths or providing appropriate treatment and palliative care in life limiting cases.
” Open source report
26 May 2016 Peter Scott · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 2 Insufficient ambulance service resources and staffing capacity View source Delays in hospital handover of ambulance patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter Scott · 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 Scott suffered an aortic dissection at home on 3 December 2015 and experienced a substantial delay in ambulance attendance after a call was prioritised as Green 2. The principal concern was that resource shortages, frequent use of Capacity Management Plans, recruitment problems and delayed hospital handovers posed a serious risk to the public and could contribute to future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient ambulance service resources and staffing capacity
Wider context from the report “I remain very concerned about resource issues for this ambulance service . I raised similar concerns in a Prevention of Future Deaths Report in the case of MG, dated 11 May 2016.
We heard evidence from a senior manager at EMAS during the inquest. I asked the service to advise me to what extent they had had to invoke Capacity Management Plans in the last 12 months. I was advised that EMAS has had to invoke such a Plan (to at least level 3) for 9 out of the last 12 months .
The issue in this case and that of MG was essentially a matter of resource. In essence, I found that there is only so much an ambulance service can do where they simply do not have an ambulance to send . Demand is clearly greater than the resources they have most of the time , given that a CMP has been in place for 75% of the last 12 month period.
I am very concerned that this poses a serious risk to the public served by this ambulance service . We heard also that recruitment is an ongoing problem – which may be exacerbated by the huge demand placed on its employees by this resource issue.
Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals. I believe the trust is already working to improve this, and I include EMAS in this report in this respect only. Other recipients of the report are required to respond with regard to matters of resourcing only.
1. I consider that there is a risk of future deaths as set out above unless an urgent review of resources is undertaken.
2. Consideration should be given to strategies to improve handover times at hospitals.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 hospital handover of ambulance patients
Wider context from the report “I remain very concerned about resource issues for this ambulance service. I raised similar concerns in a Prevention of Future Deaths Report in the case of MG, dated 11 May 2016.
We heard evidence from a senior manager at EMAS during the inquest. I asked the service to advise me to what extent they had had to invoke Capacity Management Plans in the last 12 months. I was advised that EMAS has had to invoke such a Plan (to at least level 3) for 9 out of the last 12 months.
The issue in this case and that of MG was essentially a matter of resource. In essence, I found that there is only so much an ambulance service can do where they simply do not have an ambulance to send. Demand is clearly greater than the resources they have most of the time, given that a CMP has been in place for 75% of the last 12 month period.
I am very concerned that this poses a serious risk to the public served by this ambulance service. We heard also that recruitment is an ongoing problem – which may be exacerbated by the huge demand placed on its employees by this resource issue.
Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals . I believe the trust is already working to improve this, and I include EMAS in this report in this respect only. Other recipients of the report are required to respond with regard to matters of resourcing only.
1. I consider that there is a risk of future deaths as set out above unless an urgent review of resources is undertaken.
2. Consideration should be given to strategies to improve handover times at hospitals.
” 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 Work with East Midlands Ambulance Service and partner organisations to address resourcing and improve emergency-call response times.
Verbatim wording from the response “I was very sorry to learn of the death of Mr Scott and the circumstances that led to it. NHS Improvement takes cases such as these very seriously and I would like to offer you the assurance that we are already working with the East Midlands Ambulance Service NHS Trust and other partner organisations to address the issue of resourcing and to improve response times to emergency calls.” Source location 2016-0199-Response-by-NHS-Improvment
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for reviewing EMAS resources rests with local commissioners, who will undertake a joint external capacity-and-demand review.
Verbatim wording from the response “The need to review the resources available to EMAS has been recognised locally. The responsible commissioners, NHS Hardwick Clinical Commissioning Group (“CCG”), on behalf of 22 CCGs across the East Midlands, have committed to jointly undertake an external strategic review of capacity and demand with EMAS. The review, which was agreed as part of the 2016/17 contract between EMAS and CCG commissioners, will consider a wide range of issues including the current delivery model, staffing issues and vehicle numbers.” Source location 2016-0199-Response-by-NHS-England
Open published response
Concerns raised 2 Unavailability of literature or guidance on the risk of air embolization during catheter changes View source Lack of staff awareness of the risk of air embolization during catheter changes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Patricia Steer · 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
Patricia Steer became unresponsive on 16 June 2015 while a central venous catheter connection was being changed, after a port was left open to air. The report identified concerns that the staff involved were unaware of the risk of air embolization and that relevant literature or guidance could not be located.
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 literature or guidance on the risk of air embolization during catheter changes
Wider context from the report “(1) Neither the staff nurse who changed the catheter nor the supervising senior staff nurse who was present throughout the procedure were aware of the risk of air embolization in the process of changing the catheter, where as it was in this case, left uncapped and unclamped. Whilst the attending Consultant was aware of the risk, the Serious Incident Investigator identified that it had not been possible to locate any literature or guidance on this point , having contacted other Trusts, and making an extensive literature search. The relevant bibliography was made available to the inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 staff awareness of the risk of air embolization during catheter changes
Wider context from the report “(1) Neither the staff nurse who changed the catheter nor the supervising senior staff nurse who was present throughout the procedure were aware of the risk of air embolization in the process of changing the catheter , where as it was in this case, left uncapped and unclamped. Whilst the attending Consultant was aware of the risk, the Serious Incident Investigator identified that it had not been possible to locate any literature or guidance on this point, having contacted other Trusts, and making an extensive literature search. The relevant bibliography was made available to the inquest.
” 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 Published safety guidance addressing air embolism risk during central-line removal.
Verbatim wording from the response “Work undertaken by the patient safety team to minimise risks associated with central lines:” Source location 2016-0201-Response-by-NHS-Improvement
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 Professional organisations are best placed to communicate the risk to staff responsible for leadership, training, supervision and direct patient care.
Verbatim wording from the response “We have discussed the issue with the Safe Anaesthesia Liaison Group (SALG), which includes representatives from the Royal College of Anaesthetists (RCoA), the Association of Anaesthetists of Great Britain and Ireland (AAGBI), the Medicines and Healthcare Products Regulatory Agency (MHRA), the Faculty of Intensive Care Medicine and the College of Operating Department Practitioners (CODP). Their belief is that the risk is widely appreciated and is routinely covered in local training and protocols but they accept that the findings of your inquest indicate this was not the case in at least one organisation. These organisations have undertaken to raise awareness amongst their members about the risk of leaving a CVC line uncapped during use.” Source location 2016-0201-Response-by-NHS-Improvement
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 Appropriate guidance addressing the risk of leaving central venous catheter ports uncapped or exposed has been established.
Verbatim wording from the response “In relation to your specific concerns, we have been able to identify that appropriate guidance on this risk for nurses has been established. There are two key sources:” Source location 2016-0201-Response-by-NHS-Improvement
Open published response
18 May 2016 Christopher Philip Fields · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to safeguard an injured or intoxicated vulnerable person before police departure View source Failure to protect a witness from an assailant during police information gathering View source Failure of ambulance call-coding algorithms to generate an appropriate Red response for critically injured patients View source Delays in ambulance response to coded emergency calls 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
Christopher Philip Fields · 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
Christopher Philip Fields was attacked twice at his home on 12 December 2014 and sustained fatal head injuries during the second attack. Concerns included police leaving before the ambulance arrived and leaving him in the care of another intoxicated person, a substantial delay in the ambulance response, and ambulance call-coding algorithms that may not have identified the need for a Red response.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to safeguard an injured or intoxicated vulnerable person before police departure
Wider context from the report “1. The police were called to the address after the first assault had occurred and were still in attendance when the assailant re-entered the premises via the broken window, which he had smashed out of its frame when entering the first time. Despite this rather bizarre set of occurrences, the police then decided to leave the deceased before the ambulance service arrived . Sometime later, the assailant re-entered the flat and beat the deceased to his death.
Various issues arise as a result of the police actions, being why did they leave a vulnerable person in this manner , why did they not await the arrival of the ambulance, why did they not take the witness (female) who was there at the time to a place where she could give them details out of the earshot of the assailant etc., why did they leave an injured and/or intoxicated person in the sole care of another who was also intoxicated , why did they consider it appropriate to accept the view of the injured/intoxicated person as to whether it was safe to leave him in the situation in which he was found ?
Are there issues of training for all GMP officers or did the officers fail to adhere to the approved guidance? (POLICE)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to protect a witness from an assailant during police information gathering
Wider context from the report “1. The police were called to the address after the first assault had occurred and were still in attendance when the assailant re-entered the premises via the broken window, which he had smashed out of its frame when entering the first time. Despite this rather bizarre set of occurrences, the police then decided to leave the deceased before the ambulance service arrived. Sometime later, the assailant re-entered the flat and beat the deceased to his death.
Various issues arise as a result of the police actions, being why did they leave a vulnerable person in this manner, why did they not await the arrival of the ambulance, why did they not take the witness (female) who was there at the time to a place where she could give them details out of the earshot of the assailant etc., why did they leave an injured and/or intoxicated person in the sole care of another who was also intoxicated, why did they consider it appropriate to accept the view of the injured/intoxicated person as to whether it was safe to leave him in the situation in which he was found?
Are there issues of training for all GMP officers or did the officers fail to adhere to the approved guidance? (POLICE)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance call-coding algorithms to generate an appropriate Red response for critically injured patients
Wider context from the report “3. The fact that the call taker coded the call properly and yet this case involved a patient who was clearly critically injured and despite that fact still did not generate a Red response , suggests that the algorithms used for coding are not accurate and not fit for purpose . In my view this is an extremely serious flaw and may/will lead to future deaths occurring unless it is remedied . (NWAS, SECRETARY OF STATE and NHS ENGLAND)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance response to coded emergency calls
Wider context from the report “2. The calls (999) to the ambulance service were properly coded and applied by the call-taker leading to a Green 2 response. This should have led to a vehicle attending within 20 minutes . In the event, the vehicle did not arrive for 2 hours 8 minutes . Why was the response time so dramatically lengthier than prescribed and is this a matter of resources? (NWAS)
” 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 Lead a complete review of ambulance coding systems, incorporating previous call outcomes and Coroners’ concerns.
Verbatim wording from the response “NHS England is currently leading a complete review of ambulance coding systems and trialling a new system. This review will take into account both the” Source location 2016-0194-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 Trial a new ambulance coding system.
Verbatim wording from the response “NHS England is currently leading a complete review of ambulance coding systems and trialling a new system. This review will take into account both the” Source location 2016-0194-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 The ambulance coding system is generally fit for purpose; inaccuracies can arise from caller information and staff interpretation.
Verbatim wording from the response “I note the response from North West Ambulance Service (NWAS), letter dated 10 June 2016, confirming that the initial ambulance call was correctly coded as Green 2 because the deceased was conscious, breathing and able to walk at that time. It appears from the limited material in my possession to have been the second assault that inflicted critical injuries and proved fatal, as indicated by the Pathologist’s report.” Source location 2016-0194-Response-by-NHS-England
Open published response
11 May 2016 Mia Gibson · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Failure to schedule ambulance crew meal breaks to maintain emergency availability View source Lack of training on placental abruption presentations and fetal risk despite reassuring maternal signs View source Insufficient availability of ambulance resources for urgent emergencies View source Failure to issue open-mic reports to mobilise available ambulance crews 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
Mia Gibson · 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
Mia Gibson was born in very poor condition after her mother suffered a sudden placental abruption on 16 November 2015 and died later that day. The report identifies delays in ambulance availability and transfer to hospital, alongside concerns about recognition of the risk to the baby, ambulance crew availability and meal-break planning.
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 schedule ambulance crew meal breaks to maintain emergency availability
Wider context from the report “3. Dispatchers appear to have allowed a situation to arise whereby the only 2 DCAs not attending other jobs were both on compulsory meal breaks and therefore unavailable at the same time . Whilst meal breaks are vital for staff, planning the timing of these, by ambulance control, is critical for patient safety . Meal break management is already under review by EMAS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 on placental abruption presentations and fetal risk despite reassuring maternal signs
Wider context from the report “1. It appears that great reliance was placed on the fact that ████████ was not in pain and had normal observations. Little consideration appears to have been given to the ‘second patient’ (Mia), whose condition could not be monitored by paramedics. We heard evidence that in fact not all placental abruptions cause the mother significant pain, or concerning observations, but for the baby, it can be akin to a cardiac arrest. This factor appears to have been overlooked in the trust’s subsequent investigation report, which refers several times to how reassuring ████████ clinical condition was, and was repeated in evidence by the paramedic witnesses. This is a clear training issue, and may well apply 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 Insufficient availability of ambulance resources for urgent emergencies
Wider context from the report “5. It is clear that resources played a part in these tragic events. No DCA was available to attend this emergency until 30 minutes after the call, and it took a further 12 minutes for a DCA to arrive after that. The time between the 999 call and ████████ being handed over to maternity staff was an hour and 15 minutes. It was clear from the outset that ████████ would require urgent transfer to hospital – a mere 4 miles from her home address – but no resource was available. The evidence of those ‘on the ground’ clearly showed that this is far from an isolated incident , and I remain concerned that there is a risk of future deaths if this is not addressed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to issue open-mic reports to mobilise available ambulance crews
Wider context from the report “2. No ‘open mic’ report was put out to see if other crews could make themselves available to attend this emergency.
” Open source report
3 May 2016 Shalan Blackwood · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 6 Lack of proper provision for care and supervision of prisoners with complex physical and/or mental health needs View source Insufficient prison staffing for proper regimes and unlocking of prisoners requiring four person unlocks in the Segregation Unit View source Rife use of New Psychoactive Substances within the prison View source Insufficient staffing of the Substance Misuse Team View source Failure of healthcare staff to recognise urgent physical symptoms obscured by mental health issues View source Unclear or unavailable documentary tool for decisions about prisoners remaining in Segregation View source See 3 more concerns
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AI-generated summary
Shalan Blackwood · 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
Shalan Blackwood died at HMP Nottingham on 5 August 2015 as a result of bleeding from a duodenal ulcer. The report identified concerns about inadequate care and supervision for prisoners with complex physical or mental health needs, insufficient staffing for prisoners in segregation requiring a four-person unlock, unclear decision-making tools, widespread use of New Psychoactive Substances, and insufficient recognition of urgent physical symptoms obscured by mental health issues.
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 proper provision for care and supervision of prisoners with complex physical and/or mental health needs
Wider context from the report “1. That there is no proper provision for the care and supervision of prisoners who present with complex physical and/or mental health needs . It is understood that such a provision could be provided by means of an inpatient unit within the prison, such as for example is the case at HMP Liverpool.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 prison staffing for proper regimes and unlocking of prisoners requiring four person unlocks in the Segregation Unit
Wider context from the report “2. That at present, if a prisoner is assessed as needing a four person unlock, and is within the Segregation Unit, there are insufficient prison staff to provide him with a proper regime and to unlock him after lunchtime , for example to allow
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Rife use of New Psychoactive Substances within the prison
Wider context from the report “3. That the use of New Psychoactive Substances (NPS) remains rife within the prison , and presentations such as Mr Blackwood’s are not diminishing , and that the Substance Misuse Team requires further staff to be effective in future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing of the Substance Misuse Team
Wider context from the report “3. That the use of New Psychoactive Substances (NPS) remains rife within the prison, and presentations such as Mr Blackwood’s are not diminishing, and that the Substance Misuse Team requires further staff to be effective in 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 Failure of healthcare staff to recognise urgent physical symptoms obscured by mental health issues
Wider context from the report “5. That healthcare staff are insufficiently alert to the issue that physical symptoms which require urgent medical attention may be occluded by mental health issues .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 or unavailable documentary tool for decisions about prisoners remaining in Segregation
Wider context from the report “4. That the documentary tool for decision making between prison staff and healthcare staff , as to whether a prisoner is fit to remain in Segregation and should do so , is unclear in or in use .
” 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