Concerns raised 3 Highly flammable paraffin-based product with ignition risk View source Lack of fire-hazard warnings on E45 prescriptions and product packaging View source Failure to communicate E45 fire hazards by GPs 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
Michael Holyoake · 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
Michael Holyoake, who was bed bound with a terminal and inoperable brain tumour, died after a fire at his home while he was being cared for there. The fire was thought most likely to have involved his lighter and E45 emollient residue on his bedding and clothing, which acted as an accelerant. The principal concerns were a lack of awareness of E45’s flammability and the absence of fire hazard warnings on its prescription or packaging.
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 Highly flammable paraffin-based product with ignition risk
Wider context from the report “1. E45 is highly flammable as it is a paraffin based product, the residue of which acts as an accelerant. In this case there was a distinct lack of awareness of this fact, by the carers and the deceased. This was in part due to lack of communication by the GP but also due to the fact that there were no fire hazard warnings on the prescription or the product itself.
This product is widely available over the counter to the general public and commonly used for vulnerable individuals such as children and the elderly. Worryingly there would appear to be no warnings on the packaging that this is indeed highly flammable, with the potential risk of ignition .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 fire-hazard warnings on E45 prescriptions and product packaging
Wider context from the report “1. E45 is highly flammable as it is a paraffin based product, the residue of which acts as an accelerant. In this case there was a distinct lack of awareness of this fact, by the carers and the deceased. This was in part due to lack of communication by the GP but also due to the fact that there were no fire hazard warnings on the prescription or the product itself .
This product is widely available over the counter to the general public and commonly used for vulnerable individuals such as children and the elderly. Worryingly there would appear to be no warnings on the packaging that this is indeed highly flammable , with the potential risk of ignition.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate E45 fire hazards by GPs
Wider context from the report “1. E45 is highly flammable as it is a paraffin based product, the residue of which acts as an accelerant. In this case there was a distinct lack of awareness of this fact, by the carers and the deceased. This was in part due to lack of communication by the GP but also due to the fact that there were no fire hazard warnings on the prescription or the product itself.
This product is widely available over the counter to the general public and commonly used for vulnerable individuals such as children and the elderly. Worryingly there would appear to be no warnings on the packaging that this is indeed highly flammable, with the potential risk of ignition.
” 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 Communicate the fire risk to the Medication Safety Officer network for dissemination and organisational action.
Verbatim wording from the response “NHS England and the MHRA have a network of Medication Safety Officers (MSOs) working within NHS trusts and other providers of NHS-funded healthcare. The role of MSOs is to ensure that systems are in place to improve medication safety. This risk will be communicated by NHS Improvement to this MSO network so the risk can be appropriately communicated and addressed within their organisations.” Source location 2016-0163-Response-by-NHS-Improvement
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 Ask care-sector organisations and professional bodies to communicate the fire risk through suitable newsletters and bulletins.
Verbatim wording from the response “Whilst the MHRA Bulletin, the MSO network and the changes to BNF are helpful for healthcare professionals, including GPs, as you are aware, E45 cream® is widely available to the general public without prescription. The changes of labelling will be important to ensure awareness of the risk reaches people who buy E45 cream® without prescription. We appreciate that similar risks may apply even to substances sold as moisturisers when these are used by less mobile adults and children. As this vulnerable group may not always have routine contact with NHS staff we have asked the Care Quality Commission, the Royal College of Nursing, and networks within the care home sector to communicate the risk via suitable newsletter and bulletin articles.” Source location 2016-0163-Response-by-NHS-Improvement
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 Inform BNF editors that fire-risk warnings should cover less concentrated aqueous paraffin-containing products.
Verbatim wording from the response “The British National Formulary (BNF) is a widely used resource that contains essential information on the safe and effective use of medicines that are prescribed, monitored, supplied and administered to patients by healthcare professionals. The BNF already provides important safety information on fire hazard for paraffin based emollients such as emulsifying ointment, white soft paraffin 50% and liquid paraffin 50% ointment in their online and paper based publications. NHS Improvement have informed the editors of the BNF that the risk also applies to less concentrated aqueous based paraffin containing products, and the BNF will in future include a revised warning that will inform healthcare professionals of the risk applying to all paraffin containing products.” Source location 2016-0163-Response-by-NHS-Improvement
Open published response
16 Mar 2016 Steven James May · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 10 Inadequate First Aid training for prison staff View source Selective emergency First Aid training among prison staff View source Lack of mental health experience and/or training among reception nursing staff View source Involvement of prison staff lacking relevant training or appropriate rank in the ACCT process View source Hesitancy to enter a cell during an emergency because of an instruction not to enter cells alone View source Failure to ensure medical professional attendance at First Care Reviews View source Failure of reception nursing staff to consult historical medical notes during reception interviews View source Limited accessibility of health and/or mental health care during weekends and Bank Holidays View source Reliance on verbal handovers rather than written records for prisoner information View source Failure to prepare sufficiently full ACCT assessment notes View source See 7 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
Steven James May · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Steven James May died by hanging at HMP Ranby on 25 May 2015 at 01:45, after previously expressing suicidal intent and being placed on the ACCT programme. The report identified concerns about failures in reception health screening, ACCT documentation and reviews, information handovers, staff training and involvement, emergency first aid, cell-entry procedures, and access to health and mental health care.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequate First Aid training for prison staff
Wider context from the report “(9) The inadequacy of First Aid training provided to prison staff in any event (namely, the administration of CPR by prison staff whilst the deceased was lying on a bed );
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Selective emergency First Aid training among prison staff
Wider context from the report “(7) The selective training of prison staff in emergency First Aid (namely the first member of prison staff on the scene of the death was not trained in the administration of CPR and was ignorant of the location of and method of use of defibrillators );
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of mental health experience and/or training among reception nursing staff
Wider context from the report “(2) The lack of experience and/or training of reception nursing staff in the field of mental health ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Involvement of prison staff lacking relevant training or appropriate rank in the ACCT process
Wider context from the report “(5) The involvement in the ACCT process of prison staff possessing neither relevant training nor the appropriate rank ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Hesitancy to enter a cell during an emergency because of an instruction not to enter cells alone
Wider context from the report “(8) The hesitancy of the first member of prison staff on the scene to enter the deceased’s cell in apparent adherence to an instruction not to enter cells alone ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 medical professional attendance at First Care Reviews
Wider context from the report “(6) The failure of prison staff to ensure the attendance of a medical professional at the First Care 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 Failure of reception nursing staff to consult historical medical notes during reception interviews
Wider context from the report “(1) The failure of reception nursing staff , by reason of lack of training and/or instruction or lack of staff and/or time , to consult the deceased’s historical medical notes prior to or during the reception interview ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 accessibility of health and/or mental health care during weekends and Bank Holidays
Wider context from the report “(10) The accessibility of health and/or mental health care to inmates at weekends and during Bank Holidays .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Reliance on verbal handovers rather than written records for prisoner information
Wider context from the report “(4) Reliance by prison staff on verbal and/or oral handovers of information, rather than written records , regarding the deceased ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to prepare sufficiently full ACCT assessment notes
Wider context from the report “(3) The failure of prison staff when preparing the ACCT document to prepare as full a note as possible . For example, to follow the subject areas suggested in the narrative accompanying sections 1-8 of the Assessment Interview ;
” Open source report
Concerns raised 3 Potential for Miconazole Gel and Warfarin interaction causing increased blood clotting time and INR View source Lack of knowledge of the Miconazole Gel and Warfarin interaction among health professionals View source Unclear or difficult-to-locate resources for checking the Miconazole Gel and Warfarin interaction 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
Patricia Margaret Thomas · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Patricia Margaret Thomas died at Morriston Hospital on 30 October 2013 after suffering an intracerebral haemorrhage, following an episode of unresponsiveness and left-sided weakness. The report identified a potential interaction between Miconazole Gel and Warfarin, a lack of awareness of this interaction among health professionals, and possible difficulties locating clear interaction-checking resources.
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 Potential for Miconazole Gel and Warfarin interaction causing increased blood clotting time and INR
Wider context from the report “It became apparent in the course of the evidence that
(1) There is a potential for Miconazole Gel to have an interaction with Warfarin such as to increase the blood clotting time and hence a higher INR reading than should be expected. This could lead to significant uncontrolled bleeding.
(2) There is a significant lack of knowledge of the interaction among health professionals and/or
(3) The resources available to check the interaction may not be entirely clear on this issue or readily straight forward to locate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 knowledge of the Miconazole Gel and Warfarin interaction among health professionals
Wider context from the report “It became apparent in the course of the evidence that
(1) There is a potential for Miconazole Gel to have an interaction with Warfarin such as to increase the blood clotting time and hence a higher INR reading than should be expected. This could lead to significant uncontrolled bleeding.
(2) There is a significant lack of knowledge of the interaction among health professionals and/or
(3) The resources available to check the interaction may not be entirely clear on this issue or readily straight forward to locate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 difficult-to-locate resources for checking the Miconazole Gel and Warfarin interaction
Wider context from the report “It became apparent in the course of the evidence that
(1) There is a potential for Miconazole Gel to have an interaction with Warfarin such as to increase the blood clotting time and hence a higher INR reading than should be expected. This could lead to significant uncontrolled bleeding.
(2) There is a significant lack of knowledge of the interaction among health professionals and/or
(3) The resources available to check the interaction may not be entirely clear on this issue or readily straight forward to locate.
” Open source report
25 Feb 2016 Amy Rose COOPER · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1 Lack of compatible digital record-keeping and medical note systems enabling information sharing between maternity services 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
Amy Rose COOPER · 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
Amy was born at 40 weeks’ gestation by caesarean section on 8 July 2015 and required immediate resuscitation before being confirmed dead later that evening. Intrauterine growth restriction was not evident to the community midwives or hospital maternity unit until post-mortem investigations; the report also raised concerns about incompatible record-keeping systems and the sharing of maternity information between services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of compatible digital record-keeping and medical note systems enabling information sharing between maternity services
Wider context from the report “It was clear at the inquest that maternity services which had been commissioned in this region had not been required to have a specification for record keeping, notes and scans which could be digitally available to other maternity services operating in the same area . Such that Arrowe Park Hospital needed to have the paper notes from One to One North West Ltd. to ensure continuity of care.
This does not appear to be the most efficient system for continuity of patient care and could have been remedied by the commissioners of the services requiring compatible record keeping and medical note systems to ensure the easy sharing of information .
This would also enable community based midwives to refer a patient to a consultant without the patient necessarily having to attend the maternity unit in the first place.
Further access to notes would make the admission to the maternity unit safer and seamless, delivering what should be a better patient experience and outcome.
” Open source report
16 Feb 2016 Philip Anthony Denning · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 6 Risk of future deaths from fragmented provision by a separate substance misuse organisation View source Unclear remit of CRI in managing patients with co-occurring substance misuse and mental health problems View source Failure to establish consent arrangements and information-sharing between CRI and Nottinghamshire Healthcare View source Lack of primary care understanding of access routes and service roles for patients with co-occurring substance misuse and mental health problems View source Failure of CRI to provide or arrange additional psychological support for patients with co-occurring substance misuse and mental health problems View source Lack of CRI access to Nottinghamshire Healthcare electronic patient records 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
Philip Anthony Denning · 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 Anthony Denning, who had a history of substance misuse and mental health problems, died from diamorphine intoxication on 23 July 2015 after using heroin. The report raised concerns about fragmented services, limited psychology provision, poor information-sharing between organisations, and a lack of clarity in primary care about accessing appropriate support for people with both substance misuse and mental health needs.
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 Risk of future deaths from fragmented provision by a separate substance misuse organisation
Wider context from the report “6. Even aside from the question of shared access to key records held by Nottinghamshire Healthcare and CRI, I am concerned that the current approach of having a separate organisation dealing only with substance misuse carries a risk of future deaths . Commissioners and providers will need to consider these matters carefully.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 remit of CRI in managing patients with co-occurring substance misuse and mental health problems
Wider context from the report “2. Since the introduction of the CRI in October 2014, patients with both categories of problem, have, in the county, been managed by CRI. They are not equipped or commissioned to deal with the additional psychology needs of their patients. We were told that the only way that they can try to arrange this for their patients is via their GPs. It appears that, on the facts of this tragic case, even an employee of CRI itself may have mistaken their remit .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 consent arrangements and information-sharing between CRI and Nottinghamshire Healthcare
Wider context from the report “5. As I understand it, the question of patients giving their consent for access to the records by CRI (and indeed for Nottinghamshire Healthcare to have access to CRI records) has not been considered by either organisation. Aside from potential cost and governance issues, none of the senior clinicians involved could tell me any disadvantage to such access being considered. It appears not to have been considered at all to date. There appears to be very little currently by way of joint working or information-sharing between CRI and Nottinghamshire Healthcare.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 primary care understanding of access routes and service roles for patients with co-occurring substance misuse and mental health problems
Wider context from the report “7. It is also clear that there is a significant lack of understanding in primary care about how to access help for patients like Philip . The respective roles of CRI, Nottinghamshire Healthcare and primary care talking therapies appear to be widely misunderstood. I have included reference to GPs and primary care largely with a view to raising awareness in this area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 CRI to provide or arrange additional psychological support for patients with co-occurring substance misuse and mental health problems
Wider context from the report “2. Since the introduction of the CRI in October 2014, patients with both categories of problem, have, in the county, been managed by CRI. They are not equipped or commissioned to deal with the additional psychology needs of their patients. We were told that the only way that they can try to arrange this for their patients is via their GPs. It appears that, on the facts of this tragic case, even an employee of CRI itself may have mistaken their remit.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 CRI access to Nottinghamshire Healthcare electronic patient records
Wider context from the report “4. The CRI is an entirely separate entity from Nottinghamshire Healthcare and has no access to RiO, Nottingham Healthcare’s electronic record-keeping system . If, for instance, one of their patients had been seen regularly by Nottinghamshire Healthcare following overdoses, they would not be aware of this unless their patient told them about this.
” Open source report
15 Feb 2016 Adam James Withers · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Failure to identify retrospective patient-record entries View source Lack of clear guidance on preserving original records after a patient’s death View source Insufficient recording of psychiatric patient observations and interactions View source Lack of prescribed safe nursing staffing levels for acute psychiatric wards 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
Adam James Withers · 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
Adam James Withers, who was suffering from an acute psychotic illness and detained in hospital, climbed a 130-foot chimney and fell from it, suffering fatal injuries. The report identified concerns about failures to manage his known risk of absconding, reassess his risk after he spoke about climbing the chimney ladder, prevent access to the ladder, communicate environmental risks, and ensure adequate supervision and reliable record-keeping.
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 identify retrospective patient-record entries
Wider context from the report “It was clear from the evidence that any note made in a patient’s record should be made contemporaneously or, if made later, should be timed, dated and labelled as retrospective . This is necessary to ensure that all notes are accurate and reliable.
The evidence at the inquest revealed that at least one member of nursing staff made entries on Adam Withers’ manuscript observation record after he had died, without marking the entries as retrospective . When giving evidence, the member of staff in question did not appear to understand that he ought not to have done so.
If permitted to continue, this practice could result in current and future patients’ notes containing inaccurate and unreliable, and potentially misleading, information and this could have an adverse impact on their assessment, treatment and care and upon the protection of their lives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance on preserving original records after a patient’s death
Wider context from the report “At the inquest an issue arose as to when the manuscript observation record for Adam Withers for the 9th May 2014 was completed and I asked to see the original document. I was provided with a witness statement from the Trust’s Medical Records Manager indicating that, after Adam Withers’ death, the original record had been scanned in to his electronic records and then destroyed. The Trust considers that this is permitted by the NHS Code of Practice on Record Management. It is not clear to me whether that is a correct analysis of the Code or not. No clear guidance appears to exist .
Whilst I understand that paper records may now routinely be scanned in to a patient’s electronic record and then destroyed, my concern relates to that taking place after a patient has died and it is apparent that the death must be reported to the police and/or coroner. The destruction of any original document which is still in existence at the time of death could undermine the efficacy of the police investigation and/or the coroner’s investigation. In turn, this could adversely affect the coroner’s ability to establish the facts of how the deceased person came by his death and to report concerns for the prevention of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient recording of psychiatric patient observations and interactions
Wider context from the report “It was apparent from the evidence that periodic observations of psychiatric patients are conducted not only to check that each is present, but also in order to observe and assess their current state of mind and presentation, by means of a meaningful interaction, if possible. The importance of nursing staff (Registered Nurses and Health Care Assistants) making a sufficient written record of these observations was acknowledged. Regular notes of a patient’s condition are important for the purposes of diagnosis and they provide the information which is needed for a reliable assessment of the patient’s progress and current level of risk of harm or death. It was accepted in evidence that this is especially so in relation to any patient whose condition fluctuates.
It was clear from the evidence that the nursing staff involved in Adam Withers’ care failed to record sufficiently his presentation and their interactions with him . For example, on the day of his death Adam Withers was subject to four observations per hour but no entries were made on his RIO notes or elsewhere about his state of mind or presentation at these observation points and no record was made about the conversation a nurse conducted with him that afternoon .
Some of the nursing staff who gave evidence appeared to have little understanding of the need to make such written records and/or their importance .
If permitted to continue, the insufficient recording of observations and events could have an adverse impact on the assessment, treatment and care of current and future patients and upon the protection of their lives .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 prescribed safe nursing staffing levels for acute psychiatric wards
Wider context from the report “At the inquest the number of nursing staff (Registered Nurses and Health Care Assistants) on duty on Elgar Ward was considered. It was apparent from the evidence that the nursing staff levels could result in patients on the ward being insufficiently supervised at meal times and staff stated in evidence that they did not always have time to read patients’ notes as they should.
Further, Elgar Ward is an acute psychiatric ward with both detained and voluntary patients. It is foreseeable that reactive and unplanned interventions will be required at times and that the level of observation needed by each patient will fluctuate. The staffing levels on Elgar Ward were deemed sufficient for only a fixed number of patients to be subject to increased observation levels, and only one patient to be under constant observation, at any one time. I was informed that if more patients required increased or constant observation, additional staff would be needed but may not be readily available.
I have been told by the Trust that no nationally prescribed safe staffing levels are in place for an acute psychiatric ward (whether based on patient to staff ratios or otherwise) and that the Trust considers its staffing levels to be in accordance with such guidelines as do exist. The Mental Health Taskforce’s recently published report entitled “The Five Year Forward View For Mental Health” does not appear to address this issue.
It does seem that the absence of prescribed safe nursing staff levels for acute psychiatric wards could leave such wards unable to provide, throughout each shift, the level of patient supervision, observation and intervention needed . This could adversely affect the staff’s ability to protect their patients’ lives.
” Open source report
15 Feb 2016 Eileen Annie Thompson · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 2 Inaccessibility of inner-wheel locking mechanisms when beds are placed against walls View source Failure to lock the inner wheels of beds 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
Eileen Annie Thompson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Eileen Annie Thompson, who had dementia, fell between her bed and a wall after the bed moved and sustained serious head injuries. She died shortly after admission to hospital. The concerns were that the bed’s inner wheels were not locked because their locking mechanisms were inaccessible against the wall, creating a risk of recurrence for other service users.
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 Inaccessibility of inner-wheel locking mechanisms when beds are placed against walls
Wider context from the report “(1) The bed was able to move from the wall because the two inner wheels were not locked.
(2) The locking mechanism for the inner wheels was not easily accessible when the bed was placed against a wall .
(3) There is risk of recurrence in respect of service users who are provided with this type of bed when the bed is placed against a wall.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 lock the inner wheels of beds
Wider context from the report “(1) The bed was able to move from the wall because the two inner wheels were not locked .
(2) The locking mechanism for the inner wheels was not easily accessible when the bed was placed against a wall.
(3) There is risk of recurrence in respect of service users who are provided with this type of bed when the bed is placed against a wall.
” 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 occupational therapy and other stakeholders to develop new national resources for assessing and safely using beds.
Verbatim wording from the response “We feel that staff is aware of the problem but that the solution is not always straight forward. We therefore think that new resources are required for staff to assess the risks more carefully and to be able to make adequate decisions with regards to the safe use of beds.” Source location E-Thompson-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss the bed-wheel safety risk and identified guidance gaps with the MHRA.
Verbatim wording from the response “Our planned action:
We will discuss the risk and our findings with the MHRA as we feel that it is within their remit to improve the advice provided in user instructions. We will highlight the fact that some IFUs do not seem to provide enough guidance for staff and that advice is needed on how to safely use a bed with individual wheels, if it is positioned against a wall. Advice is also required on how many wheels need to be locked to hold the bed in position.” Source location E-Thompson-Response2
Open published response
9 Dec 2015 Jake Robinson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Lack of medication-prescribing capability within substance misuse services View source Failure to identify relevant safety issues in reviews of deaths View source Failure to prioritise Community Mental Health Team appointments for patients at high risk of harm View source Failure to ensure relevant prescribing information is received and communicated to drug services View source Fragmented substance-misuse care requiring young people to engage with an age-inappropriate second service View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jake Robinson · 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
Jake Robinson died at home on 23 August 2015 after taking his own life; the recorded cause of death was hanging and illicit drug use. Concerns included failures to share information about prescribing diazepam, the failure to identify this issue in the review of his death, fragmented substance-misuse services, and the unexplained rearrangement of a Community Mental Health Team appointment shortly before 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 Lack of medication-prescribing capability within substance misuse services
Wider context from the report “3) The fact that Phoenix Futures have no ability to prescribe medication to their services users was a concern. It meant that young people with substance misuse issues have to be referred to Trafford Aim, who are a service for people over the age of 26. Jake had a good relationship with Phoenix Futures but he did struggle to engage with services. The fact that he then had to engage with two services added to what in the Courts view was a disconnected approach to dealing with Jakes increasing difficulties.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 relevant safety issues in reviews of deaths
Wider context from the report “2) The failure to identify the above issue as part of the review into the death of Jake Robinson is a concern as it highlights a missed opportunity to potentially learn lessons .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 prioritise Community Mental Health Team appointments for patients at high risk of harm
Wider context from the report “4) There was no explanation in the review as to why the appointment clash between Trafford Aim and the Community Mental Health Team led to the appointment with the CMHT being rearranged . Particularly as Jake had made two recent serious attempts of self-harm in July 2015 and was at the very least recognised as a high risk of accidental harm . Given that Trafford Aim were not prescribing Jake at this time the Court had some difficulties in understanding what their role was given that he was also under Phoenix Futures for his substance misuse.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 relevant prescribing information is received and communicated to drug services
Wider context from the report “1) The Court heard evidence that his GP had written to Greater Manchester West on the 23rd June 2015 (exactly to whom this letter was addressed is not known as it was not provided in the evidence from the GP practice) indicating that Jake could be prescribed diazepam following the investigation for his seizure. There was no indication in the review by GM West as to whether this letter had been received and if not why not. However neither of the Drug Services who were involved with Jake were aware of this information and therefore he was not commenced on any benzodiazepine reduction. This issue is being brought to the attention of all the recipients of this Regulation 28 report including the Medical Director for the Greater Manchester NHS Area who will be aware of the same concern raised in a separate recent case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Fragmented substance-misuse care requiring young people to engage with an age-inappropriate second service
Wider context from the report “3) The fact that Phoenix Futures have no ability to prescribe medication to their services users was a concern. It meant that young people with substance misuse issues have to be referred to Trafford Aim, who are a service for people over the age of 26 . Jake had a good relationship with Phoenix Futures but he did struggle to engage with services. The fact that he then had to engage with two services added to what in the Courts view was a disconnected approach to dealing with Jakes increasing difficulties.
” 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 Send all mental health service commissioners NHS England expectations for commissioned arrangements covering urgent correspondence, clinical risk assessment, shared care, incident learning, and vulnerable patients who miss appointments.
Verbatim wording from the response “In order to reduce the risks of recurrence of a similar incident at these and other organisations across Greater Manchester so that referrals are managed and monitored by the responsible commissioning and provider organisations I intend to undertake the following actions by 29 April 2016.” Source location 2015-0474-Response-by-GMCA
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 Send all GPs guidance on verifying receipt of urgent correspondence, documenting confirmation, and recording persistent suicide risk.
Verbatim wording from the response “In order to reduce the risks of recurrence of a similar incident at these and other organisations across Greater Manchester so that referrals are managed and monitored by the responsible commissioning and provider organisations I intend to undertake the following actions by 29 April 2016.” Source location 2015-0474-Response-by-GMCA
Open published response
Concerns raised 9 Failure to provide longitudinal management of recurring asthma exacerbations View source Failure to recognise deterioration in respiratory condition View source Failure to enable appropriate referrals to the tertiary paediatric service View source Failure to ensure understanding of the purpose and limits of asthma plans View source Lack of a long-term management plan for chronic asthma View source Lack of effective communication between primary and secondary care services View source Lack of a coordinating record of recurrent asthma presentations View source Failure to assign overall clinical management responsibility View source Failure to refer paediatric asthma patients to tertiary respiratory specialists 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.
×
AI-generated summary
Tamara Mills · 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
Tamara Mills, who had longstanding asthma and repeated acute exacerbations, developed breathing difficulties during the night of 10th/11th April 2015 and died after paramedics were called. The principal concerns were fragmented care, inadequate coordination and communication, insufficient recognition of her deteriorating chronic respiratory condition, and the absence of a long-term management plan.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide longitudinal management of recurring asthma exacerbations
Wider context from the report “1. The care management and treatment of this child on the innumerable occasions she presented with an exacerbation of asthma, was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family .
2. There was :-
i) No co-ordinating record of these occasions
ii) No analysis of the frequency or circumstances of the events
iii) No analysis of the medication or level of medication prescribed
iv) No determination of its effectiveness the frequency or regularity of its use
v) No appreciation of the deteriorating nature of her respiratory condition
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 deterioration in respiratory condition
Wider context from the report “1. The care management and treatment of this child on the innumerable occasions she presented with an exacerbation of asthma, was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family.
2. There was :-
i) No co-ordinating record of these occasions
ii) No analysis of the frequency or circumstances of the events
iii) No analysis of the medication or level of medication prescribed
iv) No determination of its effectiveness the frequency or regularity of its use
v) No appreciation of the deteriorating nature of her respiratory condition
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 enable appropriate referrals to the tertiary paediatric service
Wider context from the report “8. Two further areas of concern presented, inter related but independently significant and critical in this matter :
A) Tamara’s mother readily presented her child for care in an out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment.
B) Evidence was also received of the development of a Tertiary service designed to improve medical care in the area of paediatrics.
i) There was a singular lack of understanding by practitioners of how referrals to the service were to be made and once made an anxiety that the receiving trust not be seen to be acquiring a patient at the expense of the referring trust . The net result of this inhibition a further fragmentation in the care and management of the patient.
ii) Within this service there were and indeed are specialist Respiratory Physicians who because of their level of expertise could and did demonstrate their ability to make a difference if they had been permitted in one instance to assume long term management of the child’s care
and
iii) More tragically in another because she was referred to the hospital but not to the service and therefore not to the Tertiary Specialists, managed only as an acute presentation
9. Tamara was never formally referred to this level of service.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure understanding of the purpose and limits of asthma plans
Wider context from the report “3. Despite the presence of a significant number of health care professional involved in her care and some frequently, no single individual assumed management for her care overall
4. In the absence of no one individual assuming responsibility for her care, there was no plan directed towards her long term management and care identifying the chronic nature of her condition, seeking a sustained and balanced level of treatment, control and resolution of the recurring episodes.
5. Insofar as planning occurred it was in the last six months of her life and was in the form of an emergency plan directed towards the next and apparently accepted inevitable acute event, but not as a part of the necessary strategy to control and avoid such events.
6. Not only did those advised of such a plan fail to understand its limited objective they misinterpreted its purpose and consoled themselves in the false belief there was a purposeful strategy designed to protect this child in the long term.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a long-term management plan for chronic asthma
Wider context from the report “3. Despite the presence of a significant number of health care professional involved in her care and some frequently, no single individual assumed management for her care overall
4. In the absence of no one individual assuming responsibility for her care, there was no plan directed towards her long term management and care identifying the chronic nature of her condition, seeking a sustained and balanced level of treatment, control and resolution of the recurring episodes .
5. Insofar as planning occurred it was in the last six months of her life and was in the form of an emergency plan directed towards the next and apparently accepted inevitable acute event, but not as a part of the necessary strategy to control and avoid such events.
6. Not only did those advised of such a plan fail to understand its limited objective they misinterpreted its purpose and consoled themselves in the false belief there was a purposeful strategy designed to protect this child in the long term.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 effective communication between primary and secondary care services
Wider context from the report “8. Two further areas of concern presented, inter related but independently significant and critical in this matter :
A) Tamara’s mother readily presented her child for care in an out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment .
B) Evidence was also received of the development of a Tertiary service designed to improve medical care in the area of paediatrics.
i) There was a singular lack of understanding by practitioners of how referrals to the service were to be made and once made an anxiety that the receiving trust not be seen to be acquiring a patient at the expense of the referring trust. The net result of this inhibition a further fragmentation in the care and management of the patient.
ii) Within this service there were and indeed are specialist Respiratory Physicians who because of their level of expertise could and did demonstrate their ability to make a difference if they had been permitted in one instance to assume long term management of the child’s care
and
iii) More tragically in another because she was referred to the hospital but not to the service and therefore not to the Tertiary Specialists, managed only as an acute presentation
9. Tamara was never formally referred to this level of service.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a coordinating record of recurrent asthma presentations
Wider context from the report “1. The care management and treatment of this child on the innumerable occasions she presented with an exacerbation of asthma, was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family.
2. There was :-
i) No co-ordinating record of these occasions
ii) No analysis of the frequency or circumstances of the events
iii) No analysis of the medication or level of medication prescribed
iv) No determination of its effectiveness the frequency or regularity of its use
v) No appreciation of the deteriorating nature of her respiratory condition
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 assign overall clinical management responsibility
Wider context from the report “3. Despite the presence of a significant number of health care professional involved in her care and some frequently, no single individual assumed management for her care overall
4. In the absence of no one individual assuming responsibility for her care, there was no plan directed towards her long term management and care identifying the chronic nature of her condition, seeking a sustained and balanced level of treatment, control and resolution of the recurring episodes.
5. Insofar as planning occurred it was in the last six months of her life and was in the form of an emergency plan directed towards the next and apparently accepted inevitable acute event, but not as a part of the necessary strategy to control and avoid such events.
6. Not only did those advised of such a plan fail to understand its limited objective they misinterpreted its purpose and consoled themselves in the false belief there was a purposeful strategy designed to protect this child in the long term.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to refer paediatric asthma patients to tertiary respiratory specialists
Wider context from the report “8. Two further areas of concern presented, inter related but independently significant and critical in this matter :
A) Tamara’s mother readily presented her child for care in an out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment.
B) Evidence was also received of the development of a Tertiary service designed to improve medical care in the area of paediatrics.
i) There was a singular lack of understanding by practitioners of how referrals to the service were to be made and once made an anxiety that the receiving trust not be seen to be acquiring a patient at the expense of the referring trust. The net result of this inhibition a further fragmentation in the care and management of the patient.
ii) Within this service there were and indeed are specialist Respiratory Physicians who because of their level of expertise could and did demonstrate their ability to make a difference if they had been permitted in one instance to assume long term management of the child’s care
and
iii) More tragically in another because she was referred to the hospital but not to the service and therefore not to the Tertiary Specialists, managed only as an acute presentation
9. Tamara was never formally referred to this level of service .
” Open source report
Concerns raised 2 Lack of a formalised objective risk assessment process throughout the prison estate View source Failure to consult relevant healthcare, chaplaincy, unit management or ACCT review officers before closing an ACCT View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Samuel William Gale · 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
Samuel William Gale, aged 18, was received into custody at HMP Doncaster after recent self-harm and a suicide attempt, and was placed on an ACCT with half-hourly observations. The ACCT was closed on 16 May 2014, and he was found hanging the following day; the report raised concern that it was closed without reference to healthcare, chaplaincy, a unit manager, or an officer who had carried out an ACCT review.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a formalised objective risk assessment process throughout the prison estate
Wider context from the report “(2) The importance of an objective risk assessment has been recognised by the Trust which now uses a mandatory risk assessment from on System One. It is understood that NHS England is in the process of procuring a new version of System One, and is invited to consider whether this procurement exercise provided an opportunity for formalising the risk assessment process throughout the prison estate nationally .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to consult relevant healthcare, chaplaincy, unit management or ACCT review officers before closing an ACCT
Wider context from the report “i) The ACCT was closed by a person who had previous dealings with Samuel without reference to healthcare, the chaplaincy or a unit manager or any officer who had carried out an ACCT review.
ii) The Deputy Director was asked to consider whether only the person who is primarily responsible for a prisoner’s ACCT should be the one to close it.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review national templates, including first-night screening and risk assessment, with the relevant information and clinical reference organisations.
Verbatim wording from the response “The new Health & Justice Information System will be a national system for the residential estate and as part of the deployment we are working with the Health and Social Care Information Centre and NHS England Clinical Reference Group to review a number of templates and first night screening and risk assessment is one of these templates.” Source location 2015-0454-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 Deploy and roll out the new Health & Justice Information System to all sites, including any new national templates, with full functionality planned by July 2017.
Verbatim wording from the response “The timeline for the work is that from July 2016 NHS England will be undertaking the deployment and roll out to all sites of the new system, with an expectation that the full functionality will be in place by July 2017. This will include the roll out of any new national templates.” Source location 2015-0454-Response-by-NHS-England
Open published response
21 Oct 2015 David Baddeley · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Delays in reviewing and summarising patients' paper medical records View source Failure of electronic record transfer systems to highlight key information View source Failure of initial new-patient health screening to identify serious psychiatric illness and absence of antipsychotic medication View source Failure to notify the outgoing practice when a new practice takes over patient care View source Delays in receiving full paper medical records View source Failure of paper-record review to identify mental health diagnoses and lack of medication 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
David Baddeley · 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 Baddeley, who had a history of schizophrenia, died at home on 23 June 2015 after tying a ligature around his neck; the cause of death was recorded as hanging, with schizophrenia also noted. Concerns included delays and gaps in transferring and reviewing medical records, incompatibility between electronic systems, and the failure to identify his psychiatric illness and lack of antipsychotic medication during primary-care handovers and checks.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in reviewing and summarising patients' paper medical records
Wider context from the report “Due to the volume of work the fact that it takes 8 weeks for a patients paper medical records to be reviewed and summarised .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 electronic record transfer systems to highlight key information
Wider context from the report “That the transfer of 4 patients electronic records between medical practices can mean that key information is not highlighted due to the incompatibility of the systems .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 initial new-patient health screening to identify serious psychiatric illness and absence of antipsychotic medication
Wider context from the report “The fact that the initial new patients health screenings did not note that Mr Baddeley had a serious psychiatric illness , which could have made him a risk to himself or indeed others as he was not taking his antipsychotic medication .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the outgoing practice when a new practice takes over patient care
Wider context from the report “The practice which a patient is leaving is not notified of the new practice taking over the patients care so that doctors can speak and discuss any pertinent medical 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 Delays in receiving full paper medical records
Wider context from the report “The length of time it takes for a medical practice to receive the full paper medical records .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of paper-record review to identify mental health diagnoses and lack of medication
Wider context from the report “That when his paper records were reviewed on the 15th June nothing pertinent was thought required and again his mental health diagnosis and lack of medication not picked up .
” Open source report
16 Oct 2015 Adrian Mark Smith · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Failure to follow specialist advice View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Adrian Mark Smith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Adrian Mark Smith attended hospital after seizures and was later found to have a bilateral frontal brain haemorrhage and sagittal sinus thrombosis. He underwent decompression surgery after a further brain bleed and died on 8 June 2015; the inquest concluded that his death resulted from a complication of heparin treatment. The principal concern was that Good Hope Hospital did not follow specialist advice to undertake an MRI scan to confirm the possible diagnosis.
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 follow specialist advice
Wider context from the report “(1) Clear instruction was given by the Queen Elizabeth hospital to undertake an MRI scan to confirm the possible diagnosis. This instruction was not followed by the staff at Good Hope Hospital. Systems need to be put in place to ensure that specialist advice is followed.
” Open source report
16 Oct 2015 Louise Sharon Henry · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 5 Lack of GP awareness and use of EMIS Special Patient Note and Right Care Plan facilities for mental health risk information View source Failure to ensure shared understanding of care co-ordinator roles and Care Programme Approach responsibilities View source Failure of discharge letters to identify mental health relapse risks and indicators View source Failure to distinguish Recovery Team services operated by different agencies View source Failure to follow required patient discharge processes and procedures View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Louise Sharon Henry · 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
Louise Sharon Henry was found deceased at home on 1 April 2013 after consuming a substantial amount of amphetamine and ibuprofen while experiencing a deterioration in her mental state, including psychotic symptoms and hallucinations. The report identified concerns about her discharge from mental health services, including failures to communicate relapse triggers and a clear contingency plan, lack of reassessment after reports of deterioration, and ambiguity between agencies about care-coordination roles and procedures.
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 GP awareness and use of EMIS Special Patient Note and Right Care Plan facilities for mental health risk information
Wider context from the report “4. That GPs do not appreciate the use that can be made of the Special Patient Note facility and Right Care plan facility on the EMIS system operated by GPs. I heard evidence that key information relating to patients and in particular mental health patients can be updated on to the Special Patient Note facility and the Right Care Plan facility by GPs and used to record risk relapse triggers and indicators for patient’s with mental health difficulties and risk of suicide/ self harm. This enables Out of Hours Services such as those operated by Derbyshire HealthCare United to access key risk information when they are called out of hours when the GP and the full GP records with this key information is not available. There appears to be action that can be taken by NHS England through the Clinical Commissioning Groups to educate GPs as to this facility.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 shared understanding of care co-ordinator roles and Care Programme Approach responsibilities
Wider context from the report “1. The CMHT from the evidence I heard did not understand that the DCC Recovery Team is not following the Care Programme approach, neither are lead professionals from the DCC Recovery Team acting as care co-ordinators for the purposes of the Care Programme Approach [CPA]. I heard evidence that the Psychiatrist from the CMHT understood that the social worker from the DCC Recovery Team was Louise Henry’s Care coordinator for CPA purposes and was following the Care Programme Approach. I also heard evidence that when the services of the DCC Recovery Team and CMHT ceased to be an Integrated service the understanding of the psychiatrist had been that the DCC Recovery Team workers would be following the CPA. I heard evidence from DCC Recovery Team that this was not the case and that they were not following the CPA or acting as the care co-ordinator for the purposes of CPA but instead worked to the Self Directed Support framework. It is important that the CMHT understand the roles and responsibilities of the Lead professional from the DCC Recovery Team and that they are not following the Care Programme approach or acting as the care co-ordinator. It is of concern that workers from the CMHT and DCC Recovery Team who often are involved in providing multi agency mental health services and joint working to patients misunderstand each others roles, responsibilities and processes. The care co-ordinator is a key role in the management of a patient with mental health difficulties and it is important that there is no ambiguity in respect of who is acting in this capacity.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 discharge letters to identify mental health relapse risks and indicators
Wider context from the report “2. That both the CMHT and the Recovery Team of DCC ensure that when discharging patients all necessary processes and procedures indicated in policies are followed by the lead professional and / or care co-ordinator and that discharge letters sent to GPs and to patients identify risk relapse triggers and indicators to ensure re-assessment if there are signs of deterioration in mental health and speedy referral back to secondary mental health services if required . My concern is that the processes and procedures indicated on discharge for Louise Henry were not followed and the confusion as to roles and responsibilities risks this re-occurring.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 distinguish Recovery Team services operated by different agencies
Wider context from the report “3. There is a misunderstanding in respect of the Recovery Team from DCC and the Recovery Team within the CMHT and potential for confusion between professionals and service users due to there being 2 services operating under the title “Recovery Team” operated by different agencies namely DCC and the CMHT.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to follow required patient discharge processes and procedures
Wider context from the report “2. That both the CMHT and the Recovery Team of DCC ensure that when discharging patients all necessary processes and procedures indicated in policies are followed by the lead professional and / or care co-ordinator and that discharge letters sent to GPs and to patients identify risk relapse triggers and indicators to ensure re-assessment if there are signs of deterioration in mental health and speedy referral back to secondary mental health services if required. My concern is that the processes and procedures indicated on discharge for Louise Henry were not followed and the confusion as to roles and responsibilities risks this re-occurring.
” Open source report
Concerns raised 3 Failure to use a sepsis screening tool in community healthcare View source Failure to recognise or adopt a UK sepsis clinical toolkit View source Failure to recognise repeated attendances as clinically significant 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
Caroline Robey · 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
Caroline Robey was a fit 34-year-old working mother who became unwell and attended community healthcare providers on six occasions over five days. She was initially diagnosed with a viral infection and later diarrhoea and vomiting, before being admitted to hospital with suspected sepsis; despite treatment, she died the following day from Group A streptococcal infection and evolving sepsis. The principal concerns were the absence of sepsis screening by community healthcare providers, failure to adopt available sepsis toolkit resources, and inadequate consideration of her repeated attendances.
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 use a sepsis screening tool in community healthcare
Wider context from the report “1. No sepsis screening tool was being used by the community health care providers , and so opportunities were lost to consider a diagnosis of sepsis and refer as an emergency for hospital admission and treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 or adopt a UK sepsis clinical toolkit
Wider context from the report “2. A patient safety alert issued 2 September 2014 by NHS England clearly sets out resources available in the provision of a UK sepsis clinical tool kit, but this had not been recognised or adopted by the health care providers involved in this case .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise repeated attendances as clinically significant
Wider context from the report “3. Inadequate note was taken of the number of different attendances Mrs Robey had initiated despite previous good health, and there was no suggestion she was a frequent attender or had ever sought medical assistance inappropriately.
” Open source report
Concerns raised 2 Failure to implement thromboprophylaxis guidance for patients requiring temporary limb immobilisation View source Lack of a protocol for assessing patients attending the Plaster Room View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
LORRAINE JOYCE BIRD · 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
Lorraine Joyce Bird fractured her ankle after a fall and later attended a plaster room with numbness in her foot. The report identifies concerns that a developing deep vein thrombosis was not recognised or medically reviewed, that there was no adequate assessment protocol, and that she had not received low molecular weight heparin. The inquest concluded that this resulted in a lost opportunity for further treatment and that she died on 13 September 2014.
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 implement thromboprophylaxis guidance for patients requiring temporary limb immobilisation
Wider context from the report “(1) In September 2013 The College of Emergency Medicine issued a “Guideline for the use of Thromboprophylaxis in Ambulatory Patients Requiring Temporary Limb Immobilisation”. This recommends the use of Low Molecular Weight Heparin (LMWH) to be used until the plaster is removed.
(2) When Lorraine Bird attended Colchester Hospital she was not given LMWH. The hospital had not yet introduced the Guideline , although they were in the process of trying to agree the funding to enable them to adopt it.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a protocol for assessing patients attending the Plaster Room
Wider context from the report “(2) There appears to be a complete lack of a Protocol for the assessment of patients who attend for treatment at the Plaster Room .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implementation of the new pathway is delayed because funding is not assured.
Verbatim wording from the response “• An Education programme for the Emergency Department has been introduced to support the implementation of the guidance. The new pathway across primary and secondary care will commence on the 2 November 2015 as funding is not assured for implementation.” Source location 2015-0315-Response-by-NHS-England
Open published response
Concerns raised 4 Delays in patient care allowing further deterioration and loss of treatment options View source Lack of a bed bureau system for identifying calls requiring emergency admission independently of bed availability View source Failure to arrange immediate emergency ambulance transfer for potential stroke symptoms View source Failure to escalate stroke-patient collection requests to a medical emergency response 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
George Boulton · 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
George Boulton developed an intracerebral bleed at home on 12 February 2015 and died on 14 February 2015 at Leicester Royal Infirmary. The report identified delays in arranging emergency transfer and failures to communicate or recognise the need to withhold dalteparin, which materially contributed to the continuing bleed.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in patient care allowing further deterioration and loss of treatment options
Wider context from the report “4. This culmination of events in this particular case allowed for the unexpected intervention of the District Nurse; while this is very case specific, similar delays in another patient's care may allow further deterioration and the loss of treatment options .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a bed bureau system for identifying calls requiring emergency admission independently of bed availability
Wider context from the report “2. The bed bureau did not appear from the evidence available in court to have a system for identifying calls that should have been re-routed to an emergency admission , and not be dependent on a bed , as early scanning was essential for proper diagnosis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange immediate emergency ambulance transfer for potential stroke symptoms
Wider context from the report “1. It was recognised by all witnesses to the inquest that response to potential stroke symptoms should be on an emergency basis , in accordance with "FAST" criteria ie a timely response. The GP attempted to arrange admission but accepted delays via bed bureau rather than convert to a 999 call and obtain immediate ambulance transfer .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate stroke-patient collection requests to a medical emergency response
Wider context from the report “3. East Midlands Ambulance Service did not identify that a request to collect a stroke patient should have been escalated to a medical emergency and a 20 minute response time , rather than the actual allocated 2 hour response time .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop guidance on practical design principles for faster, safer urgent and emergency care pathways.
Verbatim wording from the response “In terms of national work, in January 2013 NHS England launched a review of urgent and emergency care services in England. The new urgent and emergency care system will ensure that those people with more serious or life threatening emergency needs receive treatment in centres with the right facilities and expertise. We have developed guidance which summarises practical design principles that local health communities should adopt to deliver faster, better, safer care. This will help front line providers and commissioners improve the flow of patients through the urgent and emergency pathway, increasing the availability of resources.” Source location 2015-0255-Responses
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 Undertake a clinical review of ambulance response protocols and develop recommendations for changes to national ambulance service standards.
Verbatim wording from the response “3. East Midlands Ambulance Service did not identify that a request to collect a stroke patient should have been escalated to a medical emergency and a 20 minute response time, rather than the actual allocated 2 hour response time.” Source location 2015-0255-Responses
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 Contact GP practices through membership organisations to reiterate that suspected strokes require an urgent 999 response.
Verbatim wording from the response “1. Response to potential stroke symptoms should be on an emergency basis, in accordance with FAST criteria. The GP attempted to arrange admission but accepted delays via bed bureau rather than convert to a 999 call and obtain immediate ambulance transfer.” Source location 2015-0255-Responses
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 Bed Bureau services are locally organised and guided by the referring GP’s opinion and requirements regarding emergency admission.
Verbatim wording from the response “Bed Bureau Services are local and variable in their organisation; however such services are guided by the opinion and requirements of the referring GP. As stated above, NHS England proposes to engage with GPs through their membership organisations so that all suspected strokes receive a 999 response.” Source location 2015-0255-Responses
Open published response
Concerns raised 2 Lack of acute psychiatric beds in Cornwall View source Failure to staff designated mental health places of safety to the appropriate level 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
James Reuben Maxwell Adams · 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 Adams was found dead at home on 10 August 2012 with a plastic bag and helium cylinders, and suicide notes were found nearby. He had persistent depressive disorder, alcohol dependency and a mixed type personality disorder, and was being treated by mental health services. Concerns included the police response to a welfare concern, information sharing, shortages of acute psychiatric beds, and inadequate staffing at designated mental health places of safety.
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 acute psychiatric beds in Cornwall
Wider context from the report “The inquest heard how lessons had been learnt from the inquest and that the working relationship with the Devon and Cornwall Police and the local Mental Health Services (provided by Cornwall Partnership NHS Foundation Trust) had been improved and formalised through appropriate protocols and Memorandum of Understanding. One continuing difficulty was the “lack of acute psychiatric beds” in Cornwall. In addition, the police had found that on a regular basis, the designated mental health places of safety were not staffed to the appropriate level and the patient could not be left there. The result of this was that patients were being inappropriately detained in police cells by way of a safety net or were regularly being transported out of County as far as Manchester and Bournemouth to access the appropriate acute mental health bed.
Cornwall Partnership NH Foundation Trust representative advised the Coroner that Cornwall has pro-rata less acute mental health beds than the national average. The preferred option for the mental health professionals was to treat local patients locally where they are known or are able to build up relationships with the local mental health team which is something that cannot happen if the patient is transported out of County. Further, the treating Psychiatrist is required to travel to the out of county unit to review the patient which results in valuable Consultant time not being available to local patients which may need access to them at a critical time. The result of this is that unnecessary stress is put on patients which can result in a deterioration of the patients mental health (and possibility death) at a time when the patient needs increased support and treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 staff designated mental health places of safety to the appropriate level
Wider context from the report “The inquest heard how lessons had been learnt from the inquest and that the working relationship with the Devon and Cornwall Police and the local Mental Health Services (provided by Cornwall Partnership NHS Foundation Trust) had been improved and formalised through appropriate protocols and Memorandum of Understanding. One continuing difficulty was the “lack of acute psychiatric beds” in Cornwall. In addition, the police had found that on a regular basis, the designated mental health places of safety were not staffed to the appropriate level and the patient could not be left there . The result of this was that patients were being inappropriately detained in police cells by way of a safety net or were regularly being transported out of County as far as Manchester and Bournemouth to access the appropriate acute mental health bed.
Cornwall Partnership NH Foundation Trust representative advised the Coroner that Cornwall has pro-rata less acute mental health beds than the national average. The preferred option for the mental health professionals was to treat local patients locally where they are known or are able to build up relationships with the local mental health team which is something that cannot happen if the patient is transported out of County. Further, the treating Psychiatrist is required to travel to the out of county unit to review the patient which results in valuable Consultant time not being available to local patients which may need access to them at a critical time. The result of this is that unnecessary stress is put on patients which can result in a deterioration of the patients mental health (and possibility death) at a time when the patient needs increased support and treatment.
” Open source report
Concerns raised 4 Failure to escalate the level of care when there is a deviation from the norm View source Unsuitability of the clinical learning environment for Student Midwives View source Insufficient fetal monitoring View source Failure to correctly interpret CTG traces 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
Casey Paul GARRETT · 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
Casey Paul Garrett was born at Bedford Hospital on 10 September 2014 and died on 11 September 2014 at 07:10 from perinatal asphyxia. The inquest identified failures to recognise his deteriorating condition and escalate care to expedite delivery, while the stated concerns included insufficient fetal monitoring, misinterpretation of a CTG trace, failure to escalate care, and the suitability of the hospital as a clinical learning environment for student midwives.
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 escalate the level of care when there is a deviation from the norm
Wider context from the report “My concern was regarding the clinical learning environment, in that a Student Midwife was working with a Midwife and witnessed/carried out entirely inappropriate midwifery care which led to this infant’s death, including insufficient fetal monitoring, mis-interpretation of a CTG trace and the failure to escalate the level of care when there was a “deviation from the norm” .
1. The incident raises questions about the suitability of Bedford Hospital NHS Trust being used as a clinical learning environment for Student Midwives – this needs an urgent review in the interests of safety of mothers and babies to avoid similar deaths in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unsuitability of the clinical learning environment for Student Midwives
Wider context from the report “My concern was regarding the clinical learning environment, in that a Student Midwife was working with a Midwife and witnessed/carried out entirely inappropriate midwifery care which led to this infant’s death, including insufficient fetal monitoring, mis-interpretation of a CTG trace and the failure to escalate the level of care when there was a “deviation from the norm”.
1. The incident raises questions about the suitability of Bedford Hospital NHS Trust being used as a clinical learning environment for Student Midwives – this needs an urgent review in the interests of safety of mothers and babies to avoid similar deaths in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient fetal monitoring
Wider context from the report “My concern was regarding the clinical learning environment, in that a Student Midwife was working with a Midwife and witnessed/carried out entirely inappropriate midwifery care which led to this infant’s death, including insufficient fetal monitoring , mis-interpretation of a CTG trace and the failure to escalate the level of care when there was a “deviation from the norm”.
1. The incident raises questions about the suitability of Bedford Hospital NHS Trust being used as a clinical learning environment for Student Midwives – this needs an urgent review in the interests of safety of mothers and babies to avoid similar deaths in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly interpret CTG traces
Wider context from the report “My concern was regarding the clinical learning environment, in that a Student Midwife was working with a Midwife and witnessed/carried out entirely inappropriate midwifery care which led to this infant’s death, including insufficient fetal monitoring, mis-interpretation of a CTG trace and the failure to escalate the level of care when there was a “deviation from the norm”.
1. The incident raises questions about the suitability of Bedford Hospital NHS Trust being used as a clinical learning environment for Student Midwives – this needs an urgent review in the interests of safety of mothers and babies to avoid similar deaths in the future.
” Open source report
23 Jul 2015 Doreen England · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 7 Lack of staff knowledge about pressure sore formation and prevention View source Lack of clear ward leadership View source Inadequate on-site medical cover View source Failure to provide staff training on pressure sore formation and prevention View source Failure to prepare care plans for patients at high risk of pressure sore formation View source Inadequate RMN training on pressure sores View source Failure to act on identified clinical risks View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Doreen England · 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
Doreen England, an 81-year-old woman with vascular dementia, developed a severe pressure sore during her admission to Rosemary Suite from 20 July 2014 and died on 30 September 2014. The principal concerns were the failure to prepare and implement a care plan despite her high risk, inadequate staff knowledge and training about pressure sore prevention, and insufficient ward leadership and medical cover.
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 staff knowledge about pressure sore formation and prevention
Wider context from the report “(1) Despite a waterlow score on admission confirming she was at high risk of pressure sore formation no care plan was prepared. Staff at the inquest confirmed they had a lack of knowledge about pressure sore formation and how to prevent pressure sores occurring. Staff working on mental health wards dealing with elderly patients must have a clear understanding of basic medical care in particular how pressure sores occur and what steps are required to address those at high risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of clear ward leadership
Wider context from the report “(3) Rosemary suite had no leadership at the time. Staff were completing paperwork but not then actioning risks that were identified. The consultant and ward doctor were on leave at the same time and medical cover was only available from doctors off site who had to be requested to attend. The ward and trust need to ensure there is clear leadership on the ward with adequate medical cover.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 on-site medical cover
Wider context from the report “(3) Rosemary suite had no leadership at the time. Staff were completing paperwork but not then actioning risks that were identified. The consultant and ward doctor were on leave at the same time and medical cover was only available from doctors off site who had to be requested to attend. The ward and trust need to ensure there is clear leadership on the ward with adequate medical cover.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 staff training on pressure sore formation and prevention
Wider context from the report “(2) Since these events staff confirmed at the inquest that they had still not had training on pressure sore formation and prevention.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 prepare care plans for patients at high risk of pressure sore formation
Wider context from the report “(1) Despite a waterlow score on admission confirming she was at high risk of pressure sore formation no care plan was prepared. Staff at the inquest confirmed they had a lack of knowledge about pressure sore formation and how to prevent pressure sores occurring. Staff working on mental health wards dealing with elderly patients must have a clear understanding of basic medical care in particular how pressure sores occur and what steps are required to address those at high 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 Inadequate RMN training on pressure sores
Wider context from the report “(4) Registered Mental Health Nurses at the inquest confirmed their RMN training had not covered the subject of pressure sores in any detail and they felt they had inadequate awareness and knowledge . This is a subject that should be covered in the RMN curriculum.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to act on identified clinical risks
Wider context from the report “(3) Rosemary suite had no leadership at the time. Staff were completing paperwork but not then actioning risks that were identified. The consultant and ward doctor were on leave at the same time and medical cover was only available from doctors off site who had to be requested to attend. The ward and trust need to ensure there is clear leadership on the ward with adequate medical cover.
” 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 Birmingham Cross City CCG commissions the service and is undertaking work to address the identified care deficiencies.
Verbatim wording from the response “It is also a significant concern that at the time of the inquest the organisation involved does not appear to have responded in correcting these issues. We are in communication with Birmingham Cross City CCG which has undertaken a significant amount of work in relation to this case already and who commission the service and will also ensure CQC are aware of the case.” Source location 2015-0291-Responses
Open published response
Concerns raised 3 Lack of auditing and follow-up procedures for vaccination advice systems View source Failure of local healthcare provider systems to capture responsibility for advising all pregnant women about the importance of whooping cough vaccination View source Failure to maintain effective communication links between ante-natal healthcare providers 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
Isabella Rosa Drew · 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
Isabella Rosa Drew was a 29-day-old infant who contracted whooping cough in early September 2014 and died on 9 September 2014; the recorded causes of death were severe acute pneumonia and Bordetella pertussis. The report raised concerns that pregnant women were not consistently offered whooping cough vaccination, and that national guidance did not provide sufficient detail on local procedures, auditing, follow-up, and communication between antenatal healthcare providers.
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 auditing and follow-up procedures for vaccination advice systems
Wider context from the report “(1) consideration needs to be given as to whether there needs to be further and more explicit guidance as to how local healthcare providers ensure systems put in place effectively capture their responsibility to advise all pregnant women of the importance of whooping cough vaccination with provision for auditing and follow up 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 of local healthcare provider systems to capture responsibility for advising all pregnant women about the importance of whooping cough vaccination
Wider context from the report “(1) consideration needs to be given as to whether there needs to be further and more explicit guidance as to how local healthcare providers ensure systems put in place effectively capture their responsibility to advise all pregnant women of the importance of whooping cough vaccination with provision for auditing and follow up 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 maintain effective communication links between ante-natal healthcare providers
Wider context from the report “(2) a need for further national guidance regarding the importance of effective communication links between the various limbs of ante-natal healthcare providers .
” Open source report
14 Jul 2015 Emma Carpenter · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Lack of inpatient beds for mentally ill children and adolescents View source Lack of sustainable long-term commissioning for specialist eating disorder services for children and adolescents View source Lack of clear connections between mental health professionals and education pastoral care staff View source Failure of school nurses to attend multidisciplinary meetings reliably View source Lack of professional links between the specialist Eating Disorder Service and Bassetlaw Hospital 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
Emma Carpenter · 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
Emma Carpenter was treated as an outpatient by child and adolescent mental health services from February 2004 to November 2006 and died from multi-organ failure caused by severe anorexia nervosa. The report identified insufficient physical-health monitoring, lack of specialist paediatric or physician input, and delay in accessing effective inpatient treatment as concerns.
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 inpatient beds for mentally ill children and adolescents
Wider context from the report “2. There remains still a national lack of provision of inpatient beds for mentally ill children and adolescents including those who suffer from eating disorders .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 sustainable long-term commissioning for specialist eating disorder services for children and adolescents
Wider context from the report “1. Although the Trust has now set up a specialist Eating Disorder Service for children and adolescents, there is only short term funding in place for this service and a lack of commitment from Commissioners for its long term future .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of clear connections between mental health professionals and education pastoral care staff
Wider context from the report “4. In the absence of school nurses, there is a lack of clear connections between the mental health professionals and those in the education system who have responsibility for the pastoral care of mentally ill children and adolescents .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 school nurses to attend multidisciplinary meetings reliably
Wider context from the report “3. Although the view of mental health professionals was that it was important for school nurses to attend Multi Disciplinary Meetings to understand and assist with care planning, this does not happen on a regular, reliable basis due to lack of funding for school nurses.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 professional links between the specialist Eating Disorder Service and Bassetlaw Hospital
Wider context from the report “1. The Trust has now set up a specialist Eating Disorder Service for children and adolescents, and reports that although this service now has good professional links with named paediatricians at Kings Mill Hospital and Queen’s Medical Centre, there are no equivalent links with Bassetlaw Hospital .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest £30 million annually to enable CCGs to develop and deliver evidence-based community eating-disorder services.
Verbatim wording from the response “NHS England is investing £30m per year for Clinical Commissioning Groups (CCG’s) to develop and deliver evidence based community Eating Disorder services. This funding is in addition to resources already in place to deliver treatment for young people with eating disorders. In July 2015 NHS England published an access and waiting time standard and commissioning guidance on how the additional funds are to be used to commission evidence based community Eating Disorder services for children and young people (http://www.bing.com/search?q=access+and+waiting+time+standard+for+children+and+young+people+with+an+eating+disorder&src=IE-TopResult&FORM=IE10TR&adlt=strict). This is to support CCG’s preparation to meet a new standard for evidence based eating disorder treatment to be delivered within a maximum of 4 weeks from first contact for routine cases and 2 weeks for urgent cases.” Source location 2015-0276-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 Invest in inpatient CAMHS capacity and increase eating-disorder bed availability in the East Midlands and nationally.
Verbatim wording from the response “Admission into hospital, in the majority of cases, ought to be the result of all community interventions being exhausted. Since NHS England became responsible for commissioning inpatient services in 2013, we have invested financial resources and increased the capacity of inpatient beds both in the East Midlands and across the country to enable greater access to beds at time of clinical need. Working with expert clinicians and service managers, NHS England has developed national service specifications that require acute inpatient mental health units (also known as CAMHS Tier 4 units) for children and young people to manage a range of mental illnesses including eating disorders. In addition, NHS England also commissions specialist inpatient eating disorder units across the country.” Source location 2015-0276-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 Plan a procurement process to commission inpatient beds according to assessed need rather than historical provision.
Verbatim wording from the response “Further to the additional beds already commissioned by NHS England, we are currently in the planning stage of a procurement process which will help to ensure that we commission inpatient beds according to need rather than based on history.” Source location 2015-0276-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 Pilot a single point-of-access programme linking specialist community CAMHS with schools across at least 15 CCGs, including joint NHS and school staff training.
Verbatim wording from the response “• NHS England are about to pilot an initiative with the Department for Education to develop a programme for single points of access in Tier 3 (specialist community) CAMHS and schools, testing it over at least 15 CCGs. The training will be for an identified member of staff from the NHS CAMHS team plus a member of the school staff and additional colleagues such as, Special Educational Needs Co-ordinators, school nurses and counsellors. This is linked to a recommendation from Future in Mind. The Spring Budget allocated £1.5 million to support this pilot over the next year from July 2015 to June 2016.” Source location 2015-0276-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 Commission specialist inpatient eating-disorder units nationally.
Verbatim wording from the response “Admission into hospital, in the majority of cases, ought to be the result of all community interventions being exhausted. Since NHS England became responsible for commissioning inpatient services in 2013, we have invested financial resources and increased the capacity of inpatient beds both in the East Midlands and across the country to enable greater access to beds at time of clinical need. Working with expert clinicians and service managers, NHS England has developed national service specifications that require acute inpatient mental health units (also known as CAMHS Tier 4 units) for children and young people to manage a range of mental illnesses including eating disorders. In addition, NHS England also commissions specialist inpatient eating disorder units across the country.” Source location 2015-0276-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 NHS England understood that inpatient beds were available when the death occurred, disputing a premise of insufficient bed availability.
Verbatim wording from the response “Whilst it is our understanding that there were beds available at the time of this tragic death, NHS England also recognises the importance of appropriate community eating disorder services and gaps in this provision across the country. This is reflected in the recent report of the Children and Young People’s Mental Health Taskforce ‘Future in” Source location 2015-0276-Response-by-NHS-England
Open published response
12 Jun 2015 Marie Gretta Harding · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 3 Lack of trust guidelines for chest drain insertion View source Lack of awareness of on-call weekend availability of interventional radiologists View source Lack of up-to-date training on chest drain insertion 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
Marie Gretta Harding · 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
Marie Gretta Harding, who had chronic obstructive pulmonary disease, was admitted with breathlessness and a left-sided pneumothorax requiring chest drains. A chest drain inserted on 12 October 2014 more likely than not penetrated her left lung, after which she deteriorated and died on 14 October 2014. The inquest identified a lack of Trust guidelines and up-to-date training for chest drain insertion, and unawareness of the availability of an on-call interventional radiologist.
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 trust guidelines for chest drain insertion
Wider context from the report “During the course of the inquest I heard that their was no trust guidelines for the insertion of chest drains , lack of up to date training on chest drain insertion and an unawareness of the existence of the on call weekend availability of interventional radiologist. Although I acknowledge that the Trust has now fully instigated remedial changes in this regard;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 awareness of on-call weekend availability of interventional radiologists
Wider context from the report “During the course of the inquest I heard that their was no trust guidelines for the insertion of chest drains, lack of up to date training on chest drain insertion and an unawareness of the existence of the on call weekend availability of interventional radiologist . Although I acknowledge that the Trust has now fully instigated remedial changes in this regard;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 up-to-date training on chest drain insertion
Wider context from the report “During the course of the inquest I heard that their was no trust guidelines for the insertion of chest drains, lack of up to date training on chest drain insertion and an unawareness of the existence of the on call weekend availability of interventional radiologist. Although I acknowledge that the Trust has now fully instigated remedial changes in this regard;
” Open source report
13 Apr 2015 Hayden Meirion NORTON · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 3 Unavailability of an emergency code protocol for calling an ambulance View source Lack of recorded blood-pressure monitoring View source Failure to inform inmates about screening for aortic aneurysm 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
Hayden Meirion NORTON · 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
Hayden Meirion NORTON, a prisoner at HMP Dartmoor, became unwell with flank pain on 6 January 2014, suffered cardiac arrest, and died after resuscitation attempts. The report states that he died from a ruptured atherosclerotic abdominal aortic aneurysm. Concerns included a lack of recorded blood-pressure monitoring, no record that he had been informed about screening for aortic aneurysm, and a delay in calling an emergency ambulance because HMP Dartmoor did not have an emergency code protocol.
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 an emergency code protocol for calling an ambulance
Wider context from the report “The Deceased was medically assessed whilst an inmate of HMP Albany (now part of HMP Isle of Wight) on 28 September 2006 and known to have extensive and well documented history of high cholesterol, ischaemic heart disease with episodic angina, two previous myocardial infarctions, blood pressure 220/100. But after arrival at HMP Dartmoor on 15 March 2013,
(1) there was no record that his blood pressure was monitored; or
(2) that he had been informed of a screening test for aortic aneurysm.
He died on 6th January 2014 from a ruptured aortic aneurysm at HMP Dartmoor.
(3) There was a delay in calling an emergency ambulance because HMP Dartmoor did not have an emergency code (unlike HMP Exeter) protocol.
There was insufficient evidence to say the above were causative of Mr NORTON’s death but there would have been an awareness of possible problems to come.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 recorded blood-pressure monitoring
Wider context from the report “The Deceased was medically assessed whilst an inmate of HMP Albany (now part of HMP Isle of Wight) on 28 September 2006 and known to have extensive and well documented history of high cholesterol, ischaemic heart disease with episodic angina, two previous myocardial infarctions, blood pressure 220/100. But after arrival at HMP Dartmoor on 15 March 2013,
(1) there was no record that his blood pressure was monitored ; or
(2) that he had been informed of a screening test for aortic aneurysm.
He died on 6th January 2014 from a ruptured aortic aneurysm at HMP Dartmoor.
(3) There was a delay in calling an emergency ambulance because HMP Dartmoor did not have an emergency code (unlike HMP Exeter) protocol.
There was insufficient evidence to say the above were causative of Mr NORTON’s death but there would have been an awareness of possible problems to come.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to inform inmates about screening for aortic aneurysm
Wider context from the report “The Deceased was medically assessed whilst an inmate of HMP Albany (now part of HMP Isle of Wight) on 28 September 2006 and known to have extensive and well documented history of high cholesterol, ischaemic heart disease with episodic angina, two previous myocardial infarctions, blood pressure 220/100. But after arrival at HMP Dartmoor on 15 March 2013,
(1) there was no record that his blood pressure was monitored; or
(2) that he had been informed of a screening test for aortic aneurysm .
He died on 6th January 2014 from a ruptured aortic aneurysm at HMP Dartmoor.
(3) There was a delay in calling an emergency ambulance because HMP Dartmoor did not have an emergency code (unlike HMP Exeter) protocol.
There was insufficient evidence to say the above were causative of Mr NORTON’s death but there would have been an awareness of possible problems to come.
” Open source report
30 Mar 2015 Sabrina Stevenson · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 15 Variation in paramedic training View source Failure to implement or consider automated call recategorisation View source Training case studies failing to cover relevant ectopic pregnancy and transient capacity issues View source Failure to provide call-handlers with feedback on current time-frames View source Failure to address increasing ambulance response times View source Failure of the Manchester Triage System to presume pregnancy for women of child-bearing age with abdominal pain View source Insufficient availability of trained paramedics due to vacant positions View source Shortfalls in the ability to undertake internal investigations View source Failure of pregnancy-related assessment and testing training for women of child-bearing age with abdominal pain View source Insufficient crew knowledge of alternative patient extraction techniques View source Failure to progress a pre-hospital validated early warning score system View source Failure to implement or consider clinical re-triaging View source Failure to address increasing ambulance response times View source Lack of steps to take forward a pre-hospital validated early warning score system View source Unaddressed ambulance service staffing vacancies View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sabrina Stevenson · 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
Sabrina Stevenson, aged 28, died on 16 December 2012 from a ruptured ectopic pregnancy after delays in ambulance response and assessment. The report identified concerns about ambulance response times, staffing vacancies, outstanding training issues, the absence of certain call-handling and clinical systems, pre-hospital assessment, extraction techniques, and governance processes.
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 Variation in paramedic training
Wider context from the report “(3) A related issue was raised at the inquest, regarding whether the increasingly complex clinical role of paramedics means that they should be recruited through graduate, rather than vocational schemes. I am sufficiently concerned by the apparent variation in training that I consider this issue to warrant consideration;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to implement or consider automated call recategorisation
Wider context from the report “(4) The potential for systems improvements, such as automated recategorisation , clinical re-triaging and feedback to call-handlers regarding current time-frames were raised during the inquest. These are issues which, if not implemented could risk future deaths and I remain concerned that they have apparently not been implemented or considered by LAS;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Training case studies failing to cover relevant ectopic pregnancy and transient capacity issues
Wider context from the report “(3) Several training issues were prominent at the inquest and evidence has been provided as to how some issues have been addressed. However, I am concerned that some training issues remain outstanding;
(a) I heard from the consultant Gynaecologist that all women of child-bearing age, with abdominal pain, should be considered to be pregnant, until proven otherwise through pregnancy testing. This contrasts with the training material provided by LAS and also with their stance on not (currently) testing for pregnancy on the scene;
(b) Given the issues raised by the independent expert regarding extraction techniques, I remain concerned that the crews had insufficient knowledge of alternatives steps, which could have been taken to remove Sabrina to the ambulance;
(c) Evidence has been provided that specific training ‘case studies’ will be or have been published on the issues of ectopic pregnancy and transient capacity. Given that issues arose during the inquest, as to whether such case studies appropriately covered the relevant points , I seek confirmation that these case studies have been published (through provision of copies), so that I can be reassured that these training issues have been addressed ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide call-handlers with feedback on current time-frames
Wider context from the report “(4) The potential for systems improvements, such as automated recategorisation, clinical re-triaging and feedback to call-handlers regarding current time-frames were raised during the inquest. These are issues which, if not implemented could risk future deaths and I remain concerned that they have apparently not been implemented or considered by LAS;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 address increasing ambulance response times
Wider context from the report “(1) Ambulance response times were the focus of evidence provided at the inquest. The most recent available response times show a worsening picture and submissions to date from LAS set out only a proposed investment business case’ as to how resources can be freed-up. I have not been provided with the details of this proposal. I am not satisfied that sufficient steps have been taken to demonstrate that the risk of future deaths, from increasing response times, has been 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 of the Manchester Triage System to presume pregnancy for women of child-bearing age with abdominal pain
Wider context from the report “(4) Concern has been raised by Sabrina’s family, with whom I concur, that the Manchester Triage System should reflect the evidence of the consultant Gynaecologist ; that any woman of child-bearing age with abdominal pain should be presumed to be pregnant, until proven otherwise by pregnancy testing .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 trained paramedics due to vacant positions
Wider context from the report “(2) I am concerned by evidence provided from LAS that there are 400 vacant positions within the Trust . This connotes a significant recruitment issue for the profession , which could risk future deaths occurring simply through a lack of available trained paramedics ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Shortfalls in the ability to undertake internal investigations
Wider context from the report “(6) Substantial concerns were raised in the inquest regarding LAS’ governance processes, specifically regarding its ability to undertake internal investigations . Attempts were made to address this but more recent evidence submitted demonstrates that significant shortfalls remain . It is clear that the Trust are taking further steps to address this; however, more detailed information as to time-frames and progress in this regard are required.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 pregnancy-related assessment and testing training for women of child-bearing age with abdominal pain
Wider context from the report “(3) Several training issues were prominent at the inquest and evidence has been provided as to how some issues have been addressed. However, I am concerned that some training issues remain outstanding;
(a) I heard from the consultant Gynaecologist that all women of child-bearing age, with abdominal pain, should be considered to be pregnant, until proven otherwise through pregnancy testing. This contrasts with the training material provided by LAS and also with their stance on not (currently) testing for pregnancy on the scene ;
(b) Given the issues raised by the independent expert regarding extraction techniques, I remain concerned that the crews had insufficient knowledge of alternatives steps, which could have been taken to remove Sabrina to the ambulance;
(c) Evidence has been provided that specific training ‘case studies’ will be or have been published on the issues of ectopic pregnancy and transient capacity. Given that issues arose during the inquest, as to whether such case studies appropriately covered the relevant points, I seek confirmation that these case studies have been published (through provision of copies), so that I can be reassured that these training issues have been 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 Insufficient crew knowledge of alternative patient extraction techniques
Wider context from the report “(3) Several training issues were prominent at the inquest and evidence has been provided as to how some issues have been addressed. However, I am concerned that some training issues remain outstanding;
(a) I heard from the consultant Gynaecologist that all women of child-bearing age, with abdominal pain, should be considered to be pregnant, until proven otherwise through pregnancy testing. This contrasts with the training material provided by LAS and also with their stance on not (currently) testing for pregnancy on the scene;
(b) Given the issues raised by the independent expert regarding extraction techniques, I remain concerned that the crews had insufficient knowledge of alternatives steps, which could have been taken to remove Sabrina to the ambulance ;
(c) Evidence has been provided that specific training ‘case studies’ will be or have been published on the issues of ectopic pregnancy and transient capacity. Given that issues arose during the inquest, as to whether such case studies appropriately covered the relevant points, I seek confirmation that these case studies have been published (through provision of copies), so that I can be reassured that these training issues have been 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 progress a pre-hospital validated early warning score system
Wider context from the report “(5) The potential for an ‘early warning score’ system, which is specifically validated for pre-hospital use, was welcomed by LAS but without further evidence as to how this might be taken forward by the Trust, in collaboration with other agencies . Further steps in this regard are required in my view ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to implement or consider clinical re-triaging
Wider context from the report “(4) The potential for systems improvements, such as automated recategorisation, clinical re-triaging and feedback to call-handlers regarding current time-frames were raised during the inquest. These are issues which, if not implemented could risk future deaths and I remain concerned that they have apparently not been implemented or considered by LAS;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 address increasing ambulance response times
Wider context from the report “(1) Ambulance response times were the focus of evidence provided at the inquest. The most recent available response times show a worsening picture and submissions to date from LAS set out only a proposed ‘investment business case’ as to how resources can be freed-up. I have not been provided with the details of this proposal. I am not satisfied that sufficient steps have been taken to demonstrate that the risk of future deaths, from increasing response times, has been 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 Lack of steps to take forward a pre-hospital validated early warning score system
Wider context from the report “(1) The potential for an ‘early warning score’ system, which is specifically validated for pre-hospital use, was welcomed by LAS but without further evidence as to how this might be taken forward by the Trust, in collaboration with other agencies . Further steps in this regard are required in my view and I believe that the College of Paramedics may be in a position to assist in this process;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unaddressed ambulance service staffing vacancies
Wider context from the report “(2) A related issue about which I am also concerned is that LAS set out that there are 400 vacant positions , without further detail as to what steps are being taken to address this shortfall ;
” 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 Assure delivery of the LAS Improvement Programme through the NHS England LAS Oversight Group and regular assurance of the lead commissioner.
Verbatim wording from the response “NHS England and the CCGs undertook a systematic review of the staffing and operational delivery of the London Ambulance Service from January to March 2015. Through the annual contract, CCGs have now invested an additional £19m in an LAS Improvement Programme for 2015/16. This programme will ensure appropriate staffing numbers to enable the delivery of national targets and the timely arrival of ambulances or other LAS resources to patients in need. Implementation of the programme will be governed by an LAS Contracts and Performance Group. The Group will review achievement of a number of metrics including ambulance response times. NHS England will assure delivery through the NHS England LAS Oversight group during 2015/16 and regular assurance of the lead commissioner - Brent CCG.” Source location 2015-0126-Response-by-NHS-England1
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 LAS operational performance weekly and agree additional actions to maintain resilience and improve ambulance response times.
Verbatim wording from the response “LAS undertook a number of steps to ensure the service remained resilient, safe and to secure improved ambulance response times in 2015. I will cover each step in turn:” Source location 2015-0126-Response-by-NHS-England1
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 Monitor LAS ambulance response-time and utilisation performance through the LAS Contracts and Performance Group during 2015/16.
Verbatim wording from the response “NHS England and the CCGs undertook a systematic review of the staffing and operational delivery of the London Ambulance Service from January to March 2015. Through the annual contract, CCGs have now invested an additional £19m in an LAS Improvement Programme for 2015/16. This programme will ensure appropriate staffing numbers to enable the delivery of national targets and the timely arrival of ambulances or other LAS resources to patients in need. Implementation of the programme will be governed by an LAS Contracts and Performance Group. The Group will review achievement of a number of metrics including ambulance response times. NHS England will assure delivery through the NHS England LAS Oversight group during 2015/16 and regular assurance of the lead commissioner - Brent CCG.” Source location 2015-0126-Response-by-NHS-England1
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission and complete a diagnostic review of the key operational drivers of LAS underperformance, including utilisation and vehicle-hour constraints.
Verbatim wording from the response “NHS England, London Region and TDA also commissioned a diagnostic review of the key drivers of underperformance. The key findings were that utilisation of the service had increased significantly so impacting on the operational capability of the service. Utilisation levels are driven by the number of Category A incidents, the job cycle time and the number of vehicle hours. During the last year, the level of Category A incidents had risen and available vehicle hours had reduced and the nominal net turnover rate was rising. The requirement to reduce utilisation rates became a key objective for securing medium and long term resilience of the service. The business case agreed by London CCGs and the TDA aims to improve ambulance response times on a sustainable basis by reducing vehicle utilisation to optimal levels.” Source location 2015-0126-Response-by-NHS-England1
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 steps taken are considered sufficient to address the risk of future deaths from increasing ambulance response times.
Verbatim wording from the response “I was very sorry to learn of the death of Sabrina Stevenson through your Regulation 28 report. I hope that my response has given you assurance that NHS England has taken sufficient steps to demonstrate that the risk of future deaths, from increasing response times, has been addressed.” Source location 2015-0126-Response-by-NHS-England1
Open published response
25 Mar 2015 Keith John MURPHY · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Lack of defibrillator-use familiarisation for prison officers and staff with direct access to prisoners View source Limited availability of healthcare staff beyond 7am–6.30pm View source Lack of basic first aid training for prison officers and staff with direct access to prisoners View source Lack of CPR training for prison officers and staff with direct access to prisoners 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
Keith John MURPHY · 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
Keith John Murphy became physically ill in prison after using SPICE and was later found on his cell floor, where he was pronounced dead on 18 July 2013. The report raises concerns about basic first aid, CPR and defibrillator training for prison staff, and the availability of Healthcare staff outside the hours of 7am to 6.30pm.
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 defibrillator-use familiarisation for prison officers and staff with direct access to prisoners
Wider context from the report “1. Action is required to ensure that Prison Officers and Staff with direct access to prisoners have basic first aid training, CPR training and familiarisation with the use of a defibrillator.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Limited availability of healthcare staff beyond 7am–6.30pm
Wider context from the report “2. Action is required to ensure someone from Healthcare is available beyond the current arrangement of 7am – 6.30pm to provide an
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 basic first aid training for prison officers and staff with direct access to prisoners
Wider context from the report “1. Action is required to ensure that Prison Officers and Staff with direct access to prisoners have basic first aid training , CPR training and familiarisation with the use of a defibrillator.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 CPR training for prison officers and staff with direct access to prisoners
Wider context from the report “1. Action is required to ensure that Prison Officers and Staff with direct access to prisoners have basic first aid training, CPR training and familiarisation with the use of a defibrillator.
” 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