9 Mar 2015 Craig Douglas Bell · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 7 Failure to use CCTV monitoring as an adjunct to ACCT observation procedures View source Failure to share timely information about risk and suicidal or self-harming behaviour between clinical and HMPS staff View source Lack of psychological therapy identification and treatment for prisoners with personality disorders or related traits View source Lack of suitably senior psychiatric clinician attendance at discharge case reviews View source Insufficient availability of safer cells across prison wings for prisoners on ACCT View source Unavailability of cells or facilities fitted with CCTV monitoring View source Lack of graduated risk management planning after transfer to an ordinary wing location View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Craig Douglas Bell · 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
Craig Douglas Bell was found dead in his cell at HMP Manchester on 13 December 2012 after taking his own life by hanging using a self-constructed ligature. He had a history of self-harm and suicidal ideation and was subject to ACCT procedures. The principal concerns included inadequate sharing of risk information, insufficient senior psychiatric involvement in discharge planning, the lack of a graduated risk-management plan, and limited availability of safer or CCTV-monitored cells for prisoners at risk of suicide.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to use CCTV monitoring as an adjunct to ACCT observation procedures
Wider context from the report “6. In 2011 there were a limited number of cells which had been fitted with CCTV monitoring cameras. Very sadly Anthony Raymond Gillard was found dead in such a cell on the 24 December 2011 but that the use of CCTV was not part of his observation regime although he was subject to ACCT procedures . No one looked at or considered the CCTV pictures until after his death but they clearly demonstrated that he had been suffering the effects of over sedation from opiate drugs which no witness had seen or noticed. The use of CCTV monitored cells was discontinued after his death and was not available at the time of Mr Bell’s death . One reason given was that if they were used it required a Prison Officer to be monitoring the CCTV images constantly 24 hours a day. They could , of course , be used as an adjunct or in addition to usual ACCT observation procedures. This would not require constant CCTV monitoring. NOMS have replied to the court’s Regulation 28 PFD report and a copy is attached. I am concerned that if such cells/facilities are not provided and used then there is a risk that prisoners on ACCT’s will continue to be able to kill themselves. The same considerations would apply nationally to the entire HMPS estate. I attach copies of the NOMS response to my Regulation 28 PFD and letter under paragraphs 37/38 of the Chief Coroner’s guidance in relation to Mr Gillard’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to share timely information about risk and suicidal or self-harming behaviour between clinical and HMPS staff
Wider context from the report “2. I am concerned that the appropriate sharing of information relating to risk and suicidal or self harming behaviour did not take place between the clinical team and HMPS staff . For example, the direct threat of suicide made at the review on the 27 November 2012 was not disclosed to HMPS staff. Appropriate, timely mutual information exchange had not taken place and there is a concern that this may be vital but may be overlooked if steps are not taken to make this a matter of routine. It means that clinical staff have to be able to review the clinical record appropriately and share information with their HMPS colleagues.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 psychological therapy identification and treatment for prisoners with personality disorders or related traits
Wider context from the report “1. The evidence established a significant unmet need for psychological therapies to treat patient prisoner suffering from personality disorders or those suffering from traits of such personality disorders. These prisoners are recognised as being at higher risk of self harm ( which may ultimately result in death ) or suicide. Without NHS Commissioners allocating more resources to identifying and treating such patients there is a concern that further prisoners suffering from these conditions will end up deliberately or accidentally killing themselves.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 suitably senior psychiatric clinician attendance at discharge case reviews
Wider context from the report “3. I am concerned at the lack of attendance of the Consultant Psychiatrist or a suitably qualified and experienced junior colleague at the discharge case review/meeting . In a case of patient still on an ACCT and being discharged to an ordinary wing location without as senior clinician being able to attend and participate in the discharge case review , risk assessment at that stage and risk planning. In this case there was no attendance on the 6 December 2012 and no clinician had seen him since 27 November 2012. This would allow a more sophisticated and timely assessment of risk at that time. Measures to try and reduce or mitigate the risks could then be discussed and put in place in a graduated manner. It is appreciated that such case reviews may have to be rearranged so as to facilitate full attendance. The court has previously identified the concern arising from that fact that no senior clinician took the opportunity at the appropriate time to stand back and take an overall view of the entire circumstances and the risks presented.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 safer cells across prison wings for prisoners on ACCT
Wider context from the report “5. At the present time the HCC caters for some 22 patient prisoners and has 10 safer cells. I am concerned that the prison has a very limited number of safer cells on a limited number of other wings . At the present time there are no safer cells on all the wings ( invariably single occupancy designed to minimise the risk of using ligatures ). If prisoners are subject to ACCT’s and either transferred from one wing to another or transferred from the HCC to an ordinary wing location ( for what ever reason ) there is no half way house facility providing increased levels of safety . The provision of safer cells has demonstrably reduced the opportunity for fatal self harming in the over whelming majority of cases. Without HMPS investing in the provision of safer cells on every wing or of an increased number of wings there is a concern that prisoners will continue to kill themselves in non safer cells when they are on ACCT’s. The same considerations would apply nationally to the entire HMPS estate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 cells or facilities fitted with CCTV monitoring
Wider context from the report “6. In 2011 there were a limited number of cells which had been fitted with CCTV monitoring cameras. Very sadly Anthony Raymond Gillard was found dead in such a cell on the 24 December 2011 but that the use of CCTV was not part of his observation regime although he was subject to ACCT procedures. No one looked at or considered the CCTV pictures until after his death but they clearly demonstrated that he had been suffering the effects of over sedation from opiate drugs which no witness had seen or noticed. The use of CCTV monitored cells was discontinued after his death and was not available at the time of Mr Bell’s death . One reason given was that if they were used it required a Prison Officer to be monitoring the CCTV images constantly 24 hours a day. They could , of course , be used as an adjunct or in addition to usual ACCT observation procedures. This would not require constant CCTV monitoring. NOMS have replied to the court’s Regulation 28 PFD report and a copy is attached. I am concerned that if such cells/facilities are not provided and used then there is a risk that prisoners on ACCT’s will continue to be able to kill themselves. The same considerations would apply nationally to the entire HMPS estate. I attach copies of the NOMS response to my Regulation 28 PFD and letter under paragraphs 37/38 of the Chief Coroner’s guidance in relation to Mr Gillard’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of graduated risk management planning after transfer to an ordinary wing location
Wider context from the report “4. I am concerned by the lack of planning or consideration of a graduated risk management plan in such circumstances . This was identified by the clinical reviewer. In other words increased frequency of day time interactions and throughout the whole day and MHIT and Psychiatrist contacts very shortly after the move . In this case the deceased was on the waiting list for a MHIT contact and was due to be seen within 2 weeks by the Psychiatrist.
” Open source report
Concerns raised 1 GPs' interpretation of patient confidentiality preventing concerned family members from passing pertinent information about vulnerable persons at potential risk of suicide 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
Colin Tyson · 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
Colin Tyson attempted suicide by carbon monoxide poisoning on 6 August 2014 and was resuscitated. On 11 August 2014, he stepped in front of a high-speed train and died from the impact. The principal concern was that GPs’ interpretation of patient confidentiality could prevent concerned family members from passing on pertinent information about vulnerable people at risk of suicide.
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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 GPs' interpretation of patient confidentiality preventing concerned family members from passing pertinent information about vulnerable persons at potential risk of suicide
Wider context from the report “(1) Concern regarding GPs interpretation of patient confidentiality preventing concerned family members passing pertinent information regarding vulnerable persons who are potentially at risk of suicide .
” Open source report
Concerns raised 2 Failure to use a consistent approach during patient assessment View source Lack of nationally agreed standard assessment forms for cross-organisational mental health transfers 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
Simion Costin · 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
Simion Costin died at Leicester Royal Infirmary on 25 March 2014 after admission with a self-inflicted neck incision, having attended the hospital twice in the preceding four days and been discharged after mental health assessments. Concerns included inconsistent approaches to patient assessment and the second discharge plan being based on incomplete data, with communication challenges when care crossed hospital or regional boundaries.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to use a consistent approach during patient assessment
Wider context from the report “(1) Evidence was heard that during patient assessment, the same approach was not adopted by all clinicians . As a result standardised assessments forms have now been developed and are being used within the Leicestershire Partnership Trust. This includes the need to involve family / friends in the assessment (with the consent of the patient). However, it was recognised that mental health care often crosses borders with an initial assessment made in a neighbouring hospital but then the patient transferred for care and treatment elsewhere. The Consultant gave evidence that it would be better if there were nationally agreed standard forms so that communication in these complex situations is best served.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 nationally agreed standard assessment forms for cross-organisational mental health transfers
Wider context from the report “(1) Evidence was heard that during patient assessment, the same approach was not adopted by all clinicians. As a result standardised assessments forms have now been developed and are being used within the Leicestershire Partnership Trust. This includes the need to involve family / friends in the assessment (with the consent of the patient). However, it was recognised that mental health care often crosses borders with an initial assessment made in a neighbouring hospital but then the patient transferred for care and treatment elsewhere . The Consultant gave evidence that it would be better if there were nationally agreed standard forms so that communication in these complex situations is best served .
” Open source report
Concerns raised 2 Failure of software programs to provide interruptive alerts for important diagnosed conditions View source Lack of adequate training on the use of electronic software systems 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
Alan Vaughan Jones · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alan Vaughan Jones had Addison’s disease and became unable to take his steroid medication after developing gastroenteritis. His condition deteriorated, and he died at 08.50 hours on 8 April 2011; the inquest concluded that Addison’s Disease resulted from neglect. Concerns included inadequate training in the use of electronic patient-record software and failures of the software to highlight important diagnosed conditions as alerts.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of software programs to provide interruptive alerts for important diagnosed conditions
Wider context from the report “(2) An apparent failure in the software programs themselves to highlight important diagnosed conditions as an alert, when the patient record is opened and to prevent any further steps being taken to navigate the program (and make any entries) without consciously closing the “alert” first .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 adequate training on the use of electronic software systems
Wider context from the report “(1) An apparent lack of adequate training on the use of the software systems . This meant that important clinical information could not be made available easily . The expert GP gave evidence that this training deficit was not uncommon . He had the experience of using 4 different software programs in his career and had identical issues over lack of training .
” Open source report
2 Feb 2015 Kimberley Lauren Lindfield · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 6 Lack of a written protocol defining increased observations and required recording View source Lack of auditing of the appropriateness and timeliness of responses to mental health assessment presentations View source Failure to assign clear responsibility for recording increased observations View source Failure to ensure nursing and clinical staff understand their record-keeping responsibilities View source Lack of written guidance for clinical review and care-plan changes in response to new risks View source Lack of periodic audits of record keeping in similar cases 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
Kimberley Lauren Lindfield · 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
Kimberley Lauren Lindfield, who had a history of mental health problems and self-harm, was admitted to hospital after taking an overdose. While on Ward A10, she was found hanging from a dressing gown cord and died several days later after suffering severe brain damage. The principal concerns were failures to arrange a timely mental health assessment, record and respond to increased self-harm observations and risk information, maintain appropriate clinical management, and ensure staff followed relevant referral policies.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a written protocol defining increased observations and required recording
Wider context from the report “2. Whenever an increased level of observations is initiated pending a mental health assessment because of the concern about a patient’s mental state and/or self harm/suicidal behaviour there should be a clear written policy or protocol setting out what those observations actually involve (e.g. what 1 in every 15 minutes means and precisely what should be recorded) and the recording of them with a clear chain of responsibility with the obligation on one appropriate member of staff to ensure that this is done. I am concerned that at present such does not exist .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 of the appropriateness and timeliness of responses to mental health assessment presentations
Wider context from the report “1. I am told that all patients presenting with symptoms of mental illness/mental disorder and/or after reported self harm/suicidal behaviour will now be automatically referred for a mental health assessment to be conducted as soon as possible whether that referral is from A& E or any ward. Pending that assessment, mental health staff can give advice by phone concerning the patients interim care and management. Both UHSM and MHSC provided evidence about a joint understanding and approach as well as a training and induction of staff. GMW may also be involved in such a case. That was to a very large extent the assurance I was provided after the death of Mr Dean. There were no plans or thoughts to audit whether or not in practice there was an appropriate and timely response to such presentations to ensure that the new system was actually working. In view of the history I am concerned that without such an auditing process failures of care may take place as identified above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 clear responsibility for recording increased observations
Wider context from the report “2. Whenever an increased level of observations is initiated pending a mental health assessment because of the concern about a patient’s mental state and/or self harm/suicidal behaviour there should be a clear written policy or protocol setting out what those observations actually involve (e.g. what 1 in every 15 minutes means and precisely what should be recorded) and the recording of them with a clear chain of responsibility with the obligation on one appropriate member of staff to ensure that this is done . I am concerned that at present such does not exist .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 nursing and clinical staff understand their record-keeping responsibilities
Wider context from the report “4. I am concerned that all UHSM Nursing and Clinical staff should be reminded of their responsibilities for good quality record keeping as an essential part of patient care and that there are periodic audits of record keeping in similar cases to ensure that appropriate standards are being met.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 written guidance for clinical review and care-plan changes in response to new risks
Wider context from the report “3. I am concerned that there is currently no written protocol or guidance where there is an appropriate clinical review and there should be a change in the care and management plan in response to new or changed circumstances or new risks .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of periodic audits of record keeping in similar cases
Wider context from the report “4. I am concerned that all UHSM Nursing and Clinical staff should be reminded of their responsibilities for good quality record keeping as an essential part of patient care and that there are periodic audits of record keeping in similar cases to ensure that appropriate standards are being met .
” Open source report
9 Jan 2015 Annette Charlton · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Almost identical medication boxes 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
Annette Charlton · 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
Annette Charlton, who had emphysema and lung fibrosis requiring continuous oxygen therapy, was dispensed Naproxen instead of prescribed antibiotics and died on 28 September 2014. The principal concern was that medication manufacturers used almost identical packaging, which was considered likely to contribute to dispensing errors and potentially patient deaths.
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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 Almost identical medication boxes
Wider context from the report “(1) Manufacturers are able to produce medication in almost identical boxes which is very likely to contribute to dispensing errors and potentially patient deaths.
” Open source report
Concerns raised 5 Lack of a computer-driven system to flag prescription non-attendance View source Lack of a specific policy for prisoners requiring 24-hour medical observation where constant medical supervision is unavailable View source Lack of a computer-driven system to flag lapsed prescriptions View source Distance and waiting times inhibiting prisoner attendance at the medical centre View source Failure of welfare checks to ascertain death 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
Jason Edward Lawson · 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
Jason Edward Lawson, who had epilepsy and schizophrenia, was found dead in his prison cell at HMP Stocken on 17 March 2013; the time of death was uncertain but likely late on 16 March or early on 17 March. Concerns included welfare checks that did not establish that he had died, systems that did not reliably identify medication non-attendance or lapsed prescriptions, access delays to healthcare, and the absence of a specific policy for 24-hour medical observation where constant medical supervision was unavailable.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a computer-driven system to flag prescription non-attendance
Wider context from the report “3. The current system relies on healthcare staff/pharmacy staff recognising that prisoners have not attended to collect their prescription , without having a computer driven system to flag up non-attendance .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 specific policy for prisoners requiring 24-hour medical observation where constant medical supervision is unavailable
Wider context from the report “5. There is no specific policy to deal with the situation where a prisoner needs 24 hour observation from medical staff where the prison is not equipped for constant medical supervision .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 computer-driven system to flag lapsed prescriptions
Wider context from the report “4. The current system relies on healthcare staff/pharmacy staff recognising that prescriptions have lapsed without having a computer driven system to flag it up .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Distance and waiting times inhibiting prisoner attendance at the medical centre
Wider context from the report “2. On some wings there is still some distance to walk to the medical centre and the time to wait mitigates against prisoners bothering to do attend .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of welfare checks to ascertain death
Wider context from the report “1. The welfare check did not ascertain that he had died . He was certainly dead at the time of the check at 7.30am and 8.20am on the 17th March.
” Open source report
19 Dec 2014 Ms Samia Yasmin Shara · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 2 Lack of auditability of long and complex 999 and 111 calls View source Failure to prevent call takers from downgrading calls to lower-acuity pathways 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
Ms Samia Yasmin Shara · 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
Ms Samia Yasmin Shara, aged 15, died from acute heart failure caused by an aneurysm of the aortic sinus and a ruptured cusp of the aortic valve, following an undiagnosed congenital heart problem. Her brother made calls to 999 and 111, but the seriousness of her condition was not recognised until the final 999 call, delaying emergency ambulance services. Concerns included the audit of complex 999 and 111 calls and preventing call takers from downgrading calls to a lower-acuity pathway.
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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 auditability of long and complex 999 and 111 calls
Wider context from the report “(1) That long and complex calls made to 999 and 111 should be available for audit by the CCG to identify learning opportunities and thus improve outcomes via a quality assurance 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 Failure to prevent call takers from downgrading calls to lower-acuity pathways
Wider context from the report “(2) That call takers should not be able to downgrade a call by moving to a pathway of lower acuity .
” Open source report
18 Dec 2014 John Derek Stabler · Prevention of Future Deaths report Central Lincolnshire
View report summary
Concerns raised 2 Inadequacy of the Prisoner Escort Record View source Unavailability of System 1 medical records in specified reception units 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
John Derek Stabler · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Derek Stabler was found hanging in a cell at HMP Lincoln on 4 March 2013 and died in Lincoln County Hospital on 6 March 2013. The substantive concerns were the need to review and redesign the Prisoner Escort Record and to ensure medical records were available at HMP North Sea Camp and HMP Lincoln.
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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 Inadequacy of the Prisoner Escort Record
Wider context from the report “(i) That there is a need for the Prisoner Escort Record to be reviewed and redesigned
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 System 1 medical records in specified reception units
Wider context from the report “(II) The requirements for System 1 (Medical Records) to be made available in Reception at HMP North Sea Camp and in The Care and Reception Unit at HMP Lincoln
” Open source report
25 Nov 2014 Sophie RYAN-PALMER and 3 others · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Lack of disease-specific national benchmarking for autologous stem cell engraftment recovery View source Failure to make relevant international SIOPEN trial results publicly available View source Lack of an appropriate national control risk group with a national lead for autologous stem cell transplant governance 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
Sophie RYAN-PALMER and 3 others · 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
Four children died in 2013 following treatment at the National Hospital for Sick Children at Great Ormond Street in London. They had been treated with stem cell transplants, and a possible problem with cryopreservation of the stem cells later emerged. Concerns included the lack of national governance and disease-specific benchmarking for autologous stem cell engraftment, which made it difficult to identify abnormal recovery and could compromise the optimal care of some children with cancer.
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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 disease-specific national benchmarking for autologous stem cell engraftment recovery
Wider context from the report “1. I heard at inquest that there is concern within the medical community over the whole governance structure for autologous stem cell transplant in this country, most especially regarding the lack of any one appropriate control risk group with a national lead.
2. I also heard that there is at present no disease specific national benchmarking available for autologous stem cell engraftment . The relevant results of an international SIOPEN trial (that aspect of which closed in 2011) have not been made publicly available.
Those treating children following autologous bone marrow transplant, do not know how many days to recovery is normal, so they do not know what is abnormal, and whether the results in their own hospital fall below the results elsewhere .
The failure to unlock the results of the SIOPEN trial could, therefore, compromise the optimal care of some children with cancer.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 make relevant international SIOPEN trial results publicly available
Wider context from the report “1. I heard at inquest that there is concern within the medical community over the whole governance structure for autologous stem cell transplant in this country, most especially regarding the lack of any one appropriate control risk group with a national lead.
2. I also heard that there is at present no disease specific national benchmarking available for autologous stem cell engraftment. The relevant results of an international SIOPEN trial (that aspect of which closed in 2011) have not been made publicly available .
Those treating children following autologous bone marrow transplant, do not know how many days to recovery is normal, so they do not know what is abnormal, and whether the results in their own hospital fall below the results elsewhere.
The failure to unlock the results of the SIOPEN trial could, therefore, compromise the optimal care of some children with cancer.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 an appropriate national control risk group with a national lead for autologous stem cell transplant governance
Wider context from the report “1. I heard at inquest that there is concern within the medical community over the whole governance structure for autologous stem cell transplant in this country , most especially regarding the lack of any one appropriate control risk group with a national lead .
2. I also heard that there is at present no disease specific national benchmarking available for autologous stem cell engraftment. The relevant results of an international SIOPEN trial (that aspect of which closed in 2011) have not been made publicly available.
Those treating children following autologous bone marrow transplant, do not know how many days to recovery is normal, so they do not know what is abnormal, and whether the results in their own hospital fall below the results elsewhere.
The failure to unlock the results of the SIOPEN trial could, therefore, compromise the optimal care of some children with cancer.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a national oncology expert group to review research and cases and inform transplant indications, protocols, audit and benchmarking.
Verbatim wording from the response “3. Establishment of a new national expert group: NHS England has agreed with the Paediatric Cancer Clinical Reference Group (CRG) and JACIE to establish a national oncology group of experts systematically reviewing research and cases to inform indications, protocols and benchmarking. We consider that this will enhance governance and reduce the risk of future deaths occurring. The Paediatric Cancer CRG is leading the establishment of this group, with the first meeting being planned for February 2015. This group will report on a review of the indications for autologous transplants for solid tumours and advise on any changes required to the clinical commissioning policy. The group will also review individual cases and act as the forum for audit and benchmarking.” Source location 2014-0520-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 Enhance expert-group reporting to the BSBMT registry to strengthen benchmarking and support NHS England’s Quality Dashboard.
Verbatim wording from the response “4. Improved reporting: This expert oncology group will enhance the current reporting into the BSBMT registry to enhance the benchmarking through this route. This will in turn support the ongoing development and refinement of the NHS England Quality Dashboard, which we use as a key tool to compare outcomes and identify good practice.” Source location 2014-0520-Response-by-NHS-England
Open published response
19 Nov 2014 George Christian Werb · Prevention of Future Deaths report Exeter & Greater Devon
View report summary
Concerns raised 4 Failure to provide locally accessible child psychiatric inpatient care View source Insufficient availability of child psychiatric inpatient beds View source Ineffective multidisciplinary CPA meeting participation and communication View source Lack of an effective bed bureau system for identifying child psychiatric bed spaces View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
George Christian Werb · 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 Christian Werb was receiving inpatient treatment for serious mental health issues and died after walking onto a railway track near his home while on home leave. The report raises concerns about the distant placement, inadequate risk assessment, poor communication and engagement with the family, and insufficient local child psychiatric beds.
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 locally accessible child psychiatric inpatient care
Wider context from the report “(1) The community team had to spend much time making numerous telephone calls to locate a child psychiatric bed. There was not at the time, and still appears to be no, or no effective bed bureau system to identify spaces. This is wasteful of clinician time, creates inevitable delays and is indicative that there are routinely too few available beds to serve the needs of our child psychiatric patients.
(2) On a previous admission during May 2014 the bed located was in Hurncombe, and George was removed by his father as the bedroom had inadequate furniture, had no bed linen and there was concern the environment was adding to George’s distress. The distance between home and this placement was in excess of 3 hours travel time.
(3) On the index admission, George was placed in the Priory Hospital, Southampton, a distance of over 2 hours travelling time from home. This is not an NHS facility and is specifically for “overflow” patients from all across England, many of whom are therefore huge distances from their home, their family, their friends and community support.
(4) Due to the distance, the hospital made the decision that family therapy could not take place (although the parents would have engaged if the importance of this was explained) and periods of home leave were extended due to travelling times, rather than in response to clinical need.
(5) There was poor attendance at the CPA meeting, and both parents and the community team only “attended” by telephone, which was far from ideal and impacted on the effectiveness of communication between all parties.
(6) Having local accessibility where in patient care is required was recognized in the Mental Health Crisis Care Concordat published 18 February 2014 to be important to keep the young person close to home, school and friends and this was also recognized by all the clinicians at request to be important and necessary. With current provision of beds this need is not being met, and is impacting on patient care.
(7) In this case I consider the distance of the unit directly contributed to the circumstances that led to George’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of child psychiatric inpatient beds
Wider context from the report “(1) The community team had to spend much time making numerous telephone calls to locate a child psychiatric bed. There was not at the time, and still appears to be no, or no effective bed bureau system to identify spaces. This is wasteful of clinician time, creates inevitable delays and is indicative that there are routinely too few available beds to serve the needs of our child psychiatric patients.
(2) On a previous admission during May 2014 the bed located was in Hurncombe, and George was removed by his father as the bedroom had inadequate furniture, had no bed linen and there was concern the environment was adding to George’s distress. The distance between home and this placement was in excess of 3 hours travel time.
(3) On the index admission, George was placed in the Priory Hospital, Southampton, a distance of over 2 hours travelling time from home. This is not an NHS facility and is specifically for “overflow” patients from all across England, many of whom are therefore huge distances from their home, their family, their friends and community support.
(4) Due to the distance, the hospital made the decision that family therapy could not take place (although the parents would have engaged if the importance of this was explained) and periods of home leave were extended due to travelling times, rather than in response to clinical need.
(5) There was poor attendance at the CPA meeting, and both parents and the community team only “attended” by telephone, which was far from ideal and impacted on the effectiveness of communication between all parties.
(6) Having local accessibility where in patient care is required was recognized in the Mental Health Crisis Care Concordat published 18 February 2014 to be important to keep the young person close to home, school and friends and this was also recognized by all the clinicians at request to be important and necessary. With current provision of beds this need is not being met , and is impacting on patient care.
(7) In this case I consider the distance of the unit directly contributed to the circumstances that led to George’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Ineffective multidisciplinary CPA meeting participation and communication
Wider context from the report “(1) The community team had to spend much time making numerous telephone calls to locate a child psychiatric bed. There was not at the time, and still appears to be no, or no effective bed bureau system to identify spaces. This is wasteful of clinician time, creates inevitable delays and is indicative that there are routinely too few available beds to serve the needs of our child psychiatric patients.
(2) On a previous admission during May 2014 the bed located was in Hurncombe, and George was removed by his father as the bedroom had inadequate furniture, had no bed linen and there was concern the environment was adding to George’s distress. The distance between home and this placement was in excess of 3 hours travel time.
(3) On the index admission, George was placed in the Priory Hospital, Southampton, a distance of over 2 hours travelling time from home. This is not an NHS facility and is specifically for “overflow” patients from all across England, many of whom are therefore huge distances from their home, their family, their friends and community support.
(4) Due to the distance, the hospital made the decision that family therapy could not take place (although the parents would have engaged if the importance of this was explained) and periods of home leave were extended due to travelling times, rather than in response to clinical need.
(5) There was poor attendance at the CPA meeting, and both parents and the community team only “attended” by telephone, which was far from ideal and impacted on the effectiveness of communication between all parties.
(6) Having local accessibility where in patient care is required was recognized in the Mental Health Crisis Care Concordat published 18 February 2014 to be important to keep the young person close to home, school and friends and this was also recognized by all the clinicians at request to be important and necessary. With current provision of beds this need is not being met, and is impacting on patient care.
(7) In this case I consider the distance of the unit directly contributed to the circumstances that led to George’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective bed bureau system for identifying child psychiatric bed spaces
Wider context from the report “(1) The community team had to spend much time making numerous telephone calls to locate a child psychiatric bed. There was not at the time, and still appears to be no, or no effective bed bureau system to identify spaces. This is wasteful of clinician time, creates inevitable delays and is indicative that there are routinely too few available beds to serve the needs of our child psychiatric patients.
(2) On a previous admission during May 2014 the bed located was in Hurncombe, and George was removed by his father as the bedroom had inadequate furniture, had no bed linen and there was concern the environment was adding to George’s distress. The distance between home and this placement was in excess of 3 hours travel time.
(3) On the index admission, George was placed in the Priory Hospital, Southampton, a distance of over 2 hours travelling time from home. This is not an NHS facility and is specifically for “overflow” patients from all across England, many of whom are therefore huge distances from their home, their family, their friends and community support.
(4) Due to the distance, the hospital made the decision that family therapy could not take place (although the parents would have engaged if the importance of this was explained) and periods of home leave were extended due to travelling times, rather than in response to clinical need.
(5) There was poor attendance at the CPA meeting, and both parents and the community team only “attended” by telephone, which was far from ideal and impacted on the effectiveness of communication between all parties.
(6) Having local accessibility where in patient care is required was recognized in the Mental Health Crisis Care Concordat published 18 February 2014 to be important to keep the young person close to home, school and friends and this was also recognized by all the clinicians at request to be important and necessary. With current provision of beds this need is not being met, and is impacting on patient care.
(7) In this case I consider the distance of the unit directly contributed to the circumstances that led to George’s death.
” 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 Commission additional Huntercombe capacity in Torquay, comprising six generic and four psychiatric intensive-care beds, through phased opening.
Verbatim wording from the response “The South West region can now also report that Wessex House, Bridgewater, Somerset is now in the process of a phased reopening. There are currently four generic beds open, with a further four opening during January 2015 and the full twelve bed commitment will be open by March 2015. In addition there has been a further six generic beds and four Psychiatric Intensive Care Unit (PICU) beds commissioned from the Huntercombe Group with a unit now based in Torquay, Devon. Again this unit has a phased opening plan, with four generic beds currently open, a further two will open during January 2015 and the PICU beds will be available by the end of January 2015. In total this will give the South West a total of fifty two generic beds and four PICU beds.” Source location 2014-0510-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 Reopen Wessex House in phases to provide twelve generic CAMHS beds in the South West.
Verbatim wording from the response “The South West region can now also report that Wessex House, Bridgewater, Somerset is now in the process of a phased reopening. There are currently four generic beds open, with a further four opening during January 2015 and the full twelve bed commitment will be open by March 2015. In addition there has been a further six generic beds and four Psychiatric Intensive Care Unit (PICU) beds commissioned from the Huntercombe Group with a unit now based in Torquay, Devon. Again this unit has a phased opening plan, with four generic beds currently open, a further two will open during January 2015 and the PICU beds will be available by the end of January 2015. In total this will give the South West a total of fifty two generic beds and four PICU beds.” Source location 2014-0510-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement weekly CAMHS bed-capacity reporting and national case-manager teleconferences to support timely identification of available placements.
Verbatim wording from the response “Since August 2013, NHS England has implemented a situation report (SITREP) process each Friday which requires all Child and Adolescent Mental Health Services (CAMHS) inpatient providers to submit numbers of available beds to a national database. This data is used to produce a report that is available from lunch time on a Friday indicating available capacity at each of the inpatient services commissioned. The report is circulated via the Area Teams to all Tier 3/Community CAMHS so they can identify capacity as required and particularly on a Friday when there is often a peak in demand and over the weekend.” Source location 2014-0510-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 additional general CAMHS and psychiatric intensive-care capacity from existing providers, targeting 50 additional beds nationally.
Verbatim wording from the response “NHS England has conducted two separate processes during 2014 to identify and commission additional inpatient general CAMHS and psychiatric intensive care capacity from existing providers that should result in an additional 50 beds nationally by the end of the financial year. This includes additional capacity in the South West area.” Source location 2014-0510-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The review identified contributory issues but could not conclusively establish that suicide would have been prevented without them or that distance caused the death.
Verbatim wording from the response “In this case I consider the distance of the unit directly contributed to the circumstances that led to George’s death.” Source location 2014-0510-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 Finding an available psychiatric bed is the responsibility of the referring community CAMHS team.
Verbatim wording from the response “Finding a bed is the responsibility of the referring community CAMHS team and they would have contacted available units and taken the bed that was made available to them. Whilst every effort is made to keep patients/children and young people as close to home as possible, sometimes lack of available beds mean that this cannot always happen.” Source location 2014-0510-Response-by-NHS-England
Open published response
14 Nov 2014 Kirk William Williams · Prevention of Future Deaths report Teesside
View report summary
Concerns raised 4 Lack of dialogue between police and local A&E departments about treatment misunderstandings View source Lack of memorandum of understanding or guideline for taking aggressive detainees to A&E departments View source Insufficient A&E consultant understanding of which detainees will be accepted for treatment View source Insufficient police understanding of A&E treatment for detainees 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
Kirk William Williams · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kirk William Williams ingested several drugs and displayed highly agitated and aberrant behaviour before being restrained by police. Although one officer considered that he should be taken to hospital, he was taken to a police station and later suffered cardiac arrest and died in hospital. The concerns included differing understandings between police and A&E staff about treating aggressive detainees, and the absence of clear dialogue or guidance for managing such medical emergencies.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of dialogue between police and local A&E departments about treatment misunderstandings
Wider context from the report “(2) Some police officers still consider that notwithstanding that they may be faced with a medical emergency, A&E departments will not treat violent or aggressive patients.
(3) The various consultants that gave evidence are clear that they will treat violent patients provided that (a) treatment is warranted and (b) they are provided with sufficient assistance from either or both the police or security staff.
(4) It therefore follows that there is a mismatch in perception and expectations between Cleveland police officers and local A&E staff.
(5) There did not appear to be a sufficiency of understanding within Cleveland Constabulary about how and whether detainees may be treated at A&E departments.
(6) Further or alternatively, the insufficiency in understanding lies with A&E consultants and their perception of what type of patients will be accepted and allowed to be treated in their departments.
(7) There does not appear to be a dialogue between Cleveland Constabulary and local A&E departments to address these particular misunderstandings or misconceptions.
(8) There does not appear to be any memorandum of understanding or guideline to cover aggressive detainees in police custody being taken to A&E departments.
(9) Without a fuller understanding of the true position, police officers will continue to be faced with the perennial dichotomy of whether to take an aggressive medical emergency detainee to an A&E department for treatment or to a police station to prevent self harm or harm to others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 memorandum of understanding or guideline for taking aggressive detainees to A&E departments
Wider context from the report “(2) Some police officers still consider that notwithstanding that they may be faced with a medical emergency, A&E departments will not treat violent or aggressive patients.
(3) The various consultants that gave evidence are clear that they will treat violent patients provided that (a) treatment is warranted and (b) they are provided with sufficient assistance from either or both the police or security staff.
(4) It therefore follows that there is a mismatch in perception and expectations between Cleveland police officers and local A&E staff.
(5) There did not appear to be a sufficiency of understanding within Cleveland Constabulary about how and whether detainees may be treated at A&E departments.
(6) Further or alternatively, the insufficiency in understanding lies with A&E consultants and their perception of what type of patients will be accepted and allowed to be treated in their departments.
(7) There does not appear to be a dialogue between Cleveland Constabulary and local A&E departments to address these particular misunderstandings or misconceptions.
(8) There does not appear to be any memorandum of understanding or guideline to cover aggressive detainees in police custody being taken to A&E departments.
(9) Without a fuller understanding of the true position, police officers will continue to be faced with the perennial dichotomy of whether to take an aggressive medical emergency detainee to an A&E department for treatment or to a police station to prevent self harm or harm to others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 A&E consultant understanding of which detainees will be accepted for treatment
Wider context from the report “(2) Some police officers still consider that notwithstanding that they may be faced with a medical emergency, A&E departments will not treat violent or aggressive patients.
(3) The various consultants that gave evidence are clear that they will treat violent patients provided that (a) treatment is warranted and (b) they are provided with sufficient assistance from either or both the police or security staff.
(4) It therefore follows that there is a mismatch in perception and expectations between Cleveland police officers and local A&E staff.
(5) There did not appear to be a sufficiency of understanding within Cleveland Constabulary about how and whether detainees may be treated at A&E departments.
(6) Further or alternatively, the insufficiency in understanding lies with A&E consultants and their perception of what type of patients will be accepted and allowed to be treated in their departments.
(7) There does not appear to be a dialogue between Cleveland Constabulary and local A&E departments to address these particular misunderstandings or misconceptions.
(8) There does not appear to be any memorandum of understanding or guideline to cover aggressive detainees in police custody being taken to A&E departments.
(9) Without a fuller understanding of the true position, police officers will continue to be faced with the perennial dichotomy of whether to take an aggressive medical emergency detainee to an A&E department for treatment or to a police station to prevent self harm or harm to others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 police understanding of A&E treatment for detainees
Wider context from the report “(2) Some police officers still consider that notwithstanding that they may be faced with a medical emergency, A&E departments will not treat violent or aggressive patients.
(3) The various consultants that gave evidence are clear that they will treat violent patients provided that (a) treatment is warranted and (b) they are provided with sufficient assistance from either or both the police or security staff.
(4) It therefore follows that there is a mismatch in perception and expectations between Cleveland police officers and local A&E staff.
(5) There did not appear to be a sufficiency of understanding within Cleveland Constabulary about how and whether detainees may be treated at A&E departments.
(6) Further or alternatively, the insufficiency in understanding lies with A&E consultants and their perception of what type of patients will be accepted and allowed to be treated in their departments.
(7) There does not appear to be a dialogue between Cleveland Constabulary and local A&E departments to address these particular misunderstandings or misconceptions.
(8) There does not appear to be any memorandum of understanding or guideline to cover aggressive detainees in police custody being taken to A&E departments.
(9) Without a fuller understanding of the true position, police officers will continue to be faced with the perennial dichotomy of whether to take an aggressive medical emergency detainee to an A&E department for treatment or to a police station to prevent self harm or harm to others.
” Open source report
7 Nov 2014 Barry Horrocks · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 3 Failure to adapt prison cells to individual activities-of-daily-living needs View source Failure to assign responsibility for the care and well-being of prisoners with complex needs View source Unavailability of social-services support for activities of daily living in prison 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
Barry Horrocks · 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
Barry Horrocks, who had vascular dementia and other physical and mental health problems, was serving a prison sentence at HMP Wakefield when he suffered a cerebral event and died in hospital on 5 April 2013. The principal concern was the lack of coordinated care and suitable support for his deteriorating ability to manage daily living and intimate personal care, including personal hygiene, toileting and medication.
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 adapt prison cells to individual activities-of-daily-living needs
Wider context from the report “(2) It was when in Prison that his immediate environment, that is his Prison cell was not in any way adapted to assist with activities of daily living . The ‘Social Services’ input’ which was a vital element of his care obviously could not be replicated whilst he was in prison. Such an input though was needed and necessary for his well-being.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 responsibility for the care and well-being of prisoners with complex needs
Wider context from the report “(3) Mr Horrocks, by virtue of his condition “fell through the net” in that none of the providers of care including health care had responsibility for a man in his condition . I was informed that assistance with intimate aspects of the activities of daily living were outside the remit of prisoner volunteers; the uniform prison officers; and those who provide primary care such as GPs and nursing staff nor, I was told, was it appropriate for him to be cared for in the Prison Healthcare Centre whether as an in-patient or out-patient. Those who provide mental health care and out of hours care did not accept any responsibility for his well-being .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 social-services support for activities of daily living in prison
Wider context from the report “(2) It was when in Prison that his immediate environment, that is his Prison cell was not in any way adapted to assist with activities of daily living. The ‘Social Services’ input’ which was a vital element of his care obviously could not be replicated whilst he was in prison . Such an input though was needed and necessary for his well-being .
” Open source report
Concerns raised 1 Extravasation of concentrated feeding fluid from low-lying UVCs 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
JACKSON TERRY SELLERS MITCHELL · 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
Jackson Terry Sellers Mitchell was born prematurely at 31 weeks and received parenteral nutrition through an umbilical venous catheter. He developed abdominal distension, deteriorated despite treatment and transfer to another hospital, and died on 10 May 2014. The post-mortem attributed his death to intraperitoneal extravasation of parenteral nutrition solution associated with umbilical vein catheterisation; concerns included the catheter's lower position and the need for further investigation into catheter positioning and fluid extravasation.
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 Extravasation of concentrated feeding fluid from low-lying UVCs
Wider context from the report “The damage found to Jackson's liver at post mortem does not appear to be from the tip of the catheter but from the concentrated feeding fluid that was passing through it .
Evidence was given that the ideal placement for a UVC tip is at the level of the diaphragm at approximately T9-T10 vertebral level. The UVC in this case was found to be in a lower lying position, but one which is presently acceptable to 80% of Doctors.
There is a presently unpublished study from Southampton which found 16 cases of extravasation of fluid from UVC over a 2 year period. Extravasation was shown following routine screening of ultra sound scans, although in the study there were no fatalities. Most of the complications in the study occurred with low lying catheters .
Further investigation is being carried out into the positioning of catheters and problems of extravasation of the fluid from UVC.
” Open source report
17 Oct 2014 Stephen Atherton · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Delays in radiologist-recommended additional investigations when GPs cannot request them View source Lack of a system at the GP practice to ensure successful receipt of important correspondence View source Failure to clinically triage routine orthopaedic referrals View source Lack of appropriate safeguards to prevent patients at risk from leaving before capacity assessment View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Stephen Atherton · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen Atherton, aged 27, died on 16 May 2013 from severe head injuries after falling from height after leaving a neurosurgical ward. The report identified concerns about delays and communication in referrals and investigations, and about the absence of safeguards to prevent him leaving the ward despite risks to himself.
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 radiologist-recommended additional investigations when GPs cannot request them
Wider context from the report “(3) Mr Atherton required multiple investigations of increasing complexity, at the recommendation of the reporting radiologists. I heard compelling evidence from Mr Atherton’s GP that this process results in delays . This is because the investigations could be undertaken more quickly if the radiologists themselves instigated the necessary additional investigations . This is particularly the case where the suggested investigations cannot actually be requested by GPs . The Trust gave evidence that this process is necessary because of the commissioning arrangements in place, which determine how payment is made for such tests. I am concerned that this process could increase the risk of future deaths occurring in similar circumstances to Mr Atherton’s 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 Lack of a system at the GP practice to ensure successful receipt of important correspondence
Wider context from the report “(1) It was clear from the evidence at the inquest that Mr Atherton’s GP was concerned that he should be seen for orthopaedic review more quickly than had been planned. However, was concerned that, given the importance of this further correspondence, there was no system in place at the GP practice to ensure successful receipt of the fax .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 clinically triage routine orthopaedic referrals
Wider context from the report “(2) I heard evidence that routine ‘choose and book’ orthopaedic referrals are not clinically triaged by the specialist to whom the referrals are made . As such, the concern was raised (which I share) that there is no potential for the triaging of apparently ‘routine’ appointments which, with specialist input might be expedited . It was clear from the evidence heard that other departments routinely triage referrals and no evidence was provided as to why this is not undertaken by the orthopaedic department.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate safeguards to prevent patients at risk from leaving before capacity assessment
Wider context from the report “(4) The neurosurgical ward from which Mr Atherton self-discharged was not locked. This was despite the risk he posed to himself and the fact that the staff were clear he should not be free to leave, without medical assessment of his capacity to self-discharge . I heard evidence that the current legislative framework and case law means that locking of wards is not acceptable. Whilst it is clear that locking ward doors by default is not appropriate, I did not hear compelling evidence as to why mechanisms could not be put in place to facilitate temporary locking . I am concerned that the legal position is being interpreted so that no appropriate safeguards exist , which would have prevented Mr Atherton from absconding. This raises concerns that future deaths could result in such circumstances, if this issue is not addressed.
” Open source report
26 Sep 2014 Emmanuel Tobiloba Akinmuyiwa · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Lack of clear West Midlands guidelines and protocols for the management and treatment location of patients with sickle cell disease View source Lack of staff knowledge of sickle cell crisis signs, symptoms and necessary treatment 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
Emmanuel Tobiloba Akinmuyiwa · 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
Emmanuel Tobiloba Akinmuyiwa was a 7-year-old boy with sickle cell disease who died after developing severe anaemia during a sickle cell crisis. The report identified failures to check his haemoglobin and provide an earlier blood transfusion, and raised concerns about the lack of clear regional protocols and staff knowledge for managing sickle cell disease.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of clear West Midlands guidelines and protocols for the management and treatment location of patients with sickle cell disease
Wider context from the report “Evidence at the inquest confirmed that there needed to be a clear protocol in the West Midlands for the management of patients with Sickle cell disease . Ordinarily they are managed at Birmingham Children's hospital. In this case as Emmanuel was admitted to Heartlands hospital various telephone calls were made to Birmingham Children's hospital. It was acknowledged in an internal investigation by Birmingham Heartlands hospital that staff had a lack of knowledge and appreciation for the signs and symptoms of a sickle cell crisis and what treatment was necessary. I was informed at the inquest that clinicians would prefer a hub and spoke approach to treatment of sickle cell disease with clear guidelines and protocols for how and where patients should be treated . I was informed that this had not happened to date due to the lack of funding available to liaise with all local hospitals and produce and put in place such protocol and guidance. A lack of guidelines and protocols for the West Midlands means future patients are at risk of death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge of sickle cell crisis signs, symptoms and necessary treatment
Wider context from the report “Evidence at the inquest confirmed that there needed to be a clear protocol in the West Midlands for the management of patients with Sickle cell disease. Ordinarily they are managed at Birmingham Children's hospital. In this case as Emmanuel was admitted to Heartlands hospital various telephone calls were made to Birmingham Children's hospital. It was acknowledged in an internal investigation by Birmingham Heartlands hospital that staff had a lack of knowledge and appreciation for the signs and symptoms of a sickle cell crisis and what treatment was necessary . I was informed at the inquest that clinicians would prefer a hub and spoke approach to treatment of sickle cell disease with clear guidelines and protocols for how and where patients should be treated. I was informed that this had not happened to date due to the lack of funding available to liaise with all local hospitals and produce and put in place such protocol and guidance. A lack of guidelines and protocols for the West Midlands means future patients are at risk of death.
” Open source report
Concerns raised 5 Failure to accurately and consistently record vital signs View source Lack of clinician knowledge of the croup severity scoring system View source Lack of paediatric expertise in the sole clinical contact for children attending A&E View source Difficulty entering Paediatric Early Warning Scoring information into GP medical records View source Failure of the GP computer system to alert clinicians to complete clinically relevant parameters 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
Evelyn Mary 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
Evelyn Mary Smith was 7 years old when she died after an acute deterioration in her breathing at home on 13 September 2013, following several healthcare consultations for croup-like symptoms. A post-mortem examination identified Parainfluenza Virus Type 2 and Staphylococcus Aureus, resulting in Acute Ulcerative Laryngotracheobronchitis. The principal concern was that a relatively inexperienced paediatric doctor was the only clinical contact for a child attending A&E, and that discussion with the paediatric team might have led to longer observation and consideration of non-viral causes.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately and consistently record vital signs
Wider context from the report “(1) The care provided to Miss Smith was reviewed by an independent paediatrician and a General Practitioner. I heard evidence that the accurate and consistent recording of Miss Smith’s vital signs may have allowed earlier recognition of the severity of her illness . I also heard that the use of the Paediatric Early Warning Scoring system in General Practice may be a useful way of documenting this information. However, it was clear that information in this form is not easy to enter into GP medical records.
(2) From the evidence heard at Miss Smith’s inquest it was apparent that the scoring system for croup severity was not widely known amongst the clinicians involved in her care. However, her GP did learn of this scoring system after reviewing the ‘clinical mentor’ tool through the practice’s computer software.
I heard evidence that systems are in place to prompt entry of certain clinical parameters in specific scenarios; predominantly chronic disease review consultations, such as for diabetes and asthma etc. I am concerned that the GP computer system contains important and clinically relevant information, such as the croup severity score but does not alert the clinician to complete it. I heard that it should be possible to prompt the entry of relevant clinical parameters after a diagnostic code has been entered into a consultation record.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 clinician knowledge of the croup severity scoring system
Wider context from the report “(1) The care provided to Miss Smith was reviewed by an independent paediatrician and a General Practitioner. I heard evidence that the accurate and consistent recording of Miss Smith’s vital signs may have allowed earlier recognition of the severity of her illness. I also heard that the use of the Paediatric Early Warning Scoring system in General Practice may be a useful way of documenting this information. However, it was clear that information in this form is not easy to enter into GP medical records.
(2) From the evidence heard at Miss Smith’s inquest it was apparent that the scoring system for croup severity was not widely known amongst the clinicians involved in her care . However, her GP did learn of this scoring system after reviewing the ‘clinical mentor’ tool through the practice’s computer software.
I heard evidence that systems are in place to prompt entry of certain clinical parameters in specific scenarios; predominantly chronic disease review consultations, such as for diabetes and asthma etc. I am concerned that the GP computer system contains important and clinically relevant information, such as the croup severity score but does not alert the clinician to complete it. I heard that it should be possible to prompt the entry of relevant clinical parameters after a diagnostic code has been entered into a consultation record.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 paediatric expertise in the sole clinical contact for children attending A&E
Wider context from the report “(1) The care provided to Miss Smith was reviewed by an independent paediatrician, who raised concerns regarding the paediatric experience of the FY2 doctor in A&E . His concern was that, whilst the care provided was not manifestly inappropriate or incorrect, he considered that discussion with the paediatric team may have prompted a longer period of observation and consideration of non-viral causes of croup-like signs. I share his overarching concern that a doctor, relatively inexperienced in paediatrics, should be the only clinical contact for a child taken to A&E .
I heard from the Hospital Trust that mandating all FY2 doctors to have postgraduate experience in paediatrics, before they were allocated to work in A&E, might have significant resource implications and may not be feasible.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Difficulty entering Paediatric Early Warning Scoring information into GP medical records
Wider context from the report “(1) The care provided to Miss Smith was reviewed by an independent paediatrician and a General Practitioner. I heard evidence that the accurate and consistent recording of Miss Smith’s vital signs may have allowed earlier recognition of the severity of her illness. I also heard that the use of the Paediatric Early Warning Scoring system in General Practice may be a useful way of documenting this information. However, it was clear that information in this form is not easy to enter into GP medical records .
(2) From the evidence heard at Miss Smith’s inquest it was apparent that the scoring system for croup severity was not widely known amongst the clinicians involved in her care. However, her GP did learn of this scoring system after reviewing the ‘clinical mentor’ tool through the practice’s computer software.
I heard evidence that systems are in place to prompt entry of certain clinical parameters in specific scenarios; predominantly chronic disease review consultations, such as for diabetes and asthma etc. I am concerned that the GP computer system contains important and clinically relevant information, such as the croup severity score but does not alert the clinician to complete it. I heard that it should be possible to prompt the entry of relevant clinical parameters after a diagnostic code has been entered into a consultation record.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 GP computer system to alert clinicians to complete clinically relevant parameters
Wider context from the report “(1) The care provided to Miss Smith was reviewed by an independent paediatrician and a General Practitioner. I heard evidence that the accurate and consistent recording of Miss Smith’s vital signs may have allowed earlier recognition of the severity of her illness. I also heard that the use of the Paediatric Early Warning Scoring system in General Practice may be a useful way of documenting this information. However, it was clear that information in this form is not easy to enter into GP medical records.
(2) From the evidence heard at Miss Smith’s inquest it was apparent that the scoring system for croup severity was not widely known amongst the clinicians involved in her care. However, her GP did learn of this scoring system after reviewing the ‘clinical mentor’ tool through the practice’s computer software.
I heard evidence that systems are in place to prompt entry of certain clinical parameters in specific scenarios; predominantly chronic disease review consultations, such as for diabetes and asthma etc. I am concerned that the GP computer system contains important and clinically relevant information, such as the croup severity score but does not alert the clinician to complete it . I heard that it should be possible to prompt the entry of relevant clinical parameters after a diagnostic code has been entered into a consultation record.
” Open source report
Concerns raised 1 Failure to ensure neurological and brain scans are viewed and reported by Neuro-Radiologists 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
Nicola Valerie MARSDEN · 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
Nicola Valerie MARSDEN developed neurological symptoms before and after giving birth by Caesarean Section at Bedford Hospital on 14 November 2012. An MRI scan was mis-interpreted, and her condition was not recognised as a haemorrhagic infarct; she died on 17 November 2012 from raised intracranial pressure due to a cerebral haemorrhage. The concern was that neurological and brain scans were interpreted by a Radiologist rather than a Neuro-Radiologist, despite a guideline for specialist review.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure neurological and brain scans are viewed and reported by Neuro-Radiologists
Wider context from the report “• That during the course of the evidence I was told that the brain scan relating to the deceased was mis-interpreted. The CT scans were viewed by a Radiologist and not a Neuro-Radiologist , despite the fact that there is a Guideline for having the scans viewed by a Neuro-Radiologist at Addenbrooke’s Hospital .
• My concern is that the interpretation of neurological scans and brain scans should be viewed and reported by Neuro-Radiologists and perhaps the Protocol for viewing of scans by non-specialists should be reviewed.
” Open source report
14 Aug 2014 Thomas Warren · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 5 Lack of regulatory monitoring and review of incomplete remediation referrals before subsequent locum employment View source Failure to secure complete employment histories, references and fitness to practise information for long-term locum doctors View source Unavailability of GMC-held fitness to practise and NCAS referral information to subsequent enquirers View source Failure to place provisional registration conditions when an NCAS assessment is at risk of remaining incomplete View source Lack of clarity over responsibility for enquiring into previous fitness to practise concerns and NCAS referrals when recruiting short-notice locum doctors 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
Thomas Warren · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Thomas Warren, a child with cerebral palsy, died after receiving a 25 microgram fentanyl patch for pain and subsequently developing symptoms before suffering a cardiac arrest. The report identified concerns about prescribing an opiate to an opiate-naïve child without hospital admission, missed opportunities to stop dispensing the drug and provide parents with adequate monitoring information, and gaps in checks on the fitness to practise of a locum doctor.
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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 regulatory monitoring and review of incomplete remediation referrals before subsequent locum employment
Wider context from the report “(4) There did not appear to be any regulatory mechanism for monitoring or reviewing cases where the doctor no longer works for the Trust where a remediation referral was made and NCAS (or other body) assessment is not completed, before subsequent locum employment. Revalidation requirements might not be an effective mechanism for employment of short notice locum vacancies.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to secure complete employment histories, references and fitness to practise information for long-term locum doctors
Wider context from the report “(2) There are particular difficulties with securing a complete sequence of employment and the associated references and confirmation about concerns for fitness to practice of long term locum doctors who may have gaps between jobs or worked abroad . Thus serious concerns about practice may have existed but not come to notice of the Agency or prospective employing NHS Trust .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unavailability of GMC-held fitness to practise and NCAS referral information to subsequent enquirers
Wider context from the report “(3) Crucial information was held by the GMC about concerns about this doctor’s fitness to practice, including his referral to NCAS. This information was not available to those enquiring about his fitness to practice at a subsequent time. Nor was any provisional condition placed on his registration, having learnt that he was leaving the NHS so that the NCAS assessment was at risk of being in abeyance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 place provisional registration conditions when an NCAS assessment is at risk of remaining incomplete
Wider context from the report “(3) Crucial information was held by the GMC about concerns about this doctor’s fitness to practice, including his referral to NCAS. This information was not available to those enquiring about his fitness to practice at a subsequent time. Nor was any provisional condition placed on his registration, having learnt that he was leaving the NHS so that the NCAS assessment was at risk of being in abeyance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity over responsibility for enquiring into previous fitness to practise concerns and NCAS referrals when recruiting short-notice locum doctors
Wider context from the report “(1) There does not appear to be clarity as to who or which organization should enquire into previous fitness to practice concerns and referrals to NCAS (or successor organization) which have not led to restrictions or conditions of registration by the GMC when locum doctors are being recruited by an Agency at short notice by prospective NHS Trusts. In this case it appears that neither the Recruitment Agency nor Trust nor consultant asked the doctor before his employment began.
” Open source report
23 Jul 2014 John William THORPE · Prevention of Future Deaths report South Lincolnshire
View report summary
Concerns raised 3 Failure to consider suicide-attempt history and antidepressant-associated risk together when assessing treatment risk View source Failure to make direct mental health referrals when self-referral is not appropriate View source Failure to arrange or record follow-up contact after clinical care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
John William THORPE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John William THORPE, aged 78, died by drowning after he was found in the Forty Foot Drain on 24 March 2014. Before his death, he had reported low mood, hopelessness and self-harm, was prescribed fluoxetine, and was asked to self-refer to psychological therapy. The concerns included the lack of a direct mental-health referral, the absence of a definite follow-up arrangement, and whether the risks associated with starting antidepressants and his history of suicidal behaviour were adequately considered.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to consider suicide-attempt history and antidepressant-associated risk together when assessing treatment risk
Wider context from the report “3 That ████████ knowledge, elicited at the inquest, that "sometimes when anti-depressant is started it can give you more energy" and that Mr Thorpe had a history of a previous suicide attempt was apparently not considered together with the advice in the British National Formulary on suicidal behaviour and treatment with anti-depressants , viz; "the use of anti-depressants has been linked with suicidal thoughts and behaviour; children, young adults and patients with a history of suicidal behaviour are particularly at risk , where necessary patients should be monitored for suicidal behaviour, self-harm, or hostility, particularly at the beginning of treatment or if the dose is changed".
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 make direct mental health referrals when self-referral is not appropriate
Wider context from the report “1. That the deceased was asked to "self-refer" himself to IAPT rather than a direct referral being made on his behalf to an appropriate mental health resource . His widow was particularly critical of this at the Inquest, commenting she attempted to fill the form in for him but it wasn't completed and she believed her husband would have responded if a direct referral had been made. I appreciate this may be 'standard practice' but the point is surely not in every case and Doctors should be encouraged to use their discretion more
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 or record follow-up contact after clinical care
Wider context from the report “2 That no intention to follow him up, with a definite appointment being given or by telephone contact, is recorded in the clinical records .
” Open source report
Concerns raised 6 Delays in initiating investigative procedures View source Unavailability of private investigative procedures View source Inconsistent timing and pathways for investigative procedures in differential diagnosis including ARVC View source Delays in multidisciplinary review of syncope investigations View source Inconsistent advice to fit young athletes about future exercise View source Inconsistent national management of syncope in young athletes 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
Peter John Hinchliffe · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter John Hinchliffe, a fit 33-year-old man, died after collapsing while cycling on 11 September 2010; the inquest concluded that the cause of death was arrhythmogenic right ventricular cardiomyopathy, which was undiagnosed and untreated. The principal concerns were delays and differing approaches in investigating syncope, including delays in transferring investigations to the NHS, and inconsistent advice about exercise for young athletes in a recognised red-flag situation.
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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 Delays in initiating investigative procedures
Wider context from the report “(2) In the private sector there was delay initiating investigative procedures after the consultation on 29th June 2010.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 private investigative procedures
Wider context from the report “(1) All investigative procedures could not be undertaken privately and transfer to the National Health Service was necessary to complete investigations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inconsistent timing and pathways for investigative procedures in differential diagnosis including ARVC
Wider context from the report “(4) Evidence revealed significant differences in the times and routes taken to undertake investigative procedures in cases where there is a differential diagnosis including ARVC.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 multidisciplinary review of syncope investigations
Wider context from the report “(3) Although Peter John Hinchliffe died approximately two weeks after transfer into the NHS system no further progress would have been made until after the MDT meeting in early October some 4 – 5 months after the incident of syncope.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inconsistent advice to fit young athletes about future exercise
Wider context from the report “(5) The evidence revealed inconsistencies of approach in advice to fit young athletes as to future exercise in what was generally acknowledged to be a ‘red flag’ situation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inconsistent national management of syncope in young athletes
Wider context from the report “(6) Whilst there has been greater awareness since 2010 both locally and nationally of the need for timely and appropriate management of syncope in young athletes the approach to the problem does not appear to be consistent nationally and there is a continuing need to emphasise and act on this issue.
” Open source report
20 Jun 2014 Samuel James Openshaw · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 2 Slow electronic transfer of echocardiograph studies to tertiary centres View source Insufficient availability of specialist paediatric retrieval teams for urgent patient transportation 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
Samuel James Openshaw · 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 James Openshaw, who had serious and complex congenital heart problems, deteriorated at West Suffolk Hospital and died hours after being admitted to the Evelina Hospital’s paediatric intensive care unit following a delay in specialist retrieval. The report raised concerns about delays in specialist paediatric retrieval and slow, insecurely difficult electronic transfer of echocardiograph images, which could affect other sick children.
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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 Slow electronic transfer of echocardiograph studies to tertiary centres
Wider context from the report “During the period of investigation and inquest, a number of other issues also became apparent but I have not touched on these in this report as they were matters related to the local hospital and I am satisfied that action has been taken to address them. I am, however, concerned that, despite undoubted attempts to remedy the problem, slow electronic transfer of Echocardiograph studies to tertiary centres remains a problem and one that may affect other hospitals as well. There were also clearly difficulties with the workload that the specialist paediatric retrieval teams were working under. While the evidence here, sadly, was that even had earlier transfer to the paediatric intensive care unit at the tertiary centre been achieved, the tragic outcome would have been the same in this instance, the availability of these specialist retrieval teams for urgent patient transportation and the need to be able to transfer electronic images in a secure and timely manner , are issues that could affect the survival of sick children in other areas and are matters requiring the involvement of those who commission healthcare services themselves. I am therefore writing to you to ask that attention be given to this to try to reduce the risk of similar fatalities in future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of specialist paediatric retrieval teams for urgent patient transportation
Wider context from the report “During the period of investigation and inquest, a number of other issues also became apparent but I have not touched on these in this report as they were matters related to the local hospital and I am satisfied that action has been taken to address them. I am, however, concerned that, despite undoubted attempts to remedy the problem, slow electronic transfer of Echocardiograph studies to tertiary centres remains a problem and one that may affect other hospitals as well. There were also clearly difficulties with the workload that the specialist paediatric retrieval teams were working under . While the evidence here, sadly, was that even had earlier transfer to the paediatric intensive care unit at the tertiary centre been achieved, the tragic outcome would have been the same in this instance, the availability of these specialist retrieval teams for urgent patient transportation and the need to be able to transfer electronic images in a secure and timely manner, are issues that could affect the survival of sick children in other areas and are matters requiring the involvement of those who commission healthcare services themselves. I am therefore writing to you to ask that attention be given to this to try to reduce the risk of similar fatalities in future.
” Open source report
20 Jun 2014 Redmond Johnson · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 7 Delays in delivering transfer information needed for fitness assessment View source Failure to identify and rebook outstanding healthcare appointments View source Lack of a robust documented process for assessing fitness to transfer View source Failure to arrange medication for periods when detainees are out of prison care View source Failure to obtain relevant medical information for care planning during initial reception assessment View source Failure to conduct medication reviews for complex medication issues View source Inadequate documentation confirming completion and clinical review of requested investigations View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Redmond Johnson · 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
Redmond Johnson, aged 67, suffered a cardio-respiratory arrest while being transferred to Ipswich Crown Court on 25 November 2011 and died after transfer to Ipswich Hospital. The report identified concerns about the assessment of his fitness for transfer, including a record stating that he had no known medical risks despite the healthcare professional not having seen him. It also identified concerns about the management and documentation of his complex healthcare needs in custody, including liaison with community providers, specialist appointments, investigations, medication and care monitoring.
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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 Delays in delivering transfer information needed for fitness assessment
Wider context from the report “(6) Information about which detainees are going to be transferred to court or other locations needs to be delivered to the individual prisons in enough time for a thorough assessment of the detainee’s fitness to be transferred (including a face to face assessment if required) to be conducted.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 and rebook outstanding healthcare appointments
Wider context from the report “(2) Reception healthcare should ask about any outstanding hospital or other healthcare appointments and rebook those if necessary .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 robust documented process for assessing fitness to transfer
Wider context from the report “(5) There must be a robust and clearly documented process in place when assessing a detainee’s fitness to transfer , together with clear arrangements made in respect of any medication that the detainee needs to take while out of the prison’s care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange medication for periods when detainees are out of prison care
Wider context from the report “(5) There must be a robust and clearly documented process in place when assessing a detainee’s fitness to transfer, together with clear arrangements made in respect of any medication that the detainee needs to take while out of the prison’s care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain relevant medical information for care planning during initial reception assessment
Wider context from the report “(1) If a detainee has a history of significant medical problems, healthcare professionals undertaking the initial reception assessment should request further information from the General Practitioner and, where necessary, hospital doctors normally involved in the detainee’s care to enable appropriate care planning while that detainee is in the custody of the prison 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 conduct medication reviews for complex medication issues
Wider context from the report “(3) Medication reviews should be conducted, with appropriate pharmacy input if required, if there are complex medication issues that need resolving or clarifying .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 documentation confirming completion and clinical review of requested investigations
Wider context from the report “(4) If medical tests or investigations are requested, there must be clear and adequate documentation to confirm that those investigations have actually been conducted and the results seen by a healthcare professional .
” Open source report
9 Jun 2014 John Cook · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 4 Lack of identifying hospital or institution details and contact telephone number on DNA CPR forms View source Failure to retrieve and clearly mark expired or non-renewed DNA CPR forms View source Failure to specify an expiry date on DNA CPR forms View source Failure to ensure that DNA CPR form wording is read and understood correctly 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
John Cook · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Cook, a 73-year-old man receiving palliative care in a nursing home, experienced severe breathing difficulty and died on 6 October 2012. Ambulance personnel believed a Do Not Attempt Resuscitation form was in effect, but it had expired when he was discharged from hospital. The report raised concerns about unclear form wording, failure to retrieve or mark expired forms, difficulty identifying the issuing hospital, and communication failures that led to an unnecessary inquest and police investigation, although the report stated these failures did not affect the outcome.
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 identifying hospital or institution details and contact telephone number on DNA CPR forms
Wider context from the report “(1) My concerns relate to the DNA CPR form coloured lilac. It is inevitable that queries will occasionally arise as to the validity of the form and related matters and by their very nature these are likely to be urgent. Although this particular Case Consultant who issued the form was reasonably clear there was no indication to which hospital or institution he worked for . It would be convenient if the name of the hospital were incorporated in the form, with a telephone number.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 retrieve and clearly mark expired or non-renewed DNA CPR forms
Wider context from the report “(2) Under Section 3 headed Review there is “Decision valid to date of discharge from hospital”. I understand that this is an unusual form of wording. Normally an expiry date would be specified which seems to me to be good practice, however, once an expiry date has been reached and if there is no renewal, it seems to me that to avoid confusion, it would be better if the form were retrieved and clearly marked ‘Cancelled’, ‘Expired’ or some similar wording . In this particular case, given the wording used on the form, I think it should never have left the hospital. In this particular case, there was failure to read and/or understand the wording used and those attending reduced that the fall-back position was not to attempt resuscitation when the opposite was the correct interpretation. The difficulties were compounded by the quality of English spoken by some concerned but this is not uncommon and should be allowed for. Having said this, I am satisfied that these failures of communication did not affect the outcome and that any attempt at resuscitation would have been quite futile. It did however mean that an Inquest which should have been unnecessary had to be conducted, there was an unnecessary Police investigation and, of course, consequent distress to the family.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 specify an expiry date on DNA CPR forms
Wider context from the report “(2) Under Section 3 headed Review there is “Decision valid to date of discharge from hospital”. I understand that this is an unusual form of wording. Normally an expiry date would be specified which seems to me to be good practice, however, once an expiry date has been reached and if there is no renewal, it seems to me that to avoid confusion, it would be better if the form were retrieved and clearly marked ‘Cancelled’, ‘Expired’ or some similar wording. In this particular case, given the wording used on the form, I think it should never have left the hospital. In this particular case, there was failure to read and/or understand the wording used and those attending reduced that the fall-back position was not to attempt resuscitation when the opposite was the correct interpretation. The difficulties were compounded by the quality of English spoken by some concerned but this is not uncommon and should be allowed for. Having said this, I am satisfied that these failures of communication did not affect the outcome and that any attempt at resuscitation would have been quite futile. It did however mean that an Inquest which should have been unnecessary had to be conducted, there was an unnecessary Police investigation and, of course, consequent distress to the family.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that DNA CPR form wording is read and understood correctly
Wider context from the report “(2) Under Section 3 headed Review there is “Decision valid to date of discharge from hospital”. I understand that this is an unusual form of wording. Normally an expiry date would be specified which seems to me to be good practice, however, once an expiry date has been reached and if there is no renewal, it seems to me that to avoid confusion, it would be better if the form were retrieved and clearly marked ‘Cancelled’, ‘Expired’ or some similar wording. In this particular case, given the wording used on the form, I think it should never have left the hospital. In this particular case, there was failure to read and/or understand the wording used and those attending reduced that the fall-back position was not to attempt resuscitation when the opposite was the correct interpretation. The difficulties were compounded by the quality of English spoken by some concerned but this is not uncommon and should be allowed for. Having said this, I am satisfied that these failures of communication did not affect the outcome and that any attempt at resuscitation would have been quite futile. It did however mean that an Inquest which should have been unnecessary had to be conducted, there was an unnecessary Police investigation and, of course, consequent distress to the family.
” Open source report
6 Jun 2014 James Edward Boylan · Prevention of Future Deaths report South and East Cumbria
View report summary
Concerns raised 6 Failure to remove removable bathroom rails except when required View source Failure to disseminate GRIST assessment information to staff View source Failure to rigorously complete GRIST assessments View source Failure to keep ligature-capable cords centrally so that patients cannot directly access them View source Failure to maintain an overall view of escalating patient risk View source Insufficient searching of patients’ property for concealed dangerous items View source See 3 more concerns
Responses linked to these concerns
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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
James Edward Boylan · 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 Edward Boylan, who had a history of anxiety and was admitted to a mental health unit, died by hanging using a phone charger cord and a bathroom rail. The concerns included removable bathroom rails creating a ligature point, insufficient searching of patients’ property, access to a cord, and failures in recognising and communicating the escalation of his condition.
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 remove removable bathroom rails except when required
Wider context from the report “(1) Removable rails in a bathroom designed for use by disabled people had been left inadvertently ever since the unit was opened. No one seemed to be aware that these rails were removable and certainly nobody had removed them. This provided a ligature point which would otherwise have been absent in a unit which was specifically designed to have as few ligature points as possible. The Coroner is concerned that this same situation may apply in other units and people need to be aware that ligature points in mental health units should be limited as far as humanly possible, and specifically that removable rails should be removed except when actually 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 to disseminate GRIST assessment information to staff
Wider context from the report “(4) GRIST: Assessments should be more rigorously completed and disseminated so that staff are aware of their contents , because in relation to Mr Boylan this did not appear to have taken place so that an opportunity for communication of information was lost .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 rigorously complete GRIST assessments
Wider context from the report “(4) GRIST: Assessments should be more rigorously completed and disseminated so that staff are aware of their contents, because in relation to Mr Boylan this did not appear to have taken place so that an opportunity for communication of information was lost.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to keep ligature-capable cords centrally so that patients cannot directly access them
Wider context from the report “(2) Mr Boylan appears to have brought onto the ward a stanley knife blade. This was not discovered for several days. Mr Boylan only left the unit on one occasion and so could only have brought the blade onto the unit either 7 days before his death or 3 days before his death. The Coroner asks that thought be given to more robust searching of patients’ property. The origin of the cord which Mr Boylan used is not clear. It may have been his own, but the policy of having these kept centrally so that patients do not have access direct to them was not adhered to on this occasion , and so again Mr Boylan had access to something which he could use to hang himself with .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 an overall view of escalating patient risk
Wider context from the report “(3) There were numerous events over the 7 days during which Mr Boylan was present on the ward for someone with an overall view to realise that his condition was escalating and that he might become a danger to himself, but because no one person had such knowledge of all the facts, this was not recognised . It is suggested that communication be improved in any way in which the Trust thinks possible.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 searching of patients’ property for concealed dangerous items
Wider context from the report “(2) Mr Boylan appears to have brought onto the ward a stanley knife blade. This was not discovered for several days. Mr Boylan only left the unit on one occasion and so could only have brought the blade onto the unit either 7 days before his death or 3 days before his death. The Coroner asks that thought be given to more robust searching of patients’ property. The origin of the cord which Mr Boylan used is not clear. It may have been his own, but the policy of having these kept centrally so that patients do not have access direct to them was not adhered to on this occasion, and so again Mr Boylan had access to something which he could use to hang himself with.
” 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