17 Oct 2025 MELANIE JAYNE WALKER · Prevention of Future Deaths report Manchester West
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Concerns raised 3 Failure to ensure staff awareness and training about current heart-monitor deficiencies View source Failure of heart monitors to alert clinicians to cardiac events View source Failure of heart monitors to re-alert when ECG leads remain disconnected View source
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AI-generated summary
MELANIE JAYNE WALKER · 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
Melanie Jayne Walker, who had a complex medical history and drug and alcohol dependency, was found collapsed and partially responsive on 17 December 2024 and later suffered an unobserved cardiac arrest in hospital. She sustained an irreversible hypoxic brain injury and died on 26 December 2024 after life support was withdrawn. The principal concern was that her heart monitor did not alert staff to the cardiac event, partly because monitoring equipment had become disconnected and the monitor’s alert system did not re-alarm after acknowledgement, creating an ongoing patient-safety risk.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff awareness and training about current heart-monitor deficiencies
Wider context from the report “1. Whilst the deceased had been fitted with a heart monitor whilst being assessed in the busy Resuscitation Department of the hospital, she experienced a cardiac event that ought to have triggered her hearty monitor to alert clinicians to this medical emergency, in fact, this did not occur.
2. A Patient Safety Incident Investigation (PSII) had been commissioned by the Hospital Trust determined:
a. Where, an untoward event – such as an abnormal reading, or (as in this case) with a monitor lead was inadvertently disconnected, this creates a blue ‘in op’ alert with a ‘bloop’ type sound (as opposed to a continuous alarm) – with the consequence that the ECG lead is unable to detect a reading and is therefore inoperable.
b. The ‘in op’ alert creates a blue banner to alert staff. Once acknowledged (by the staff member pressing the button) this does not re-alert, even if the lead remains disconnected,
c. Accordingly, there is a risk that a lead could remain disconnected, if the reason for the staff pressing ‘acknowledge’ is to acknowledge an abnormal reading.
d. Whilst Royal Bolton Hospital Trust have mitigated the identified patient safety issues and it understood that the manufacturers (Philips) are undertaking to reconfigure their monitors so that when an ECG lead is removed this creates a ‘yellow alert’ that will ensure that the monitor will re-alarm in the scenario of a patient removing the lead when unobserved – the evidence established that this risk remains an issue for other hospital trusts in the interim.
e. Royal Bolton Hospital have identified the need for patients who are deliberately or inadvertently removing monitoring equipment will be the subject of additional support, such as a 1:1 Health Care Assistant.
3. There remains an ongoing concern that until these heart monitoring machines are re-configured, and staff made aware and trained as to their current deficiencies , with no mitigating arrangements in place , that a patient can suffer a fatal cardiac event in any clinical setting and an erroneous assumption made by health care staff that a patient is being appropriately monitored .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 heart monitors to alert clinicians to cardiac events
Wider context from the report “1. Whilst the deceased had been fitted with a heart monitor whilst being assessed in the busy Resuscitation Department of the hospital, she experienced a cardiac event that ought to have triggered her hearty monitor to alert clinicians to this medical emergency, in fact, this did not occur .
2. A Patient Safety Incident Investigation (PSII) had been commissioned by the Hospital Trust determined:
a. Where, an untoward event – such as an abnormal reading, or (as in this case) with a monitor lead was inadvertently disconnected, this creates a blue ‘in op’ alert with a ‘bloop’ type sound (as opposed to a continuous alarm) – with the consequence that the ECG lead is unable to detect a reading and is therefore inoperable.
b. The ‘in op’ alert creates a blue banner to alert staff. Once acknowledged (by the staff member pressing the button) this does not re-alert, even if the lead remains disconnected,
c. Accordingly, there is a risk that a lead could remain disconnected, if the reason for the staff pressing ‘acknowledge’ is to acknowledge an abnormal reading.
d. Whilst Royal Bolton Hospital Trust have mitigated the identified patient safety issues and it understood that the manufacturers (Philips) are undertaking to reconfigure their monitors so that when an ECG lead is removed this creates a ‘yellow alert’ that will ensure that the monitor will re-alarm in the scenario of a patient removing the lead when unobserved – the evidence established that this risk remains an issue for other hospital trusts in the interim.
e. Royal Bolton Hospital have identified the need for patients who are deliberately or inadvertently removing monitoring equipment will be the subject of additional support, such as a 1:1 Health Care Assistant.
3. There remains an ongoing concern that until these heart monitoring machines are re-configured, and staff made aware and trained as to their current deficiencies, with no mitigating arrangements in place, that a patient can suffer a fatal cardiac event in any clinical setting and an erroneous assumption made by health care staff that a patient is being appropriately monitored.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 heart monitors to re-alert when ECG leads remain disconnected
Wider context from the report “1. Whilst the deceased had been fitted with a heart monitor whilst being assessed in the busy Resuscitation Department of the hospital, she experienced a cardiac event that ought to have triggered her hearty monitor to alert clinicians to this medical emergency, in fact, this did not occur.
2. A Patient Safety Incident Investigation (PSII) had been commissioned by the Hospital Trust determined:
a. Where, an untoward event – such as an abnormal reading, or (as in this case) with a monitor lead was inadvertently disconnected, this creates a blue ‘in op’ alert with a ‘bloop’ type sound (as opposed to a continuous alarm) – with the consequence that the ECG lead is unable to detect a reading and is therefore inoperable.
b. The ‘in op’ alert creates a blue banner to alert staff. Once acknowledged (by the staff member pressing the button) this does not re-alert, even if the lead remains disconnected ,
c. Accordingly, there is a risk that a lead could remain disconnected , if the reason for the staff pressing ‘acknowledge’ is to acknowledge an abnormal reading.
d. Whilst Royal Bolton Hospital Trust have mitigated the identified patient safety issues and it understood that the manufacturers (Philips) are undertaking to reconfigure their monitors so that when an ECG lead is removed this creates a ‘yellow alert’ that will ensure that the monitor will re-alarm in the scenario of a patient removing the lead when unobserved – the evidence established that this risk remains an issue for other hospital trusts in the interim .
e. Royal Bolton Hospital have identified the need for patients who are deliberately or inadvertently removing monitoring equipment will be the subject of additional support, such as a 1:1 Health Care Assistant.
3. There remains an ongoing concern that until these heart monitoring machines are re-configured, and staff made aware and trained as to their current deficiencies, with no mitigating arrangements in place, that a patient can suffer a fatal cardiac event in any clinical setting and an erroneous assumption made by health care staff that a patient is being appropriately monitored.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The MHRA is best placed to address monitor safety concerns and issue any necessary device safety bulletin.
Verbatim wording from the response “NHS England would advise that the Medicines and Healthcare products Regulatory Agency (MHRA) would be best placed to respond to these concerns. The MHRA would also be in a position to issue a Device Safety Information bulletin, if required, to advise NHS organisations of the current risk and to update on the steps taken by the manufacturer (Philips) to implement the monitor reconfiguration and the new ‘yellow alert’ system.” Source location Response from NHS England
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14 Oct 2025 Paula Doreen Hughes · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 7 Failure to prevent concurrent prescriptions of paracetamol-containing drugs View source Lack of robust mechanisms to mitigate confirmation bias and encourage professional curiosity View source Lack of a mechanism for consistently recording pre-admission over-the-counter medications View source Insufficient guidance for accurate and consistent assessment of the ACVPU confusion element View source Lack of guidance or policy for deciding when virtual reviews can replace face-to-face reviews View source Lack of a robust process for managing therapeutic excess and potential toxicity View source Risk of loss or dilution of prescribing safety nets during electronic system changes View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Paula Doreen Hughes · 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
Paula Doreen Hughes was admitted to hospital after a fall and received paracetamol in excess of the recommended dose because paracetamol was prescribed alongside co-codamol. The overdose was not recognised until she had developed fulminant acute liver failure, and timely treatment was not provided. The principal concerns included preventing duplicate paracetamol prescriptions and administration, recognising and managing therapeutic excess, accurately assessing confusion, recording over-the-counter medicines, mitigating confirmation bias, and providing guidance for virtual patient reviews.
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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 prevent concurrent prescriptions of paracetamol-containing drugs
Wider context from the report “1. In respect of preventing concurrent prescriptions of paracetamol containing drugs and otherwise preventing prescribing errors resulting in therapeutic excess of paracetamol (NHSE, RPS, Cerner, MHRA, LGT)
(1) NHSE, RPS, Cerner, MHRA
I consider that the risk of concurrent prescriptions of paracetamol containing drugs is of wider national concern.
The Cerner prescribing system offers a duplicate checking functionality that is not a standard feature. It is hard stop and can be overridden and was not adopted by the LGT when the system was introduced. All the healthcare professionals were aware that co-codamol contained paracetamol and should not be prescribed with paracetamol. However, the 2 prescribing doctors failed to recognise that Mrs Hughes was already prescribed a paracetamol containing drug. 2 nurses failed to recognise they were administering 2 paracetamol containing drugs. A pharmacist failed to identify the concurrent prescriptions during reconciliation.
(2) LGT
LGT’s response to the incident was swift and commendable. A hard stop was introduced to the electronic prescribing system which eliminated concurrent prescriptions of paracetamol containing drugs. Further refinements of the system significantly reduced therapeutic excesses of paracetamol based on weight, which had been identified as an issue when investigating Mrs Hughes’ death. However, it is my understanding that consideration is being given to changing the electronic record and prescribing system. My concern is that during any move to a new system, the safety nets introduced by the Trust will be diluted or 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 Lack of robust mechanisms to mitigate confirmation bias and encourage professional curiosity
Wider context from the report “5. Trust approach to mitigating against confirmation bias and encouraging professional curiosity (LGT)
Confirmation bias and a lack of professional curiosity were significant features in Mrs Hughes’ being administered two paracetamol containing drugs at the same time and in not investigating whether she had received a therapeutic excess and suffered consequential harm. I have found that the Trust does not have robust mechanism for mitigating against confirmation bias and encouraging professional curiosity.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 mechanism for consistently recording pre-admission over-the-counter medications
Wider context from the report “4. Mechanism for recording over the counter medications taken prior to attendance at the Emergency Department (LGT)
This concern has arisen out of my finding that Mrs Hughes had taken an over the counter (OTC) drug containing paracetamol before her admission to hospital but that this had not been recorded as part of her medication history. The Trust’s Medicines Reconciliation Policy requires that patients should be asked about OTCs. The Trust relies on individual clinical practice. There is no mechanism to ensure that pre-admission OTCs are consistently recorded such that the risk of therapeutic excess of paracetamol (or other drugs available OTC) in those circumstances continues to 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 Insufficient guidance for accurate and consistent assessment of the ACVPU confusion element
Wider context from the report “3. The assessment of the ACVPU score (LGT, RCP, NHSE)
This concern has arisen out of the fact that Mrs Hughes was scored as alert when she was confused. Confusion would have added a score of 3 to her NEWS2 score and would have resulted in an earlier escalation of her condition. I heard that confusion is not always easy to identify and that the signs can be subtle.
(1) LGT
The Trust provided training materials relating to detection and management of deteriorating patients. There was minimal guidance on how to accurately assess the ACVPU score and the confusion element in particular. There remains a tangible risk that the ACVPU score will continue to be assessed inconsistently, with new episodes of confusion continuing to be missed.
(2) NHSE, RCP
I consider that consistent and accurate assessment of the ACVPU element of the NEWS2 score is likely to a matter of wider concern. This concern is being brought to the attention of NHSE and the RCP as I consider that they have the power to support healthcare professionals to ensure consistent and accurate scoring of confusion.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance or policy for deciding when virtual reviews can replace face-to-face reviews
Wider context from the report “6. Trust policy on managing virtual patient reviews (LGT)
This concern has arisen out of the fact that Mrs Hughes had been reviewed virtually rather than face to face a resident doctor on the morning before she became unwell. The Trust has no guidance or policy on virtual reviews. I was told that this is a matter of clinical judgment. The absence of any guidance to help a still relatively inexperienced resident doctor decide when they can dispense with a face-to-face review is a circumstance that creates a risk that future deaths may occur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 process for managing therapeutic excess and potential toxicity
Wider context from the report “2. Management of therapeutic excess if it has not been prevented (LGT)
This issue has arisen from the finding that once the concurrent prescription had been identified, there had no attempt to consider whether there had been a therapeutic excess and whether Mrs Hughes had suffered harm. The Trust’s response to the incident focused on prevention. It did not consider the adequacy of the clinical response once the overdose had been identified. The Trust relies on information sharing of learning from incidents and thereafter places reliance on individual clinical practice. I received no evidence of a robust process for ensuring a consistent clinical response to the management of therapeutic excess and the potential for toxicity.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Risk of loss or dilution of prescribing safety nets during electronic system changes
Wider context from the report “1. In respect of preventing concurrent prescriptions of paracetamol containing drugs and otherwise preventing prescribing errors resulting in therapeutic excess of paracetamol (NHSE, RPS, Cerner, MHRA, LGT)
(1) NHSE, RPS, Cerner, MHRA
I consider that the risk of concurrent prescriptions of paracetamol containing drugs is of wider national concern.
The Cerner prescribing system offers a duplicate checking functionality that is not a standard feature. It is hard stop and can be overridden and was not adopted by the LGT when the system was introduced. All the healthcare professionals were aware that co-codamol contained paracetamol and should not be prescribed with paracetamol. However, the 2 prescribing doctors failed to recognise that Mrs Hughes was already prescribed a paracetamol containing drug. 2 nurses failed to recognise they were administering 2 paracetamol containing drugs. A pharmacist failed to identify the concurrent prescriptions during reconciliation.
(2) LGT
LGT’s response to the incident was swift and commendable. A hard stop was introduced to the electronic prescribing system which eliminated concurrent prescriptions of paracetamol containing drugs. Further refinements of the system significantly reduced therapeutic excesses of paracetamol based on weight, which had been identified as an issue when investigating Mrs Hughes’ death. However, it is my understanding that consideration is being given to changing the electronic record and prescribing system. My concern is that during any move to a new system, the safety nets introduced by the Trust will be diluted or lost.
” 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 Implement Patient Wellness Questionnaires and related patient-safety initiatives to support recognition of patient confusion and deterioration.
Verbatim wording from the response “NEWS2 is a scoring system in which a score is allocated to various physiological measurements when a patient presents to, or is being monitored in, hospital. It asks clinicians to distinguish between a patient being 'alert' or otherwise experiencing 'confusion' and/or 'unresponsiveness'. The existence of ‘confusion’ is sometimes subtle and hard to recognise. The subtle signs of mental alteration might be better picked up by family or friends, and the work NHS England is undertaking on implementing Patient Wellness Questionnaires and patient safety initiatives such as Martha's Rule will support this. However, the Royal College of Physicians, to whom your Report is also addressed, would be best placed to address how to support training” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission and maintain the ePRASE toolkit, including therapeutic duplication scenarios in its finalised 2025 release.
Verbatim wording from the response “NHS England commissioned the ‘ePrescribing Risk and Safety Evaluation’ (ePRASE) toolkit, which is an online self-assessment tool that NHS secondary care providers are able to register to use with annual releases. It is intended to test how effectively e-prescribing systems respond to high-risk prescribing scenarios. The 2025 release is now finalised and therapeutic duplication as a theme is included. This incident will be considered as part of the review of the scenarios for the next release in 2026 as a priority area.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review therapeutic-duplication scenarios as a priority for the 2026 ePRASE release.
Verbatim wording from the response “NHS England commissioned the ‘ePrescribing Risk and Safety Evaluation’ (ePRASE) toolkit, which is an online self-assessment tool that NHS secondary care providers are able to register to use with annual releases. It is intended to test how effectively e-prescribing systems respond to high-risk prescribing scenarios. The 2025 release is now finalised and therapeutic duplication as a theme is included. This incident will be considered as part of the review of the scenarios for the next release in 2026 as a priority area.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National training to ensure consistent ACVPU assessment is best addressed by the Royal College of Physicians.
Verbatim wording from the response “NEWS2 is a scoring system in which a score is allocated to various physiological measurements when a patient presents to, or is being monitored in, hospital. It asks clinicians to distinguish between a patient being 'alert' or otherwise experiencing 'confusion' and/or 'unresponsiveness'. The existence of ‘confusion’ is sometimes subtle and hard to recognise. The subtle signs of mental alteration might be better picked up by family or friends, and the work NHS England is undertaking on implementing Patient Wellness Questionnaires and patient safety initiatives such as Martha's Rule will support this. However, the Royal College of Physicians, to whom your Report is also addressed, would be best placed to address how to support training” Source location Response from NHS England
Open published response
Concerns raised 1 Lack of available mental health in-patient beds for very high-risk patients who cannot be safely managed in the community 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
Jack Mathew Peatling · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jack Mathew Peatling, who had a very high risk of suicide, made further serious suicide attempts and was assessed as requiring urgent inpatient mental health care. No suitable inpatient bed was available for six days, during which he was managed in the community despite clinical recognition that his risk could not be safely managed there; he died by suicide on 5 June 2023. The report identified the chronic lack of available high-risk mental health inpatient beds as a principal concern.
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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 available mental health in-patient beds for very high-risk patients who cannot be safely managed in the community
Wider context from the report “(a) A highly vulnerable 20-year-old man, with a history of anxiety, depression and impulsive previous suicide attempts made two further serious attempts to take his own life and inflicted an extensive wound to his arm ████████ after those suicide attempts were frustrated by his mother. The subsequent formal MHA assessment determined Jack to be such a high risk of suicide that an immediate period of assessment and treatment as a (voluntary) in-patient on an MHAU was required as his high risk of suicide could not be safely managed in the community.
(b) No such bed was available over the six days between the MHA assessment and Jack’s suicide with still no indication, at the time of his death, as to if or when a bed would be available. By default, and notwithstanding point (a) above, the HTT, absent an in-patient bed, became responsible for his care in the community.
(c) In his evidence, it was further expressly recognised by the HTT psychiatrist who saw Jack on the 31st May that his “very, very high risk” of suicide at that time could not be managed safely in the community by the HTT and, further, that Jack was “untreatable” in the community.
(d) Nonetheless, and notwithstanding the unanimous clinical view, the non-availability of an EPUT MHAU in-patient bed meant that the HTT were required to attempt to mitigate this unmanageable level of risk in the community, something that the HTT was, as had been anticipated, unable to do.
(e) The evidence confirmed that a lack of available in-patient beds for high-risk mental health patients who, as was acknowledged at the time, cannot be managed safely in the community, is a chronic and on-going situation in Essex and, the inquest was told, nationally.
(f) Jack took his own life by deploying a ligature ████████
████████ on the sixth day awaiting the necessary, required in-patient bed. Had an in-patient bed been made available, he would probably not have died. Jack’s death was avoidable.
(g) Absent the provision of available mental health in-patient beds for very high-risk patients that formal Mental Health Act assessments have clinically determined cannot be managed safely in the community, then further avoidable deaths by suicide amongst this cohort of vulnerable patients appears inevitable.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reduce and eliminate the use of out-of-area placements where local inpatient beds are unavailable.
Verbatim wording from the response “If local beds are not available, Out of Area Placements are currently used to ensure patient care is delivered in an inpatient setting if needed. NHS England plans to reduce and eliminate the use of Out of Area Placements as they can result in poorer outcomes for patients and provide additional risk to patient safety.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest £2.3 billion in mental health services, including approximately £1.3 billion for adult community, crisis and acute services.
Verbatim wording from the response “However, given increasing lengths of stay and the increased number of patients clinically ready for discharge, providing more beds will be considered as part of a whole system transformation approach. This was supported by the NHS Long Term Plan (LTP), which saw an additional £2.3 billion funding invested in mental health services from 2019/20 – 2023/24, around £1.3 billion of which was for adult community, crisis and acute mental health services to help people get quicker access to the care they need and prevent avoidable deterioration and hospital admission.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make £75 million of additional capital available to improve local mental health bed capacity and reduce out-of-area placements.
Verbatim wording from the response “NHS England is aware of the issues in some systems around high bed occupancy and limited local bed availability. This is related to long lengths of stay and high numbers of patients clinically ready for discharge but unable to be discharged, leading to flow pressures across systems. To improve this, in 2025/26, NHS England made £75 million of additional capital available for local systems to invest in improving local bed capacity and reduce the use of Out of Area Placements.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation When local beds are unavailable, existing out-of-area placements ensure inpatient care is delivered if clinically needed.
Verbatim wording from the response “If local beds are not available, Out of Area Placements are currently used to ensure patient care is delivered in an inpatient setting if needed. NHS England plans to reduce and eliminate the use of Out of Area Placements as they can result in poorer outcomes for patients and provide additional risk to patient safety.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation When admission capacity is insufficient, existing community safeguards and priority escalation arrangements manage risk or secure inpatient provision.
Verbatim wording from the response “Essex Partnership University NHS Foundation Trust (EPUT) has advised that when there is insufficient capacity to meet all hospital admission demands, the Chair of the twice-daily situation report meetings is mandated to seek assurance that sufficient community mitigation and safeguards are in place to continue with community intervention as an alternative to admission. Furthermore, Home Treatment Teams (HTTs) are instructed to raise as a priority for admission those individuals for whom the HTT is unable to provide adequate mitigation and/or where there is an escalating risk presentation.” Source location Response from NHS England
Open published response
23 Sep 2025 Christopher John Bird (“Chris”) · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 2 Systemic failure in communication between mental health and primary care View source Failure of nhs.net email to reliably deliver important information to GP practices 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
Christopher John Bird (“Chris”) · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher John Bird died by suicide on 19 September 2024 after placing his head on a railway line near South Marston and being struck by a freight train. The report found that a mental-health response sent to primary care was not received, and that this communication failure meant he was not updated about his referral and more likely than not exacerbated his mixed anxiety and depression. It also raised concern about the reliability of nhs.net email for transmitting important information between mental-health and primary-care services.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Systemic failure in communication between mental health and primary care
Wider context from the report “During the course of the Inquest, I heard evidence from ████████ the joint Senior Partner at The White Horse Medical Practice. Having asked colleagues to carry out a forensic search for evidence of the e-mail having been received and finding none he did allude to a view that was not shared by him alone, but by colleagues both within the Surgery and it appears colleagues in other surgeries that there were concerns that when using the nhs.net e-mail e-mails had gone missing and were not received through the system suggesting its 100% reliability. I personally have not come across another case where this issue has been raised but there is no evidence that I saw that pointed to the e-mail having been incorrectly sent by mental health to the GP practice and I have to accept ████████ evidence that there is no evidence to support it was in fact received. The systemic failure in my view more than minimally contributed to the deterioration in Chris’ mental health that led to his death late afternoon on the 19 September 2024. When Chris spoke with another GP on the 16 September 2024, she was unaware of the response from mental health because the e-mail indicating in detail the nature of that response was never received by the GP practice. She in turn contacted the embedded mental health social worker the next day via e-mail although however he was not available that day hence the assumption that that was the reason if not a combined reason for Chris’ case being discussed at the hub meeting on the 19 September 2024.
If there is a reliability issue with the use of nhs.net for whatever reason such as old infrastructure, in that clearly is a concern and one which I am of the view could impact on future deaths if important information having been sent through the system is not guaranteed to be received and is lost;
During the course of the Inquest it became clear that there had been a systemic failure in relation to the communication from mental health to primary care on the 28 August 2024 and I asked and indicated that I would like both organisations to work together to reflect on the finding in relation to ways of working relative to the interaction between secondary and primary care levels to see if there are any measures that could be undertaken to minimise and ideally exclude the repetition of such an incident occurring again . It is not the job of a Coroner to make recommendations. You are aware of my concern here and I am sure that Chris' brother, ████████ would equally welcome your joint input in respect of the matter.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of nhs.net email to reliably deliver important information to GP practices
Wider context from the report “During the course of the Inquest, I heard evidence from ████████ the joint Senior Partner at The White Horse Medical Practice. Having asked colleagues to carry out a forensic search for evidence of the e-mail having been received and finding none he did allude to a view that was not shared by him alone, but by colleagues both within the Surgery and it appears colleagues in other surgeries that there were concerns that when using the nhs.net e-mail e-mails had gone missing and were not received through the system suggesting its 100% reliability. I personally have not come across another case where this issue has been raised but there is no evidence that I saw that pointed to the e-mail having been incorrectly sent by mental health to the GP practice and I have to accept ████████ evidence that there is no evidence to support it was in fact received. The systemic failure in my view more than minimally contributed to the deterioration in Chris’ mental health that led to his death late afternoon on the 19 September 2024. When Chris spoke with another GP on the 16 September 2024, she was unaware of the response from mental health because the e-mail indicating in detail the nature of that response was never received by the GP practice . She in turn contacted the embedded mental health social worker the next day via e-mail although however he was not available that day hence the assumption that that was the reason if not a combined reason for Chris’ case being discussed at the hub meeting on the 19 September 2024.
If there is a reliability issue with the use of nhs.net for whatever reason such as old infrastructure, in that clearly is a concern and one which I am of the view could impact on future deaths if important information having been sent through the system is not guaranteed to be received and is lost ;
During the course of the Inquest it became clear that there had been a systemic failure in relation to the communication from mental health to primary care on the 28 August 2024 and I asked and indicated that I would like both organisations to work together to reflect on the finding in relation to ways of working relative to the interaction between secondary and primary care levels to see if there are any measures that could be undertaken to minimise and ideally exclude the repetition of such an incident occurring again. It is not the job of a Coroner to make recommendations. You are aware of my concern here and I am sure that Chris' brother, ████████ would equally welcome your joint input in respect of the matter.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake Clinical Safety Cases, Hazard Logs and Data Protection Impact Assessments before national NHSmail deployment.
Verbatim wording from the response “Prior to the roll out of NHSmail across England, Clinical Safety Cases, Hazard Logs, and Data Protection Impact Assessments were undertaken to support the delivery of the service at a national level. Clinical Safety Cases are used to ensure any clinical risks, hazards and potential harms are identified prior to deployment and these are managed within either product development or within system adoption methodologies. The model uses joint data controllers and clearly sets out in the requirements of organisations using the service, that they have similar local-level policies in place.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The forensic search found that the mental health email was received by the GP practice and copied into the patient's clinical record.
Verbatim wording from the response “Forensic discovery has confirmed that a referral letter was sent from the White Horse Medical Practice via the electronic referral service (e-RS) to the community mental health team at 8:40am on 28 August 2024 by the GP administration team.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHSmail is considered reliable and resilient, with monitoring, recovery mechanisms, support arrangements and established clinical safety controls.
Verbatim wording from the response “NHSmail is considered a reliable and resilient email platform, specifically designed and maintained for NHS business communications, with systems put in place to protect and recover from common IT failures like outages. While occasional incidents do occur, such as delayed arrival of emails in the destination mailbox, the overall reliability is strong, and service status is closely monitored and reported on the NHS support webpage, with disruptions usually resolved quickly and service continuity prioritized. All users of NHSmail are encouraged to contact their local administrator or service desk if they are experiencing any issues. If these cannot be resolved by the user’s local IT team, then there is a national NHSmail helpdesk which operates 24 hours a day.” Source location Response from NHS England
Open published response
Concerns raised 2 Failure to ensure prominent and accurate filing of critical respiratory action plans in online clinical records View source Lack of a coordinated process for producing and storing critical respiratory action plans in online clinical records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Kwabena Amoateng · 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
Kwabena Amoateng, a 17-year-old boy with congenital central hypoventilation syndrome, became ill on 16 September 2024 and died in hospital on 23 September 2024 after developing severe respiratory complications. A Paediatric Respiratory Action Plan for his condition was mislabelled and misfiled, so it was unavailable to emergency healthcare professionals assessing him. The report identified the absence of a coordinated process for producing and storing such documents in online clinical records as a substantive concern.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure prominent and accurate filing of critical respiratory action plans in online clinical records
Wider context from the report “1. The inquest found that a critically important document had been produced by his specialist respiratory doctors to assist emergency healthcare professionals in understanding his rare and potentially dangerous condition - CCHS. The document, A Paediatric Respiratory Action Plan (‘PRAP’) set out the necessary steps to be considered should Kwabena fall ill.
2. During Kwabena’s final illness, those assessing him from 16ᵗʰ-21ˢᵗ September 2024 were unaware of this vital document as it had been mislabelled and misfiled within the online records available to them .
3. Had the PRAP been more prominently filed it is likely that those assessing Kwabena would have escalated his treatment to admission to hospital far earlier, which may have resulted in Kwabena’s life being saved.
4. An investigation into why the PRAP was not visible to emergency services in this case has highlighted that there is no coordinated process to ensure a consistent approach in producing and storing such documents in online clinical records.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a coordinated process for producing and storing critical respiratory action plans in online clinical records
Wider context from the report “1. The inquest found that a critically important document had been produced by his specialist respiratory doctors to assist emergency healthcare professionals in understanding his rare and potentially dangerous condition - CCHS. The document, A Paediatric Respiratory Action Plan (‘PRAP’) set out the necessary steps to be considered should Kwabena fall ill.
2. During Kwabena’s final illness, those assessing him from 16ᵗʰ-21ˢᵗ September 2024 were unaware of this vital document as it had been mislabelled and misfiled within the online records available to them.
3. Had the PRAP been more prominently filed it is likely that those assessing Kwabena would have escalated his treatment to admission to hospital far earlier, which may have resulted in Kwabena’s life being saved.
4. An investigation into why the PRAP was not visible to emergency services in this case has highlighted that there is no coordinated process to ensure a consistent approach in producing and storing such documents in online clinical records .
” Open source report
11 Sep 2025 Michael Leonard MOORE · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1 Insufficient capacity to manage cancer referrals 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
Michael Leonard MOORE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Leonard Moore had recurrent, advanced urothelial carcinoma after a biopsy was delayed for approximately eight months while he remained on a waiting list. He was considered too frail for active treatment and died at home on 17 September 2024. The principal concern was that insufficient NHS capacity and lengthy waiting lists caused delays in diagnosing cancer recurrence and accessing treatment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient capacity to manage cancer referrals
Wider context from the report “The evidence of the Hospital Trust was that work had been ongoing in recent years to reduce delays, but that while there had been some initial improvement, there had been a further decline which I was told is in part due to an increase in referrals due to high profile celebrities announcing their cancer diagnoses and rightly encouraging people to come forward with any symptoms of concern. Therefore, despite local measures to improve performance, this has been significantly affected by a rise in cancer referrals. I was advised that this surge has been widely reported across the NHS and I was advised that NHS England has acknowledged persistent capacity constraints across many providers. The concern therefore is that the NHS does not have the ability to deal with the significant number of cancer referrals received and this is causing significant delays in waiting times which impacts on those awaiting a diagnosis, undergoing surveillance and delays in diagnosing a recurrence and those awaiting treatment.
” Open source report
Concerns raised 2 Use of ‘advice given’ outcomes producing misleading impressions of events View source Outcome codes failing to record patient refusal of 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
Nicholas Paul MURPHY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Nicholas Paul MURPHY reported taking an overdose on 29 December 2023, declined further assessment and hospital transfer, and was later found deceased at home on 9 January 2024 after a further welfare concern. The principal concerns were that ambulance outcome codes did not record refusal of treatment or transfer, and that recording the outcome as “Advice only” or “advice given” could mislead staff and result in critical safeguarding information being missed.
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 Use of ‘advice given’ outcomes producing misleading impressions of events
Wider context from the report “From the evidence I heard I am concerned that information critical to safeguarding and proper decision making may be missed, as it was in this case, given that the outcome codes do not include one that reveals the patient refused treatment.
I am also concerned that the outcome of ‘advice given’ can give a very misleading impression of events when used in these type of circumstances .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Outcome codes failing to record patient refusal of treatment
Wider context from the report “From the evidence I heard I am concerned that information critical to safeguarding and proper decision making may be missed, as it was in this case, given that the outcome codes do not include one that reveals the patient refused treatment .
I am also concerned that the outcome of ‘advice given’ can give a very misleading impression of events when used in these type of circumstances.
” Open source report
Concerns raised 3 Severe shortage of beds in mental health facilities View source Lack of legal powers for mental health patients in hospital Emergency Departments View source Limited resources for mental health patients in hospital Emergency Departments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Charles Andrew STONLEY · 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
Charles Andrew Stonley, who had severe depression with psychotic features, attended hospital with suicidal ideations and psychotic and paranoid symptoms while awaiting a mental health bed. After repeatedly leaving the Emergency Department, he was found deceased hanging in a wooded area. The report raises concerns about limited legal powers and resources for managing mental health patients in Emergency Departments and shortages of mental health beds, which can leave vulnerable patients at increased risk of self-harm and death.
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 Severe shortage of beds in mental health facilities
Wider context from the report “2. The severe shortage and availability of beds in mental health facilities resulting in vulnerable patients being left in the Emergency Department for days increasing the risk of self harm and 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 legal powers for mental health patients in hospital Emergency Departments
Wider context from the report “1. The legal powers and resources available for mental health patients in the Emergency Department of Hospitals is limited and as such detrimental to those attending Accident and Emergency Departments when suffering from a mental health crisis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Limited resources for mental health patients in hospital Emergency Departments
Wider context from the report “1. The legal powers and resources available for mental health patients in the Emergency Department of Hospitals is limited and as such detrimental to those attending Accident and Emergency Departments when suffering from a mental health crisis.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest £75 million in 2025/26 capital funding to reduce mental-health out-of-area placements.
Verbatim wording from the response “NHS England is also taking steps to address the current operational pressures driving these issues. The NHS operational planning guidance for this year tasks local health systems to improve patient flow through mental health crisis pathways and to reduce waits of more than 12 hours in EDs. In 2025/26, the NHS is also investing £75 million in capital funding to reduce mental health out-of-area placements, which pose an increased suicide risk and lead to longer stays away from the patients’ support networks.
At a local level, NHS Cheshire and Merseyside Integrated Care Board (ICB) is working with system partners to improve system flow for mental health inpatient beds. This” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue operational planning guidance requiring local systems to improve mental-health crisis flow and reduce emergency-department waits exceeding 12 hours.
Verbatim wording from the response “NHS England is also taking steps to address the current operational pressures driving these issues. The NHS operational planning guidance for this year tasks local health systems to improve patient flow through mental health crisis pathways and to reduce waits of more than 12 hours in EDs. In 2025/26, the NHS is also investing £75 million in capital funding to reduce mental health out-of-area placements, which pose an increased suicide risk and lead to longer stays away from the patients’ support networks.
At a local level, NHS Cheshire and Merseyside Integrated Care Board (ICB) is working with system partners to improve system flow for mental health inpatient beds. This” Source location Response from NHS England
Open published response
12 Aug 2025 Chloe Louise Barber · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 4 Insufficient knowledge among healthcare and social workers about provision of s117 Mental Health Act 1983 aftercare View source Lack of clear guidance on the location and personnel authorised to administer depot antipsychotic preparations View source Lack of a clearly defined transition pathway between CAMHS and adult psychiatric services View source Failure of healthcare and social workers to closely liaise with each other and allied professionals View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Chloe Louise Barber · 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
Chloe Louise Barber, who had a history of self-harm and multiple overdoses and had been detained under the Mental Health Act, was found at home on 3 November 2021 and was confirmed dead at 17:05. The report identified concerns about transition pathways between CAMHS and adult psychiatric services, guidance on administering depot antipsychotic preparations, and understanding of section 117 aftercare responsibilities.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient knowledge among healthcare and social workers about provision of s117 Mental Health Act 1983 aftercare
Wider context from the report “3. There was considerable uncertainty and ignorance about the provision of aftercare pursuant to s117 of the Mental Health Act 1983 amongst some healthcare workers and social workers , who should in any event be closely liaising with each other as well as with other allied professionals.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance on the location and personnel authorised to administer depot antipsychotic preparations
Wider context from the report “2. Concern was expressed by professional witnesses and experts that there are no clear guidelines about where and by whom depot preparations of antipsychotic may be administered .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 clearly defined transition pathway between CAMHS and adult psychiatric services
Wider context from the report “1. Evidence was heard at inquest from several expert witnesses that concern exists and continues to exist nationwide that there is not necessarily an clearly defined pathway that assists young persons making the transition between Childhood and Adolescent Mental Health Service (CAMHS) and adult psychiatric services , to ensure a smooth transit and continuity of 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 of healthcare and social workers to closely liaise with each other and allied professionals
Wider context from the report “3. There was considerable uncertainty and ignorance about the provision of aftercare pursuant to s117 of the Mental Health Act 1983 amongst some healthcare workers and social workers, who should in any event be closely liaising with each other as well as with other allied professionals .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue national guidance explaining section 117 aftercare obligations and when they apply.
Verbatim wording from the response “National guidance has been issued by NHS England and the Department of Health and Social Care (DHSC) providing staff with clear information about s117 and when this applies, including the following:” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen North East and Yorkshire pathways for young people transitioning from CAMHS to adult mental health services using personalised care approaches.
Verbatim wording from the response “Within the North East and Yorkshire Region, work is underway to strengthen pathways for young people transitioning from CAMHS into adult mental health services using personalised care approaches. The priority is to ensure a safe, seamless transition with continuity of care. Alongside this, section 117 aftercare, and ensuring personalised, consistent and appropriate support for all those entitled to it, is an identified area of focus within regional discussions and planned work.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Release guidance to Integrated Care Boards on intensive and assertive community mental health care, including depot medication.
Verbatim wording from the response “In July 2024, NHS England released new guidance for Integrated Care Boards (ICBs) to improve community mental health services, focusing on intensive and assertive treatment for people with Severe Mental Illness (SMI) who struggle to engage with standard services. This includes additional guidance on the use of depot medication, available here: NHS England » Guidance to integrate care boards on intensive and assertive community mental health care.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Release funding to healthcare systems to transform young adult mental health pathways.
Verbatim wording from the response “The NHS is committed to ensuring that every area across the country commissions a comprehensive mental health offer for children and young people, with a clear focus on supporting young adults as they move from child to adult mental health services. A key priority is ensuring continuity of care and a smooth transition between services. Funding was released to healthcare systems in 2022/23 to transform and focus” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold regional discussions to reinforce assurance that transitions follow relevant NICE guidance.
Verbatim wording from the response “NHS England’s case managers work across inpatient providers and the wider health system in accordance with the National Institute for Health and Care Excellence (NICE) guidance on the transition of young people from child to adult services. We recognise that transition remains a key area of focus across ICBs, adult mental health services and the broader system. This priority was also reflected in the NHS England Improvement Plan following the independent investigation by NICE Health and Social Care Consulting into West Lane Hospital, published in March 2023, which highlighted the need for robust transition processes. In 2023, regional discussions were held to reinforce the importance of NHS England, NHS providers and local authorities being assured that transitions are completed in line with the relevant NICE guidance.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Finalise a Personalised Care Framework setting minimum standards for secondary mental health services across children’s and adult services.
Verbatim wording from the response “NHS England is also finalising a new ‘Personalised Care Framework’ which sets out the minimum expected standards of care for people needing secondary mental health services. The Framework will apply to both CYP and Adult services, meaning a greater level of consistency in the offer across both services, giving young people transitioning between CYP and adult care will have greater clarity about what they should expect from their care.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The concerns about aftercare and discharge arrangements relate to locally commissioned services rather than NHS England specialised services.
Verbatim wording from the response “Colleagues from NHS England’s North East and Yorkshire region have advised that the concerns raised in your Report relate to locally commissioned services rather than specialised services. During Chloe’s admission to the Cygnet Hospital in Sheffield, oversight was provided by the Regional NHS England Mental Health, Learning Disability and Autism (MHLDA) Specialised Commissioning Team. Case management was in place to support the commissioning process and ensure the quality of care, including regular engagement with the provider and monitoring of Chloe’s care and pathway. Prior to discharge, multi-agency planning meetings were held, including a section 117 Mental Health Act discharge planning meeting. These meetings involved the multidisciplinary team (MDT), local CAMHS, adult mental health services, the local authority children’s social worker, as well as Chloe and her parents.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local ICBs determine policies and responsibilities for prescribing, administering and dispensing depot medication.
Verbatim wording from the response “All Trusts should have an up to date policy setting out the expected practise and responsibilities of both prescribers and those administering depot medications. This should cover prescribing, storage, dispensing, administration and monitoring requirements in line with the organisation’s overarching Medicines Policy.” Source location Response from NHS England
Open published response
Concerns raised 8 Failure to identify concerning intermenstrual bleeding when post-partum menstrual cycles are irregular View source Strict application of national cervical screening guidelines excluding women with atypical post-partum risk presentations View source Failure to account for women who have not received HPV vaccination in cervical cancer screening View source Unavailability of staffing for cervical screening appointments View source Failure to identify early-stage cervical cancer without bleeding symptoms View source Failure to distinguish post-partum bleeding from abnormal bleeding View source Cervical screening guidance failing to identify post-partum women without resumed coitus as potentially at risk View source Failure to provide timely post-partum cervical smear testing View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
QUY THI PHAM · 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
Quy Thi Pham died at Basildon Hospital on 3 September 2024 after an extremely rare and rapidly progressing early-stage cervical cancer caused metastatic pulmonary hypertension and irreversible cardiac arrest. She had been advised to wait until 12 weeks post-partum for cervical screening, and a later appointment was cancelled because of staff shortages and not rebooked. Concerns were raised about the application of national cervical screening guidance to post-partum women and whether it may exclude some women from timely diagnosis.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to identify concerning intermenstrual bleeding when post-partum menstrual cycles are irregular
Wider context from the report “(4) The Trust hospital Consultant had raised concerns about the National Cervical Screening Guidance in the past and that may mean that a cohort of women may be excluded:
i. The national guidance to identify post-coital bleeding as a symptom of concern for cervical cancer may not be helpful as not all post-partum women have resumed coitus
ii. Post-partum colp can persist or be misinterpreted, meaning that bleeding may not be understood as abnormal
iii. Women may not have a regular menstrual cycle, and bleeding may not be easy to identify as intermenstrual in accordance with the national guidance to give rise to a cause for concern
iv. Rare complications of early-stage cervical cancer may not always manifest with symptoms of bleeding
v. Not all women residing in the UK have had the HPV vaccine
Those providing cervical screening services may be strictly applying the national guidelines and, with the proposed changes in National Screening this may increase the risk for women 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 Strict application of national cervical screening guidelines excluding women with atypical post-partum risk presentations
Wider context from the report “(4) The Trust hospital Consultant had raised concerns about the National Cervical Screening Guidance in the past and that may mean that a cohort of women may be excluded:
i. The national guidance to identify post-coital bleeding as a symptom of concern for cervical cancer may not be helpful as not all post-partum women have resumed coitus
ii. Post-partum colp can persist or be misinterpreted, meaning that bleeding may not be understood as abnormal
iii. Women may not have a regular menstrual cycle, and bleeding may not be easy to identify as intermenstrual in accordance with the national guidance to give rise to a cause for concern
iv. Rare complications of early-stage cervical cancer may not always manifest with symptoms of bleeding
v. Not all women residing in the UK have had the HPV vaccine
Those providing cervical screening services may be strictly applying the national guidelines and, with the proposed changes in National Screening this may increase the risk for women 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 account for women who have not received HPV vaccination in cervical cancer screening
Wider context from the report “(4) The Trust hospital Consultant had raised concerns about the National Cervical Screening Guidance in the past and that may mean that a cohort of women may be excluded:
i. The national guidance to identify post-coital bleeding as a symptom of concern for cervical cancer may not be helpful as not all post-partum women have resumed coitus
ii. Post-partum colp can persist or be misinterpreted, meaning that bleeding may not be understood as abnormal
iii. Women may not have a regular menstrual cycle, and bleeding may not be easy to identify as intermenstrual in accordance with the national guidance to give rise to a cause for concern
iv. Rare complications of early-stage cervical cancer may not always manifest with symptoms of bleeding
v. Not all women residing in the UK have had the HPV vaccine
Those providing cervical screening services may be strictly applying the national guidelines and, with the proposed changes in National Screening this may increase the risk for women 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 Unavailability of staffing for cervical screening appointments
Wider context from the report “(2) Ms Pham attended the GP surgery at approximately 9 weeks post-partum and was informed that she must wait until she was at least 12 weeks post-partum to have her smear. This appointment was then cancelled due to staff shortages .
(3) The Trust hospital Consultant explained that the most important factor to diagnose a patient is having a smear test and that it was not prohibited to have a smear test at 9-weeks post-partum, especially if a patient had not had a previous smear test, as in the case of Ms Pham who had an early-stage cervical cancer with no infiltration into surrounding organs or structures.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 early-stage cervical cancer without bleeding symptoms
Wider context from the report “(4) The Trust hospital Consultant had raised concerns about the National Cervical Screening Guidance in the past and that may mean that a cohort of women may be excluded:
i. The national guidance to identify post-coital bleeding as a symptom of concern for cervical cancer may not be helpful as not all post-partum women have resumed coitus
ii. Post-partum colp can persist or be misinterpreted, meaning that bleeding may not be understood as abnormal
iii. Women may not have a regular menstrual cycle, and bleeding may not be easy to identify as intermenstrual in accordance with the national guidance to give rise to a cause for concern
iv. Rare complications of early-stage cervical cancer may not always manifest with symptoms of bleeding
v. Not all women residing in the UK have had the HPV vaccine
Those providing cervical screening services may be strictly applying the national guidelines and, with the proposed changes in National Screening this may increase the risk for women 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 distinguish post-partum bleeding from abnormal bleeding
Wider context from the report “(4) The Trust hospital Consultant had raised concerns about the National Cervical Screening Guidance in the past and that may mean that a cohort of women may be excluded:
i. The national guidance to identify post-coital bleeding as a symptom of concern for cervical cancer may not be helpful as not all post-partum women have resumed coitus
ii. Post-partum colp can persist or be misinterpreted, meaning that bleeding may not be understood as abnormal
iii. Women may not have a regular menstrual cycle, and bleeding may not be easy to identify as intermenstrual in accordance with the national guidance to give rise to a cause for concern
iv. Rare complications of early-stage cervical cancer may not always manifest with symptoms of bleeding
v. Not all women residing in the UK have had the HPV vaccine
Those providing cervical screening services may be strictly applying the national guidelines and, with the proposed changes in National Screening this may increase the risk for women 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 Cervical screening guidance failing to identify post-partum women without resumed coitus as potentially at risk
Wider context from the report “(4) The Trust hospital Consultant had raised concerns about the National Cervical Screening Guidance in the past and that may mean that a cohort of women may be excluded:
i. The national guidance to identify post-coital bleeding as a symptom of concern for cervical cancer may not be helpful as not all post-partum women have resumed coitus
ii. Post-partum colp can persist or be misinterpreted, meaning that bleeding may not be understood as abnormal
iii. Women may not have a regular menstrual cycle, and bleeding may not be easy to identify as intermenstrual in accordance with the national guidance to give rise to a cause for concern
iv. Rare complications of early-stage cervical cancer may not always manifest with symptoms of bleeding
v. Not all women residing in the UK have had the HPV vaccine
Those providing cervical screening services may be strictly applying the national guidelines and, with the proposed changes in National Screening this may increase the risk for women 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 provide timely post-partum cervical smear testing
Wider context from the report “(2) Ms Pham attended the GP surgery at approximately 9 weeks post-partum and was informed that she must wait until she was at least 12 weeks post-partum to have her smear . This appointment was then cancelled due to staff shortages.
(3) The Trust hospital Consultant explained that the most important factor to diagnose a patient is having a smear test and that it was not prohibited to have a smear test at 9-weeks post-partum , especially if a patient had not had a previous smear test, as in the case of Ms Pham who had an early-stage cervical cancer with no infiltration into surrounding organs or structures.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct research on the safety, accuracy and reliability of cervical screening within three months after birth.
Verbatim wording from the response “There is research underway supported by the cervical screening programme to collect evidence on whether it is safe, accurate and reliable to report cervical screening tests within 3 months of birth. This research is expected to conclude by September 2027. When the findings of this research are available, NHS England will consider them and update national guidance accordingly.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider the research findings when available and assess their implications for national cervical screening guidance.
Verbatim wording from the response “There is research underway supported by the cervical screening programme to collect evidence on whether it is safe, accurate and reliable to report cervical screening tests within 3 months of birth. This research is expected to conclude by September 2027. When the findings of this research are available, NHS England will consider them and update national guidance accordingly.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing guidance is considered sufficient: symptomatic women should seek GP advice, screening is non-diagnostic, and screening should be delayed for three months after birth.
Verbatim wording from the response “The aim of the national cervical screening programme is to detect asymptomatic cell changes in the cervix that could, if left untreated, develop into cervical cancer in the future. The screening programme guidance for patients with unusual bleeding or gynaecological symptoms they are concerned about is always to seek advice from their GP. A cervical screening test is not an appropriate tool to investigate these concerns as it is not a diagnostic test.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Postnatal screening would probably not have prevented the death because the cancer was aggressive, metastatic at presentation and incurable.
Verbatim wording from the response “Based on the clinical history provided which has been reviewed by clinical experts who support NHS England’s cervical screening team, Quy suffered from an aggressive form of cervical cancer which metastasised to the lungs at presentation. It is accepted that unusual and rapidly developing cervical cancers are unlikely to be prevented by screening. Even if Quy had received post-natal screening in July 2024, on the balance of probabilities, Quy would still have had an aggressive cervical cancer with lung metastases which, sadly, would still have been incurable.” Source location Response from NHS England
Open published response
Concerns raised 6 Unavailability of arrangements for locating people at immediate risk across all charity crisis text services View source Failure of crisis text services to use Greater Manchester mental health pathways for early referral View source Failure to provide crisis text services across all ICBs View source Lack of standard policies and procedures for responding to immediate suicide risk View source Failure of charity crisis text services to link with local NHS Trusts and pathways View source Lack of a commissioned crisis text mental health support service in Greater Manchester View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jessica Lynda Smithson · 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
Jessica Lynda Smithson, aged 27, died by suicide after contacting a crisis text mental health service following an alleged serious sexual assault. The service did not contact the Metropolitan Police despite messages indicating an immediate risk to her life. The report identified concerns about inconsistent procedures among charity crisis text services and the absence of a commissioned crisis text mental health service in Greater Manchester.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unavailability of arrangements for locating people at immediate risk across all charity crisis text services
Wider context from the report “(b) At present this gap in a health-related service is being filled by charity organisations who have different policies and processes regarding actions to be taken if a person is at immediate risk of suicide. The charities are not under the Department of Health so there is no standard policy or procedure for them to follow if there is a real and immediate risk to a service user’s life.
Hence there is a lack of consistency as to the support an individual can receive when there is an immediate risk to their life, for example whilst the charity involved in this case have an agreement with the Metropolitan Police Service to help locate someone whose whereabouts are unknown, this is not the case for all charities .
In addition, as they are not linked into local NHS Trusts, they have limited ability to understand local mental health NHS pathways or to offer a more co-ordinated response where someone is already under local mental health services.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of crisis text services to use Greater Manchester mental health pathways for early referral
Wider context from the report “2. Within the Greater Manchester Area there is no commissioned crisis text mental health support service. Whilst GM residents can message national services, often the location of an individual texter will not be known.
The court heard from Greater Manchester Police that they receive a significant number of referrals which have been sent by this crisis service to the Metropolitan Police, almost one a day where there has been a real and immediate risk to a person’s life identified. All of these referrals require an immediate police response (they are outside of Right Care Right Person). If there was a GM commissioned service, it is likely that any search for the location of the individual would be done by GMP and would shorten the timeframe in which they could respond to the risk.
In addition, a GM commissioned service would have a greater understanding of local pathways in order to refer people who may have a deteriorating mental health before they reached the point of crisis .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 crisis text services across all ICBs
Wider context from the report “(a) The NHSE indicated in their April 2024 Crisis Text Support Guidance and Specification document that they will oversee the rollout of these services which was expected to be rolled out by the end of March 2025. This has now been extended to March 2026.As of to date the evidence indicates only 10 have set up such a service with another 11 in the process of doing so . Some ICBs have indicated that they have no plans to do so .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of standard policies and procedures for responding to immediate suicide risk
Wider context from the report “(b) At present this gap in a health-related service is being filled by charity organisations who have different policies and processes regarding actions to be taken if a person is at immediate risk of suicide . The charities are not under the Department of Health so there is no standard policy or procedure for them to follow if there is a real and immediate risk to a service user’s life .
Hence there is a lack of consistency as to the support an individual can receive when there is an immediate risk to their life , for example whilst the charity involved in this case have an agreement with the Metropolitan Police Service to help locate someone whose whereabouts are unknown, this is not the case for all charities.
In addition, as they are not linked into local NHS Trusts, they have limited ability to understand local mental health NHS pathways or to offer a more co-ordinated response where someone is already under local mental health services.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of charity crisis text services to link with local NHS Trusts and pathways
Wider context from the report “(b) At present this gap in a health-related service is being filled by charity organisations who have different policies and processes regarding actions to be taken if a person is at immediate risk of suicide. The charities are not under the Department of Health so there is no standard policy or procedure for them to follow if there is a real and immediate risk to a service user’s life.
Hence there is a lack of consistency as to the support an individual can receive when there is an immediate risk to their life, for example whilst the charity involved in this case have an agreement with the Metropolitan Police Service to help locate someone whose whereabouts are unknown, this is not the case for all charities.
In addition, as they are not linked into local NHS Trusts , they have limited ability to understand local mental health NHS pathways or to offer a more co-ordinated response where someone is already under local mental health services.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a commissioned crisis text mental health support service in Greater Manchester
Wider context from the report “2. Within the Greater Manchester Area there is no commissioned crisis text mental health support service . Whilst GM residents can message national services, often the location of an individual texter will not be known .
The court heard from Greater Manchester Police that they receive a significant number of referrals which have been sent by this crisis service to the Metropolitan Police, almost one a day where there has been a real and immediate risk to a person’s life identified. All of these referrals require an immediate police response (they are outside of Right Care Right Person). If there was a GM commissioned service, it is likely that any search for the location of the individual would be done by GMP and would shorten the timeframe in which they could respond to the risk .
In addition, a GM commissioned service would have a greater understanding of local pathways in order to refer people who may have a deteriorating mental health before they reached the point of crisis.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request all Integrated Care Boards to establish integrated crisis text services.
Verbatim wording from the response “Anyone in England can access age-appropriate crisis support by calling NHS111 and selecting the ‘mental health option’, with services commissioned and designed to deliver consistent triage, risk assessment and, where necessary, rapid face-to-face assessments. To further enhance accessibility, NHS England has requested that all ICBs put in place integrated crisis text services and ICBs have now submitted their plans, with delivery expected across all areas by Spring 2026.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The non-NHS charity’s service delivery and clinical governance arrangements fall outside the respondent’s ability to comment on.
Verbatim wording from the response “We would suggest the Coroner’s Office approaches the charity directly for further information about the support provided, if required. As this is a non-NHS provider, we are unable to comment on their service delivery arrangements or clinical governance processes.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS Greater Manchester ICB will respond separately to concerns about the lack of a locally commissioned service.
Verbatim wording from the response “Your Report also directed some concerns to NHS Greater Manchester ICB (GM ICB), regarding the current lack of a locally commissioned service and the implications of” Source location Response from NHS England
Open published response
Concerns raised 1 Failure to provide sufficient designated clinical space for Emergency Department patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Maureen Brenda Batchelor · 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
Maureen Brenda Batchelor was admitted to hospital with diarrhoea and vomiting, was diagnosed with gastroenteritis and aspiration pneumonia, and died on 26 February 2025 from septicaemia caused by aspiration pneumonia. The report raised concerns that patients were being treated in the Emergency Department corridor, a non-clinical area, because of insufficient capacity, with this practice continuing and no evidence as to when it would end.
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 sufficient designated clinical space for Emergency Department patients
Wider context from the report “During the inquest I heard evidence from clinicians at University Hospitals Sussex NHS Foundation Trust that when the Emergency Department of the Royal Sussex County Hospital, Brighton reached capacity patients would be moved to and treated in the corridor as there was no clinical area available to do so. The area is not designated as a clinical area.
I understand that at the time of Mrs Batchelor's attendance on 25 February there were 25 patients in the Emergency Department corridor, and this increased to 32 patients.
Clinicians from University Hospitals Sussex NHS Foundation Trust gave evidence as to the action that is being taken by the Trust currently to (1) reduce the number of patients who present to the Emergency Department who could be seen by other services in the community and (2) to create an improved patient flow through the Royal Sussex County Hospital. The evidence was however that, despite these actions, the corridor remains in use for patients currently as there is insufficient space within the department to care for patients. When asked there was no evidence as to when this practice would no longer be necessary.
I was also advised that the use of corridors to care for patients is not only an issue at the Royal Sussex County Hospital, Brighton but is used throughout the country when the capacities of Emergency Departments has been reached and there is nowhere to treat patients and the only other alternative would be to hold patients in ambulances outside of the hospital.
A Prevention of Future Deaths report in relation to the use of the corridor for patient care was made during an investigation into a death which occurred in December 2022 and the use of the corridor remains ongoing.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish Temporary Escalation Space usage data during 2025/26 to drive reductions in corridor care.
Verbatim wording from the response “Furthermore, since January 2025, NHS England has mandated all acute hospitals to report daily TES usage in EDs and wards. Most are now submitting data, and NHS England is working with regional teams to improve its quality, timeliness and completeness. The goal is to begin publishing data during 2025/26, to drive reductions in the use of corridor care across the country and achieve the ambition set out in the UEC plan.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish principles for providing safer care in Temporary Escalation Spaces when demand exceeds capacity.
Verbatim wording from the response “The delivery of care in Temporary Escalation Spaces (TES) in EDs experiencing patient crowding (including providing care at beds and chairs) is not acceptable and should not be considered as standard. TES refers to care given in any unplanned settings (such as corridors) and, in September 2024, NHS England published a set of principles for supporting improved quality of care should patient demand outstrip capacity. These principles have been developed to support point-of-care staff to provide the safest, most effective and highest quality care possible when TES care has been deemed necessary, and the principles should be applied alongside any local standard operating procedures and arrangements governing flow pathways and safe staffing.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop the operating model supporting providers to eliminate emergency-department crowding and corridor care.
Verbatim wording from the response “In June 2025, NHS England published the Urgent and Emergency Care (UEC) Plan for 2025/26, which included an ambition to ‘improve flow through hospitals with a particular focus on patients waiting over 12 hours and making progress on eliminating corridor care’. NHS England is working through the operating model to support providers to eliminate crowding in EDs in the longer term. Improvements are being progressed through NHS England’s Operational Planning guidance, where healthcare systems were asked to focus on areas to deliver improved patient flow. This has included increasing the productivity of acute and non-acute hospital services, improving flow and length of stay, as well as clinical outcomes. In addition to this, we” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop services that shift unplanned urgent activity from acute hospitals to alternative settings and support proactive care and discharge.
Verbatim wording from the response “are continuing to develop services that shift activity from acute hospital settings to settings outside of an acute hospital for patients with unplanned urgent needs, supporting proactive care, alternatives to admission and improving hospital discharge.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mandate daily reporting of Temporary Escalation Space use by acute hospitals in emergency departments and wards.
Verbatim wording from the response “Furthermore, since January 2025, NHS England has mandated all acute hospitals to report daily TES usage in EDs and wards. Most are now submitting data, and NHS England is working with regional teams to improve its quality, timeliness and completeness. The goal is to begin publishing data during 2025/26, to drive reductions in the use of corridor care across the country and achieve the ambition set out in the UEC plan.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Progress patient-flow improvements through Operational Planning guidance, including productivity, reduced length of stay and improved clinical outcomes.
Verbatim wording from the response “In June 2025, NHS England published the Urgent and Emergency Care (UEC) Plan for 2025/26, which included an ambition to ‘improve flow through hospitals with a particular focus on patients waiting over 12 hours and making progress on eliminating corridor care’. NHS England is working through the operating model to support providers to eliminate crowding in EDs in the longer term. Improvements are being progressed through NHS England’s Operational Planning guidance, where healthcare systems were asked to focus on areas to deliver improved patient flow. This has included increasing the productivity of acute and non-acute hospital services, improving flow and length of stay, as well as clinical outcomes. In addition to this, we” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with regional teams to improve the quality, timeliness and completeness of Temporary Escalation Space data.
Verbatim wording from the response “Furthermore, since January 2025, NHS England has mandated all acute hospitals to report daily TES usage in EDs and wards. Most are now submitting data, and NHS England is working with regional teams to improve its quality, timeliness and completeness. The goal is to begin publishing data during 2025/26, to drive reductions in the use of corridor care across the country and achieve the ambition set out in the UEC plan.” Source location Response from NHS England
Open published response
21 Jul 2025 Jean DYE · Prevention of Future Deaths report Greater Lincolnshire
View report summary
Concerns raised 4 Unavailability of an in-room EPO circuit reset control View source Lack of guidance on remote siting of Emergency Power Off controls View source Accidental activation of Emergency Power Off circuits overriding emergency power backup systems View source Lack of in-room indication of Emergency Power Off circuit activation View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jean DYE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jean Dye died at Scunthorpe General Hospital after an artery dissection during a cardiac procedure, followed by an unexpected electrical power failure that delayed emergency stenting for approximately 10 minutes. The principal concerns were that activation of the Emergency Power Off circuit overrode backup power, there was no indicator or local reset control in the treatment room, and guidance on the location of such controls and related training may require review.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unavailability of an in-room EPO circuit reset control
Wider context from the report “The circumstances of Mrs Dye's death are set out above. Her death arose as a consequence of the combination of an iatrogenic injury sustained during a clinical procedure and an untimely loss of power to the Catheter Lab where she was being treated for a period of approximately ten minutes at exactly the time at which her treating consultant required the benefits of real time x ray to facilitate a necessary emergency stenting procedure. The delay whilst power was restored was a critical factor in this death.
The loss of power arose as a result of the Emergency Power Off (EPO) circuit activating. It overrode the emergency power back up system. The reason for that activation was unclear although a physical activation of any of the three EPO buttons was excluded on the evidence. All staff at the scene were unaware of the cause of the loss of power, never having experienced such a situation previously, and an engineer was summoned to attend to reinstate the power, which he did.
There was no light or other indicator within the lab to confirm to those present that the EPO circuit had activated. Likewise there was no restart button within the lab to permit the EPO circuit to be reset. That lay within the plant room elsewhere within the hospital.
I received evidence of a small number of accidental activations of EPO circuits nationally over a 12 month period. It is plainly something which can, and does, occur.
Had staff been aware of the exact cause of the loss of power on this occasion and had they had the opportunity to reset the circuit without the need to await the arrival of an engineer, who inturn had to attend a separate plant room , the downtime would likely have been significantly reduced . Whilst it was not possible to say that the additional time spent on this occasion made a difference between the patient surviving or not, there may well be future cases within which such fine margins are time critical.
I received evidence that there is no current guidance in relation to the siting of such controls remote from the affected room. I invite review of that guidance and of the need for any consequential training.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on remote siting of Emergency Power Off controls
Wider context from the report “The circumstances of Mrs Dye's death are set out above. Her death arose as a consequence of the combination of an iatrogenic injury sustained during a clinical procedure and an untimely loss of power to the Catheter Lab where she was being treated for a period of approximately ten minutes at exactly the time at which her treating consultant required the benefits of real time x ray to facilitate a necessary emergency stenting procedure. The delay whilst power was restored was a critical factor in this death.
The loss of power arose as a result of the Emergency Power Off (EPO) circuit activating. It overrode the emergency power back up system. The reason for that activation was unclear although a physical activation of any of the three EPO buttons was excluded on the evidence. All staff at the scene were unaware of the cause of the loss of power, never having experienced such a situation previously, and an engineer was summoned to attend to reinstate the power, which he did.
There was no light or other indicator within the lab to confirm to those present that the EPO circuit had activated. Likewise there was no restart button within the lab to permit the EPO circuit to be reset. That lay within the plant room elsewhere within the hospital.
I received evidence of a small number of accidental activations of EPO circuits nationally over a 12 month period. It is plainly something which can, and does, occur.
Had staff been aware of the exact cause of the loss of power on this occasion and had they had the opportunity to reset the circuit without the need to await the arrival of an engineer, who inturn had to attend a separate plant room, the downtime would likely have been significantly reduced. Whilst it was not possible to say that the additional time spent on this occasion made a difference between the patient surviving or not, there may well be future cases within which such fine margins are time critical.
I received evidence that there is no current guidance in relation to the siting of such controls remote from the affected room . I invite review of that guidance and of the need for any consequential training.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Accidental activation of Emergency Power Off circuits overriding emergency power backup systems
Wider context from the report “The circumstances of Mrs Dye's death are set out above. Her death arose as a consequence of the combination of an iatrogenic injury sustained during a clinical procedure and an untimely loss of power to the Catheter Lab where she was being treated for a period of approximately ten minutes at exactly the time at which her treating consultant required the benefits of real time x ray to facilitate a necessary emergency stenting procedure. The delay whilst power was restored was a critical factor in this death.
The loss of power arose as a result of the Emergency Power Off (EPO) circuit activating. It overrode the emergency power back up system. The reason for that activation was unclear although a physical activation of any of the three EPO buttons was excluded on the evidence. All staff at the scene were unaware of the cause of the loss of power, never having experienced such a situation previously, and an engineer was summoned to attend to reinstate the power, which he did.
There was no light or other indicator within the lab to confirm to those present that the EPO circuit had activated. Likewise there was no restart button within the lab to permit the EPO circuit to be reset. That lay within the plant room elsewhere within the hospital.
I received evidence of a small number of accidental activations of EPO circuits nationally over a 12 month period. It is plainly something which can, and does, occur.
Had staff been aware of the exact cause of the loss of power on this occasion and had they had the opportunity to reset the circuit without the need to await the arrival of an engineer, who inturn had to attend a separate plant room, the downtime would likely have been significantly reduced. Whilst it was not possible to say that the additional time spent on this occasion made a difference between the patient surviving or not, there may well be future cases within which such fine margins are time critical.
I received evidence that there is no current guidance in relation to the siting of such controls remote from the affected room. I invite review of that guidance and of the need for any consequential training.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 in-room indication of Emergency Power Off circuit activation
Wider context from the report “The circumstances of Mrs Dye's death are set out above. Her death arose as a consequence of the combination of an iatrogenic injury sustained during a clinical procedure and an untimely loss of power to the Catheter Lab where she was being treated for a period of approximately ten minutes at exactly the time at which her treating consultant required the benefits of real time x ray to facilitate a necessary emergency stenting procedure. The delay whilst power was restored was a critical factor in this death.
The loss of power arose as a result of the Emergency Power Off (EPO) circuit activating. It overrode the emergency power back up system. The reason for that activation was unclear although a physical activation of any of the three EPO buttons was excluded on the evidence. All staff at the scene were unaware of the cause of the loss of power, never having experienced such a situation previously, and an engineer was summoned to attend to reinstate the power, which he did.
There was no light or other indicator within the lab to confirm to those present that the EPO circuit had activated. Likewise there was no restart button within the lab to permit the EPO circuit to be reset. That lay within the plant room elsewhere within the hospital.
I received evidence of a small number of accidental activations of EPO circuits nationally over a 12 month period. It is plainly something which can, and does, occur.
Had staff been aware of the exact cause of the loss of power on this occasion and had they had the opportunity to reset the circuit without the need to await the arrival of an engineer, who inturn had to attend a separate plant room, the downtime would likely have been significantly reduced. Whilst it was not possible to say that the additional time spent on this occasion made a difference between the patient surviving or not, there may well be future cases within which such fine margins are time critical.
I received evidence that there is no current guidance in relation to the siting of such controls remote from the affected room. I invite review of that guidance and of the need for any consequential training.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update HTM 06-01, reviewing EPO content against the incident and HBN 06-01 to align the final guidance.
Verbatim wording from the response “This guidance is focused on stopping accidental activation of the EPO, but does not currently state what to do if the EPO is activated in error. The NHS England Estate’s team advise that they will address this when the HTM 06-01 guidance document is next updated.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend HBN 06-01 to address emergency-stop button locations and incorporate the discussed changes to EPO guidance.
Verbatim wording from the response “Earlier guidance, published in 2001 by the former NHS Estates (an Executive Agency of DHSC abolished in 2005) called HBN 06-01 “Facilities for diagnostic imaging and interventional radiology” is in the process of being updated, but excludes cardiac facilities covered separately in HBN 01-01. The draft updated HBN 06-01 currently includes the following text on EPO buttons:” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation An EPO control need not be located in the equipment room; a means to reset it is sufficient, subject to a room-design risk assessment.
Verbatim wording from the response “NHS England’s Head of Hard Facilities Management has been contacted by an independent advisor to the Medicines and Healthcare products Regulatory Agency (MHRA) on electrical safety, who was involved in the inquest hearing. The MHRA advisor raised that:” Source location Response from NHS England
Open published response
15 Jul 2025 Alfie Lydon · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Failure to maintain contemporaneous, accurate and immediately available documentation of external calls between community and hospital teams View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Alfie Lydon · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alfie Lydon was admitted to hospital after being found profoundly unwell at home, transferred for intensive care, and died from the consequences of a viral infection. Before admission, his parents had raised concerns about his feeding and increasing lethargy, and discussions between midwives and the neonatal team were not consistently documented. The report raised concern that inadequate, contemporaneous documentation of discussions between community and hospital teams could affect continuity and escalation of care and result in future deaths in similar circumstances.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain contemporaneous, accurate and immediately available documentation of external calls between community and hospital teams
Wider context from the report “1. I heard evidence that the vast majority of hospital Trusts do not have processes in place to document external calls from midwives to hospital teams . Concerns were raised that this can result in a lack of continuity and escalation of care, particularly with regards to parental concerns.
The hospital Trust involved has taken steps to document such calls now but this is undertaken on paper, which is subsequently uploaded to the hospital records. They plan to implement an electronic solution but not for some time.
There is a concern that a lack of contemporaneous, accurate and immediately available documentation of discussions between community and hospital teams could result in deaths in future similar circumstances. Given that this is not simply a local issue, this concern warrants raising at a national level.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise Alfie’s case with Neonatal Operational Delivery Networks and Regional maternity teams.
Verbatim wording from the response “Alfie’s case will be raised with the Neonatal Operational Delivery Networks and Regional maternity teams, with the expectation that they subsequently cascade to all maternity and neonatal units the importance of documenting such consultations.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Trusts are responsible for ensuring effective recording and access processes where digital infrastructure is unavailable.
Verbatim wording from the response “With regard to documenting communication between community midwives and staff working on acute sites, this would be a standard expectation in the provision of care for both those making and those receiving the calls. Both staff groups will typically utilise the relevant Trust’s Electronic Patient Record (EPR) system for either community midwifery services or hospital maternity / neonatal services, depending on which staff groups on the acute site are involved. This should allow them to record information directly within the patient’s record, which should be accessible to all system users regardless of setting. This is on the provision that the maternity service has the necessary digital infrastructure, including capabilities for offline working when in the community.” Source location Response from NHS England
Open published response
14 Jul 2025 Myles Edward SCRIVEN · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 6 Lack of knowledge of requirements for patients with learning disabilities and autism View source Failure to understand and use the Learning Disabilities Register View source Failure to liaise with the Learning Disabilities Service to address missing support arrangements View source Failure to undertake rigorous and detailed internal incident review for learning View source Failure to record numeric observations properly View source Failure to make appropriate adjustments for patients with learning disabilities and autism View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Myles Edward SCRIVEN · 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
Myles Edward Scriven died at Huddersfield Royal Infirmary on 16 April 2023. The report states that he had several contacts with Dalton Surgery while suffering from an ongoing pulmonary embolism, none of which resulted in referral to secondary care, and that the handling of his care contributed to his death. Concerns also included insufficient adjustments and understanding of his autism and learning disabilities, failure to record numeric observations properly, and failure to undertake a rigorous internal 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 Lack of knowledge of requirements for patients with learning disabilities and autism
Wider context from the report “While the rider of Neglect does not attach to the actions of the Dalton Surgery, the fact remains that between 16 and 20 March 2023 Myles had several contacts with the Dalton Surgery while he was suffering with an on going Pulmonary Embolism. Non of these resulted in a referral to secondary care. The combined evidence of three expert witnesses was that the manner in which his care was handled at this stage contributed to his death.
The following are concerns that I have arising from the evidence in he Inquest.
1. Ignorance of what was required for Myles in the circumstances of his Learning Disability and Autism - the GPs clearly only had a superficial grasp of the regulatory requirements and realities to do with Learning Disabilities . They are clearly well intentioned and caring but their appreciation and approach seems to have been based entirely on professional experience and good intentions rather than real knowledge of what was required and how to implement it.
Notably:
•They repeatedly used the words learning difficulties and learning disabilities interchangeably and apparently randomly – I am not told that Myles had a personal preference about which to use that they deferred to. Essentially, they seem to have been ignorant as to the distinction.
•They made only the most modest adjustments for Myles's Learning Disabilities and Autism.
•They clearly had very little grasp of what the Learning Disabilities Register was and how it worked. Neither of the GPs who gave evidence were able to provide a solid, reliable version of how it operated in their practice, when or/if Myles had been entered on to it, whether it was distinct from the psychiatric review - one seemed to conflate the two and the other said that it was something managed by a Nurse in the practice. It is quite evident that correspondence was coming in from Learning Disabilities Psychiatry but nothing at all from Social Services. This is not something that seems to have triggered any particular reaction at the GP level. They seemed to operate on the basis that the Learning Disabilities ’box had been ticked’ and that nothing further was needed. In fact, Myles seems to have been on the Register from 2020 but by the 20 October 2022 when he had been at hospital in relation to his PE he had no Learning Disability Social Worker and concomitantly no VIP passport on admission to hospital . The GPs clearly had no idea of how important all this was. I heard evidence from a secondary care Learning Disabilities Professional that they, in secondary care, rely a great deal on primary care to get these things sorted out. Here, nothing went back from the Practice to the Learning Disabilities Service to chase these things.
2. The failure of the GP to record numeric observations properly on 20 March 2023.
3. The failure of the Dalton Surgery to undertake any rigorous and detailed internal review for learning purposes after this incident.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 understand and use the Learning Disabilities Register
Wider context from the report “While the rider of Neglect does not attach to the actions of the Dalton Surgery, the fact remains that between 16 and 20 March 2023 Myles had several contacts with the Dalton Surgery while he was suffering with an on going Pulmonary Embolism. Non of these resulted in a referral to secondary care. The combined evidence of three expert witnesses was that the manner in which his care was handled at this stage contributed to his death.
The following are concerns that I have arising from the evidence in he Inquest.
1. Ignorance of what was required for Myles in the circumstances of his Learning Disability and Autism - the GPs clearly only had a superficial grasp of the regulatory requirements and realities to do with Learning Disabilities. They are clearly well intentioned and caring but their appreciation and approach seems to have been based entirely on professional experience and good intentions rather than real knowledge of what was required and how to implement it.
Notably:
•They repeatedly used the words learning difficulties and learning disabilities interchangeably and apparently randomly – I am not told that Myles had a personal preference about which to use that they deferred to. Essentially, they seem to have been ignorant as to the distinction.
•They made only the most modest adjustments for Myles's Learning Disabilities and Autism.
•They clearly had very little grasp of what the Learning Disabilities Register was and how it worked. Neither of the GPs who gave evidence were able to provide a solid, reliable version of how it operated in their practice, when or/if Myles had been entered on to it, whether it was distinct from the psychiatric review - one seemed to conflate the two and the other said that it was something managed by a Nurse in the practice. It is quite evident that correspondence was coming in from Learning Disabilities Psychiatry but nothing at all from Social Services. This is not something that seems to have triggered any particular reaction at the GP level. They seemed to operate on the basis that the Learning Disabilities ’box had been ticked’ and that nothing further was needed. In fact, Myles seems to have been on the Register from 2020 but by the 20 October 2022 when he had been at hospital in relation to his PE he had no Learning Disability Social Worker and concomitantly no VIP passport on admission to hospital . The GPs clearly had no idea of how important all this was. I heard evidence from a secondary care Learning Disabilities Professional that they, in secondary care, rely a great deal on primary care to get these things sorted out. Here, nothing went back from the Practice to the Learning Disabilities Service to chase these things.
2. The failure of the GP to record numeric observations properly on 20 March 2023.
3. The failure of the Dalton Surgery to undertake any rigorous and detailed internal review for learning purposes after this incident.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 liaise with the Learning Disabilities Service to address missing support arrangements
Wider context from the report “While the rider of Neglect does not attach to the actions of the Dalton Surgery, the fact remains that between 16 and 20 March 2023 Myles had several contacts with the Dalton Surgery while he was suffering with an on going Pulmonary Embolism. Non of these resulted in a referral to secondary care. The combined evidence of three expert witnesses was that the manner in which his care was handled at this stage contributed to his death.
The following are concerns that I have arising from the evidence in he Inquest.
1. Ignorance of what was required for Myles in the circumstances of his Learning Disability and Autism - the GPs clearly only had a superficial grasp of the regulatory requirements and realities to do with Learning Disabilities. They are clearly well intentioned and caring but their appreciation and approach seems to have been based entirely on professional experience and good intentions rather than real knowledge of what was required and how to implement it.
Notably:
•They repeatedly used the words learning difficulties and learning disabilities interchangeably and apparently randomly – I am not told that Myles had a personal preference about which to use that they deferred to. Essentially, they seem to have been ignorant as to the distinction.
•They made only the most modest adjustments for Myles's Learning Disabilities and Autism.
•They clearly had very little grasp of what the Learning Disabilities Register was and how it worked. Neither of the GPs who gave evidence were able to provide a solid, reliable version of how it operated in their practice, when or/if Myles had been entered on to it, whether it was distinct from the psychiatric review - one seemed to conflate the two and the other said that it was something managed by a Nurse in the practice. It is quite evident that correspondence was coming in from Learning Disabilities Psychiatry but nothing at all from Social Services. This is not something that seems to have triggered any particular reaction at the GP level. They seemed to operate on the basis that the Learning Disabilities ’box had been ticked’ and that nothing further was needed. In fact, Myles seems to have been on the Register from 2020 but by the 20 October 2022 when he had been at hospital in relation to his PE he had no Learning Disability Social Worker and concomitantly no VIP passport on admission to hospital . The GPs clearly had no idea of how important all this was. I heard evidence from a secondary care Learning Disabilities Professional that they, in secondary care, rely a great deal on primary care to get these things sorted out. Here, nothing went back from the Practice to the Learning Disabilities Service to chase these things.
2. The failure of the GP to record numeric observations properly on 20 March 2023.
3. The failure of the Dalton Surgery to undertake any rigorous and detailed internal review for learning purposes after this incident.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake rigorous and detailed internal incident review for learning
Wider context from the report “While the rider of Neglect does not attach to the actions of the Dalton Surgery, the fact remains that between 16 and 20 March 2023 Myles had several contacts with the Dalton Surgery while he was suffering with an on going Pulmonary Embolism. Non of these resulted in a referral to secondary care. The combined evidence of three expert witnesses was that the manner in which his care was handled at this stage contributed to his death.
The following are concerns that I have arising from the evidence in he Inquest.
1. Ignorance of what was required for Myles in the circumstances of his Learning Disability and Autism - the GPs clearly only had a superficial grasp of the regulatory requirements and realities to do with Learning Disabilities. They are clearly well intentioned and caring but their appreciation and approach seems to have been based entirely on professional experience and good intentions rather than real knowledge of what was required and how to implement it.
Notably:
•They repeatedly used the words learning difficulties and learning disabilities interchangeably and apparently randomly – I am not told that Myles had a personal preference about which to use that they deferred to. Essentially, they seem to have been ignorant as to the distinction.
•They made only the most modest adjustments for Myles's Learning Disabilities and Autism.
•They clearly had very little grasp of what the Learning Disabilities Register was and how it worked. Neither of the GPs who gave evidence were able to provide a solid, reliable version of how it operated in their practice, when or/if Myles had been entered on to it, whether it was distinct from the psychiatric review - one seemed to conflate the two and the other said that it was something managed by a Nurse in the practice. It is quite evident that correspondence was coming in from Learning Disabilities Psychiatry but nothing at all from Social Services. This is not something that seems to have triggered any particular reaction at the GP level. They seemed to operate on the basis that the Learning Disabilities ’box had been ticked’ and that nothing further was needed. In fact, Myles seems to have been on the Register from 2020 but by the 20 October 2022 when he had been at hospital in relation to his PE he had no Learning Disability Social Worker and concomitantly no VIP passport on admission to hospital . The GPs clearly had no idea of how important all this was. I heard evidence from a secondary care Learning Disabilities Professional that they, in secondary care, rely a great deal on primary care to get these things sorted out. Here, nothing went back from the Practice to the Learning Disabilities Service to chase these things.
2. The failure of the GP to record numeric observations properly on 20 March 2023.
3. The failure of the Dalton Surgery to undertake any rigorous and detailed internal review for learning purposes after this incident.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to record numeric observations properly
Wider context from the report “While the rider of Neglect does not attach to the actions of the Dalton Surgery, the fact remains that between 16 and 20 March 2023 Myles had several contacts with the Dalton Surgery while he was suffering with an on going Pulmonary Embolism. Non of these resulted in a referral to secondary care. The combined evidence of three expert witnesses was that the manner in which his care was handled at this stage contributed to his death.
The following are concerns that I have arising from the evidence in he Inquest.
1. Ignorance of what was required for Myles in the circumstances of his Learning Disability and Autism - the GPs clearly only had a superficial grasp of the regulatory requirements and realities to do with Learning Disabilities. They are clearly well intentioned and caring but their appreciation and approach seems to have been based entirely on professional experience and good intentions rather than real knowledge of what was required and how to implement it.
Notably:
•They repeatedly used the words learning difficulties and learning disabilities interchangeably and apparently randomly – I am not told that Myles had a personal preference about which to use that they deferred to. Essentially, they seem to have been ignorant as to the distinction.
•They made only the most modest adjustments for Myles's Learning Disabilities and Autism.
•They clearly had very little grasp of what the Learning Disabilities Register was and how it worked. Neither of the GPs who gave evidence were able to provide a solid, reliable version of how it operated in their practice, when or/if Myles had been entered on to it, whether it was distinct from the psychiatric review - one seemed to conflate the two and the other said that it was something managed by a Nurse in the practice. It is quite evident that correspondence was coming in from Learning Disabilities Psychiatry but nothing at all from Social Services. This is not something that seems to have triggered any particular reaction at the GP level. They seemed to operate on the basis that the Learning Disabilities ’box had been ticked’ and that nothing further was needed. In fact, Myles seems to have been on the Register from 2020 but by the 20 October 2022 when he had been at hospital in relation to his PE he had no Learning Disability Social Worker and concomitantly no VIP passport on admission to hospital . The GPs clearly had no idea of how important all this was. I heard evidence from a secondary care Learning Disabilities Professional that they, in secondary care, rely a great deal on primary care to get these things sorted out. Here, nothing went back from the Practice to the Learning Disabilities Service to chase these things.
2. The failure of the GP to record numeric observations properly on 20 March 2023.
3. The failure of the Dalton Surgery to undertake any rigorous and detailed internal review for learning purposes after this incident.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 appropriate adjustments for patients with learning disabilities and autism
Wider context from the report “While the rider of Neglect does not attach to the actions of the Dalton Surgery, the fact remains that between 16 and 20 March 2023 Myles had several contacts with the Dalton Surgery while he was suffering with an on going Pulmonary Embolism. Non of these resulted in a referral to secondary care. The combined evidence of three expert witnesses was that the manner in which his care was handled at this stage contributed to his death.
The following are concerns that I have arising from the evidence in he Inquest.
1. Ignorance of what was required for Myles in the circumstances of his Learning Disability and Autism - the GPs clearly only had a superficial grasp of the regulatory requirements and realities to do with Learning Disabilities. They are clearly well intentioned and caring but their appreciation and approach seems to have been based entirely on professional experience and good intentions rather than real knowledge of what was required and how to implement it.
Notably:
•They repeatedly used the words learning difficulties and learning disabilities interchangeably and apparently randomly – I am not told that Myles had a personal preference about which to use that they deferred to. Essentially, they seem to have been ignorant as to the distinction.
•They made only the most modest adjustments for Myles's Learning Disabilities and Autism.
•They clearly had very little grasp of what the Learning Disabilities Register was and how it worked. Neither of the GPs who gave evidence were able to provide a solid, reliable version of how it operated in their practice, when or/if Myles had been entered on to it, whether it was distinct from the psychiatric review - one seemed to conflate the two and the other said that it was something managed by a Nurse in the practice. It is quite evident that correspondence was coming in from Learning Disabilities Psychiatry but nothing at all from Social Services. This is not something that seems to have triggered any particular reaction at the GP level. They seemed to operate on the basis that the Learning Disabilities ’box had been ticked’ and that nothing further was needed. In fact, Myles seems to have been on the Register from 2020 but by the 20 October 2022 when he had been at hospital in relation to his PE he had no Learning Disability Social Worker and concomitantly no VIP passport on admission to hospital . The GPs clearly had no idea of how important all this was. I heard evidence from a secondary care Learning Disabilities Professional that they, in secondary care, rely a great deal on primary care to get these things sorted out. Here, nothing went back from the Practice to the Learning Disabilities Service to chase these things.
2. The failure of the GP to record numeric observations properly on 20 March 2023.
3. The failure of the Dalton Surgery to undertake any rigorous and detailed internal review for learning purposes after this incident.
” 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 Maintain the reasonable adjustment digital flag so services can record, share and view patients’ adjustment needs.
Verbatim wording from the response “The Equality Act 2010 places a legal duty on health and care services to make changes to their approach or provision to ensure services are as accessible for people with disabilities as they are for everyone else. NHS England has introduced the reasonable adjustment digital flag to enable health and care services to record, share and view details of the reasonable adjustments a person needs to support their care.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out staff e-learning supporting recording of reasonable adjustment needs across health and care services.
Verbatim wording from the response “Organisations are required to use their own systems and processes to record reasonable adjustment needs, and staff e-learning training has been rolled out for all health and care staff to support this.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out Oliver McGowan mandatory learning disability and autism training across the health and adult social care workforce.
Verbatim wording from the response “GPs, receive specific training on learning disability and autism appropriate to their role. On 19 June 2025, NHS England published a Code of Practice which sets out expectations for training content and delivery. This training helps to ensure that staff have the right knowledge and skills to provide safe and informed care.” Source location Response from NHS England
Open published response
14 Jul 2025 Myles Edward Scriven · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 4 Failure to audit the impact and outcomes of learning disability and autism training and provision View source Failure to act on relevant electronic patient record entries across clinical colleagues View source Lack of required adjustments for patients with learning disabilities and autism View source Failure to apply Mental Capacity Act principle 2 in clinical decision-making 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
Myles Edward Scriven · 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
Myles Edward Scriven died at Huddersfield Royal Infirmary on 16 April 2023. The report states that lack of adjustments for his Autism and Learning Disabilities contributed to incorrect decisions about his care and medication. The principal concern was that existing training, policies and support arrangements were not effectively applied or audited to ensure safe care and medication decisions.
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 audit the impact and outcomes of learning disability and autism training and provision
Wider context from the report “(brief summary of matters of concern)
The rider of Neglect attaches to the actions of the Calderdale and Huddersfield NHS Foundation Trust (‘the Trust’). It relates to the lack of adjustments, that were identified as being required to treat Myles safely in the context of his Learning Disabilities (‘LD’) and Autism notably during his admission 20-25 October 2022. It is true that evidence from Trust witnesses has been sufficient to demonstrate that the Trust is aware of the issues arising in this case at least in terms of training and professional input. It has an ongoing programme of training in relation to Learning Disabilities and Autism in clinical care and they have people in post enhancing Learning Disability provision. The crux of the remaining concern is in relation to auditing the impact of all of this in terms of auditing the outcome of this work . To be fair, Trust evidence was that there is now auditing of mental capacity assessments and there is dedicated nursing leadership walkaround of all wards auditing LD and autism policies being applied . However, there is this remaining evidential reality: much of what is now in place was already in place in 2022 – not least key personnel who gave evidence at the Inquest, but also VIP passports, training and all the underlying regulatory underpinning. But in Myles’s case it simply had no impact whatsoever. One witness’s own ‘spot-on’ entries in the EPR on 21 October were just not acted upon by colleagues and had zero effect when he went on leave thereafter. Clinicians were applying Mental Capacity Act principle 1 but not 2. ‘Culturally’ speaking, that one obtaining in secondary care after the witness went on leave seems to have been stuck in another era. So, the question is - how it is proposed to ensure full compliance with best practice and by when?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to act on relevant electronic patient record entries across clinical colleagues
Wider context from the report “(brief summary of matters of concern)
The rider of Neglect attaches to the actions of the Calderdale and Huddersfield NHS Foundation Trust (‘the Trust’). It relates to the lack of adjustments, that were identified as being required to treat Myles safely in the context of his Learning Disabilities (‘LD’) and Autism notably during his admission 20-25 October 2022. It is true that evidence from Trust witnesses has been sufficient to demonstrate that the Trust is aware of the issues arising in this case at least in terms of training and professional input. It has an ongoing programme of training in relation to Learning Disabilities and Autism in clinical care and they have people in post enhancing Learning Disability provision. The crux of the remaining concern is in relation to auditing the impact of all of this in terms of auditing the outcome of this work. To be fair, Trust evidence was that there is now auditing of mental capacity assessments and there is dedicated nursing leadership walkaround of all wards auditing LD and autism policies being applied. However, there is this remaining evidential reality: much of what is now in place was already in place in 2022 – not least key personnel who gave evidence at the Inquest, but also VIP passports, training and all the underlying regulatory underpinning. But in Myles’s case it simply had no impact whatsoever. One witness’s own ‘spot-on’ entries in the EPR on 21 October were just not acted upon by colleagues and had zero effect when he went on leave thereafter . Clinicians were applying Mental Capacity Act principle 1 but not 2. ‘Culturally’ speaking, that one obtaining in secondary care after the witness went on leave seems to have been stuck in another era. So, the question is - how it is proposed to ensure full compliance with best practice and by when?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 required adjustments for patients with learning disabilities and autism
Wider context from the report “(brief summary of matters of concern)
The rider of Neglect attaches to the actions of the Calderdale and Huddersfield NHS Foundation Trust (‘the Trust’). It relates to the lack of adjustments, that were identified as being required to treat Myles safely in the context of his Learning Disabilities (‘LD’) and Autism notably during his admission 20-25 October 2022. It is true that evidence from Trust witnesses has been sufficient to demonstrate that the Trust is aware of the issues arising in this case at least in terms of training and professional input. It has an ongoing programme of training in relation to Learning Disabilities and Autism in clinical care and they have people in post enhancing Learning Disability provision. The crux of the remaining concern is in relation to auditing the impact of all of this in terms of auditing the outcome of this work. To be fair, Trust evidence was that there is now auditing of mental capacity assessments and there is dedicated nursing leadership walkaround of all wards auditing LD and autism policies being applied. However, there is this remaining evidential reality: much of what is now in place was already in place in 2022 – not least key personnel who gave evidence at the Inquest, but also VIP passports, training and all the underlying regulatory underpinning. But in Myles’s case it simply had no impact whatsoever. One witness’s own ‘spot-on’ entries in the EPR on 21 October were just not acted upon by colleagues and had zero effect when he went on leave thereafter. Clinicians were applying Mental Capacity Act principle 1 but not 2. ‘Culturally’ speaking, that one obtaining in secondary care after the witness went on leave seems to have been stuck in another era. So, the question is - how it is proposed to ensure full compliance with best practice and by when?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 apply Mental Capacity Act principle 2 in clinical decision-making
Wider context from the report “(brief summary of matters of concern)
The rider of Neglect attaches to the actions of the Calderdale and Huddersfield NHS Foundation Trust (‘the Trust’). It relates to the lack of adjustments, that were identified as being required to treat Myles safely in the context of his Learning Disabilities (‘LD’) and Autism notably during his admission 20-25 October 2022. It is true that evidence from Trust witnesses has been sufficient to demonstrate that the Trust is aware of the issues arising in this case at least in terms of training and professional input. It has an ongoing programme of training in relation to Learning Disabilities and Autism in clinical care and they have people in post enhancing Learning Disability provision. The crux of the remaining concern is in relation to auditing the impact of all of this in terms of auditing the outcome of this work. To be fair, Trust evidence was that there is now auditing of mental capacity assessments and there is dedicated nursing leadership walkaround of all wards auditing LD and autism policies being applied. However, there is this remaining evidential reality: much of what is now in place was already in place in 2022 – not least key personnel who gave evidence at the Inquest, but also VIP passports, training and all the underlying regulatory underpinning. But in Myles’s case it simply had no impact whatsoever. One witness’s own ‘spot-on’ entries in the EPR on 21 October were just not acted upon by colleagues and had zero effect when he went on leave thereafter. Clinicians were applying Mental Capacity Act principle 1 but not 2 . ‘Culturally’ speaking, that one obtaining in secondary care after the witness went on leave seems to have been stuck in another era. So, the question is - how it is proposed to ensure full compliance with best practice and by when?
” Open source report
Concerns raised 1 Failure of different IT systems to make preceding mental health screening assessment data immediately available for subsequent assessments and onward referral View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Michael Kirkman · 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 Michael Kirkman, who had a long history of paranoid schizophrenia and previous detentions and admissions under the Mental Health Act, died after ingesting ████████ between 26 and 27 December 2023. The principal concern was that mental health screening information from one part of the country might not be promptly available in another because of different IT systems, potentially affecting subsequent assessments and referral prioritisation.
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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 different IT systems to make preceding mental health screening assessment data immediately available for subsequent assessments and onward referral
Wider context from the report “Evidence was heard that if a mental health screening assessment is carried out in one part of the country, the results and conclusions reach may not necessarily be immediately available in another part of the country, when a further assessment is carried out . Evidence suggested that such assessments capture important clinical information and the lack of availability of preceding data may adversely influence subsequent assessments . Screening may form the basis for onward referral for formal mental health assessments. Absence of vital background information could result in an incorrect prioritisation for onward referral as it did in this case. The situation is not ubiquitous but does occur due to the use of different I.T. systems in various institutions .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support broader clinical record sharing across organisational boundaries.
Verbatim wording from the response “Beyond these national services, NHS England is committed to supporting broader clinical record sharing across organisational boundaries. Since 2021, all primary and secondary care organisations have been able to share a subset of patient information within Integrated Care Board footprints via their local Shared Care Record. The Core Information Standard defines the typical content of these records and provides a consistent framework for data sharing.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue developing solutions to address fragmented IT systems and improve access to clinical information.
Verbatim wording from the response “We acknowledge the ongoing challenges posed by disparate IT systems, particularly in mental health services, where timely access to information can significantly affect assessment and referral decisions. This is a recognised patient safety and clinical quality issue. NHS England continues to develop solutions to address these challenges, including the proposed creation of a Single Patient Record as part of the NHS 10 Year Health Plan. It is intended that this record will bring a patient’s medical records into once place and will build on existing foundations to support clinicians and patients in accessing the information needed to aid clinical decision-making, subject to appropriate permissions and privacy safeguards.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a personalised-care framework specifying information availability across mental health services and geographical areas.
Verbatim wording from the response “NHS England is also developing a specific framework for delivering personalised care and support to adults and older adults with severe mental health problems. The framework will set out the core aspects of care for people who require help from secondary or integrated primary, voluntary, community and social enterprise (VCSE) and secondary care mental health services. The framework outlines that all required information relating to a person’s mental health assessment and their care and support plan should be available to all staff who need it. This includes where people move between different services across different geographical areas.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and implement the national initiative connecting Shared Care Records across England.
Verbatim wording from the response “Recognising the clinical need for greater interoperability, NHS England has launched a national initiative to connect Shared Care Records across England. This investment aims to ensure that authorised professionals can access safe, reliable, and accurate records, regardless of where care is delivered. Local organisations, including participating NHS Trusts, determine what additional information beyond the core standard is shared, and individual Trusts are responsible for negotiating data-sharing protocols to support enhanced local collaboration.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual NHS Trusts are responsible for negotiating data-sharing protocols supporting information beyond the core standard.
Verbatim wording from the response “Recognising the clinical need for greater interoperability, NHS England has launched a national initiative to connect Shared Care Records across England. This investment aims to ensure that authorised professionals can access safe, reliable, and accurate records, regardless of where care is delivered. Local organisations, including participating NHS Trusts, determine what additional information beyond the core standard is shared, and individual Trusts are responsible for negotiating data-sharing protocols to support enhanced local collaboration.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England cannot currently mandate suppliers to implement the technical work needed for mental health data sharing via the National Record Locator.
Verbatim wording from the response “The NRL functionality allows any previous health assessment to be both located and seen, however only 17 out of 54 mental health trusts can currently share data via the NRL, mainly due to the need for system suppliers to implement technical pointers, but also as there is currently limited funding for this development work. Some suppliers have not participated in using the NRL due to their preferences for structured data formats.” Source location Response from NHS England
Open published response
2 Jul 2025 Neil John Clarke · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Inaccurate handover communications for patients returning from HDU to the main ward View source Failure to consider more conservative measures for elderly patients undergoing surgical procedures View source Inadequate documentation and guidance on different treatment choices View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Neil John Clarke · 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
Neil John Clarke, aged 81, died at Stepping Hill Hospital on 26 February 2024 after vomiting, aspiration and a cardiac arrest following a right hemicolectomy. The report raises concerns about the safety and wellbeing considerations for surgical procedures involving elderly patients, documentation and guidance about treatment choices, and the accuracy of handover communications when patients return to the main ward from HDU.
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 Inaccurate handover communications for patients returning from HDU to the main ward
Wider context from the report “The considerations given to the appropriateness, from a safety and well-being perspective, of surgical procedures involving elderly patients who may benefit from more conservative measures and the associated documentation and guidance advising patients of different treatment choices.
My second concern arising from this interest was the accuracy of hand over communications between clinical staff in respect of patients returning to the main ward from HDU .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 more conservative measures for elderly patients undergoing surgical procedures
Wider context from the report “The considerations given to the appropriateness, from a safety and well-being perspective, of surgical procedures involving elderly patients who may benefit from more conservative measures and the associated documentation and guidance advising patients of different treatment choices.
My second concern arising from this interest was the accuracy of hand over communications between clinical staff in respect of patients returning to the main ward from HDU.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 and guidance on different treatment choices
Wider context from the report “The considerations given to the appropriateness, from a safety and well-being perspective, of surgical procedures involving elderly patients who may benefit from more conservative measures and the associated documentation and guidance advising patients of different treatment choices .
My second concern arising from this interest was the accuracy of hand over communications between clinical staff in respect of patients returning to the main ward from HDU.
” 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 Produce decision-support resources to help patients understand treatment, care and support options during shared decision-making.
Verbatim wording from the response “Our Personalised Care Team have also produced supporting information on shared decision making including ‘Decision support tools’ resources, also called patient decision aids, to support shared decision making by making treatment, care and support options explicit.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and update national guidance on perioperative screening, triage, risk assessment, health optimisation and shared decision-making.
Verbatim wording from the response “NHS England has also undertaken considerable work to develop the following guidance on Early screening, triaging, risk assessment and health optimisation in perioperative pathways: guide for providers and integrated care boards (published in May 2023 prior to Neil’s death and updated in May 2025), which includes information on risk assessment and shared decision making. Point 5 under the ‘Five core requirements for providers’ states:” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commenting on the appropriateness of the clinical decision to proceed with a right hemicolectomy is outside NHS England’s remit.
Verbatim wording from the response “It is outside of NHS England’s remit to provide comment on the appropriateness of the clinical decision to proceed with a right hemicolectomy in Neil’s case. The clinical team at Stepping Hill Hospital would be best placed to comment upon the specific circumstances of this case.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Stockport NHS Foundation Trust is responsible for responding to concerns about handover communications at Stepping Hill Hospital.
Verbatim wording from the response “Your second concern focused on the accuracy of handover communications between clinical staff regarding patients returning to the main ward from the High Dependency Unit (HDU) at Stepping Hill Hospital.” Source location Response from NHS England
Open published response
23 Jun 2025 Louise Elizabeth Amy Crane · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Lack of a nationwide policy or approach to anti-ligature measures in mental health settings View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Louise Elizabeth Amy Crane · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Louise Crane died at Highgate Mental Health Centre on 19 September 2024 from ligature compression to the neck while detained under section 3 of the Mental Health Act. The report identifies concerns about information sharing and recording, risk management, staffing and care and treatment on Topaz Ward, and notes a lack of a nationwide policy or approach to anti-ligature measures in mental health settings.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a nationwide policy or approach to anti-ligature measures in mental health settings
Wider context from the report “1) Evidence from a senior member of North London NHS Trust’s clinical leadership team revealed that there is a lack of a nationwide policy / approach to anti-ligature measures in mental health settings .
” 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 national requirements for ligature-resistant or tamper-proof fittings in adult acute mental health and CAMHS facilities.
Verbatim wording from the response “The Department of Health & Social Care’s Health Building Note 03-01 (Adult Acute Mental Health) and NHS England’s Health Building Note 03-02 (CAMHS) require all fittings – doors, furniture, lighting, sanitary ware – to be ligature-resistant with sloped or tamper-proof fixtures.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a national patient safety alert on ligature and ligature-point risk assessment tools and policies to all providers.
Verbatim wording from the response “In recent years, NHS England has acted upon the concerns raised above and has adopted a comprehensive, nationwide approach to anti-ligature measures. In March 2020, NHS England and Improvement (now NHS England) issued a National Patient Safety Alert specifically addressing ligature and ligature point risk assessment tools and policies, sent via the Central Alerting System to all providers – with mandated executive oversight, and compliance monitored by the Care Quality Commission (CQC). North London NHS Foundation Trust (NLFT) has confirmed to NHS England that it became compliant with this alert on 1 June 2020.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue engaging local teams for updates on implementation of the patient-safety recommendations.
Verbatim wording from the response “NHS England will continue to engage with local teams for updates on these recommendations. NLFT advise that that they are compliant with anti-ligature guidance and that all anti-ligature fixtures and fittings are procured from approved suppliers, who are required to design their solutions in accordance with the guidance. They are also a member of the Zero Suicide Alliance and has developed a structured Suicide Prevention Strategy.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing nationwide anti-ligature policies, standards, guidance and compliance monitoring are considered sufficient to address the concern about inconsistent mental-health-setting measures.
Verbatim wording from the response “Your report raises the concern that there is a lack of a nationwide policy / approach to anti-ligature measures in mental health settings. My response has been informed by NHS England’s regional London and national Mental Health Teams.” Source location Response from NHS England
Open published response
Concerns raised 1 Gap in availability of thrombectomy emergency procedures for patients with severe stroke in the South West View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 11
Action
Conduct follow-up visits to comprehensive stroke centres to assess uptake of recommended thrombectomy-access improvements.
Stated completedThe respondent said that this action was complete when they made their response on 30 June 2025. View source
Action
Regularly review thrombectomy service improvements and seek assurance through the Regional Clinical Network.
Stated completedThe respondent said that this action was complete when they made their response on 30 June 2025. View source
Action
Work with University Hospitals Plymouth NHS Trust to establish a 24/7 thrombectomy service, targeted to become functional from 1 November 2025.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 June 2025. View source
Action
Conduct site visits to every English comprehensive stroke centre and provide jointly agreed measurable improvement actions.
Stated completedThe respondent said that this action was complete when they made their response on 30 June 2025. View source
Action
Carry out clinical improvement projects covering diagnostic training, pre-hospital video triage, and clinical and ambulance pathways.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 June 2025. View source
Action
Deliver the thrombectomy credentialing programme, including training and supporting non-interventional radiologists to address workforce gaps.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 June 2025. View source
Action
Publish and establish the thrombectomy credential for non-interventional radiologists to expand the specialist workforce.
Stated completedThe respondent said that this action was complete when they made their response on 30 June 2025. View source
Action
Regularly review thrombectomy service improvements and seek assurance through the Regional Clinical Network.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 June 2025. View source
Action
Deliver the funded thrombectomy credentialing programme, including enrolling and training the first cohort of trainees.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 June 2025. View source
Action
Visit comprehensive stroke centres, identify barriers, support quality improvement, convene stakeholders and agree measurable improvement actions.
Stated completedThe respondent said that this action was complete when they made their response on 30 June 2025. View source
Action
Work with University Hospitals Plymouth NHS Trust to establish a 24/7 thrombectomy service, supported by diagnostic, triage, training and clinical-pathway improvement projects.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 June 2025. View source See 8 more actions
×
AI-generated summary
Greta Mary Ann Lewis · 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
Greta Mary Ann Lewis suffered a stroke in March 2020 and was later admitted to hospital after becoming unwell. She died at South Molton Community Hospital on 12 July 2021 due to complications caused by her stroke. The report raised concern about a gap in the availability of the time-critical and potentially lifesaving thrombectomy procedure for patients with severe strokes in the South West.
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 Gap in availability of thrombectomy emergency procedures for patients with severe stroke in the South West
Wider context from the report “The concerns relate to the provision of the thrombectomy procedure to patients suffering with a stroke in the South West.
(1) The evidence revealed that there is a gap in the availability of the time critical and potentially lifesaving thrombectomy emergency procedure to patients that have suffered a severe stroke in the South West .
” 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 Conduct follow-up visits to comprehensive stroke centres to assess uptake of recommended thrombectomy-access improvements.
Verbatim wording from the response “Each CSC was given a list of recommended actions in order to improve access to thrombectomy, focusing on pre-hospital video triage, ensuring timely diagnostic pathways, encouraging training for non-INRs and optimising all training opportunities generally to increase the workforce, developing repatriation policies to ensure that centres always have free beds, collaborating between units, and data accuracy. 12 CSCs have received second visits during 2025, to reflect on the uptake of actions.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Regularly review thrombectomy service improvements and seek assurance through the Regional Clinical Network.
Verbatim wording from the response “The regional team regularly reviews and seeks assurance on the improvements in the service through its Regional Clinical Network, and is working with University Hospitals Plymouth NHS Trust to establish a 24/7 thrombectomy service, to be functional from 1 November 2025. To support this, there are multiple clinical improvement projects underway that will include training in diagnostics, pre-hospital video triage and improved clinical and ambulance pathways.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with University Hospitals Plymouth NHS Trust to establish a 24/7 thrombectomy service, targeted to become functional from 1 November 2025.
Verbatim wording from the response “The regional team regularly reviews and seeks assurance on the improvements in the service through its Regional Clinical Network, and is working with University Hospitals Plymouth NHS Trust to establish a 24/7 thrombectomy service, to be functional from 1 November 2025. To support this, there are multiple clinical improvement projects underway that will include training in diagnostics, pre-hospital video triage and improved clinical and ambulance pathways.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct site visits to every English comprehensive stroke centre and provide jointly agreed measurable improvement actions.
Verbatim wording from the response “I would also like to advise you that, alongside the national quality improvement programme, further work to ensure the ongoing service development of mechanical thrombectomy services has been supported by a programme of NHS England site visits, led personally by my predecessor ████████ and our National Clinical Director for Stroke Medicine, ████████. During 2024, they visited every CSC in England to understand the local barriers and successes, support quality improvement, bring together the wider thrombectomy stakeholders to discuss collaborative opportunities and provide specific, jointly agreed, measurable actions for each centre.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Carry out clinical improvement projects covering diagnostic training, pre-hospital video triage, and clinical and ambulance pathways.
Verbatim wording from the response “The regional team regularly reviews and seeks assurance on the improvements in the service through its Regional Clinical Network, and is working with University Hospitals Plymouth NHS Trust to establish a 24/7 thrombectomy service, to be functional from 1 November 2025. To support this, there are multiple clinical improvement projects underway that will include training in diagnostics, pre-hospital video triage and improved clinical and ambulance pathways.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the thrombectomy credentialing programme, including training and supporting non-interventional radiologists to address workforce gaps.
Verbatim wording from the response “Since January 2021, the national stroke programme has been engaging with the General Medical Council (GMC) and Royal College of Radiologists to support the development of a thrombectomy credentialing programme, including enabling non-INRs, such as Neurosurgeons, Stroke Physicians and Cardiologists, to be trained and supported to perform thrombectomy and address the workforce gap. The GMC credential was published in June 2023. A substantial amount of revenue funding has since been made available to deliver the credentialing programme and the first cohort of trainees have already been enrolled and started the credential. The trainees are completing the credential alongside their full-time NHS employment in their main speciality, but it is hoped that some will be signed off within the next year.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish and establish the thrombectomy credential for non-interventional radiologists to expand the specialist workforce.
Verbatim wording from the response “Since January 2021, the national stroke programme has been engaging with the General Medical Council (GMC) and Royal College of Radiologists to support the development of a thrombectomy credentialing programme, including enabling non-INRs, such as Neurosurgeons, Stroke Physicians and Cardiologists, to be trained and supported to perform thrombectomy and address the workforce gap. The GMC credential was published in June 2023. A substantial amount of revenue funding has since been made available to deliver the credentialing programme and the first cohort of trainees have already been enrolled and started the credential. The trainees are completing the credential alongside their full-time NHS employment in their main speciality, but it is hoped that some will be signed off within the next year.” Source location 2025-0304 Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Regularly review thrombectomy service improvements and seek assurance through the Regional Clinical Network.
Verbatim wording from the response “The regional team regularly reviews and seeks assurance on the improvements in the service through its Regional Clinical Network, and is working with University Hospitals Plymouth NHS Trust to establish a 24/7 thrombectomy service, to be functional from 1 November 2025. To support this, there are multiple clinical improvement projects underway that will include training in diagnostics, pre-hospital video triage and improved clinical and ambulance pathways.” Source location 2025-0304 Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the funded thrombectomy credentialing programme, including enrolling and training the first cohort of trainees.
Verbatim wording from the response “Since January 2021, the national stroke programme has been engaging with the General Medical Council (GMC) and Royal College of Radiologists to support the development of a thrombectomy credentialing programme, including enabling non-INRs, such as Neurosurgeons, Stroke Physicians and Cardiologists, to be trained and supported to perform thrombectomy and address the workforce gap. The GMC credential was published in June 2023. A substantial amount of revenue funding has since been made available to deliver the credentialing programme and the first cohort of trainees have already been enrolled and started the credential. The trainees are completing the credential alongside their full-time NHS employment in their main speciality, but it is hoped that some will be signed off within the next year.” Source location 2025-0304 Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Visit comprehensive stroke centres, identify barriers, support quality improvement, convene stakeholders and agree measurable improvement actions.
Verbatim wording from the response “I would also like to advise you that, alongside the national quality improvement programme, further work to ensure the ongoing service development of mechanical thrombectomy services has been supported by a programme of NHS England site visits, led personally by my predecessor ████████ and our National Clinical Director for Stroke Medicine, ████████. During 2024, they visited every CSC in England to understand the local barriers and successes, support quality improvement, bring together the wider thrombectomy stakeholders to discuss collaborative opportunities and provide specific, jointly agreed, measurable actions for each centre.” Source location 2025-0304 Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with University Hospitals Plymouth NHS Trust to establish a 24/7 thrombectomy service, supported by diagnostic, triage, training and clinical-pathway improvement projects.
Verbatim wording from the response “The regional team regularly reviews and seeks assurance on the improvements in the service through its Regional Clinical Network, and is working with University Hospitals Plymouth NHS Trust to establish a 24/7 thrombectomy service, to be functional from 1 November 2025. To support this, there are multiple clinical improvement projects underway that will include training in diagnostics, pre-hospital video triage and improved clinical and ambulance pathways.” Source location 2025-0304 Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Trusts in each region are responsible for providing stroke thrombectomy services, rather than NHS England.
Verbatim wording from the response “Stroke thrombectomy services are now a delegated specialised service and, since 1 April 2024, NHS Devon Integrated Care Board (ICB) has been the responsible commissioner for the Devon region, rather than NHS England. Whilst NHS England was previously responsible for commissioning (funding) stroke thrombectomy services, the responsibility for providing this service rests with the Trusts in each region.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS Devon Integrated Care Board is responsible for commissioning stroke thrombectomy services in Devon.
Verbatim wording from the response “Stroke thrombectomy services are now a delegated specialised service and, since 1 April 2024, NHS Devon Integrated Care Board (ICB) has been the responsible commissioner for the Devon region, rather than NHS England. Whilst NHS England was previously responsible for commissioning (funding) stroke thrombectomy services, the responsibility for providing this service rests with the Trusts in each region.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Regional NHS Trusts are responsible for providing stroke thrombectomy services.
Verbatim wording from the response “Stroke thrombectomy services are now a delegated specialised service and, since 1 April 2024, NHS Devon Integrated Care Board (ICB) has been the responsible commissioner for the Devon region, rather than NHS England. Whilst NHS England was previously responsible for commissioning (funding) stroke thrombectomy services, the responsibility for providing this service rests with the Trusts in each region.” Source location 2025-0304 Response from NHS England
Open published response
Concerns raised 2 Internet access exposing detained adult patients to malign influences and means of serious self-harm View source Failure to monitor and control detained patients’ internet use View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sally Burr · 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
Sally Burr, who had a history of mental health difficulties and repeated serious self-harm attempts, was detained under section 3 of the Mental Health Act and admitted to Meadowfield Hospital. While detained, she used internet access to research and obtain toxic plant material and needles, which she consumed on 30 May 2024 with fatal results. The principal concern was that detained adult patients’ internet access could enable them to obtain means and methods to cause serious self-harm, while staff lacked practical ways to monitor or control internet use without restricting privacy and communication.
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 Internet access exposing detained adult patients to malign influences and means of serious self-harm
Wider context from the report “Whilst the Trust applied its policy on mobile phone use and internet access to Sally Burr correctly, it was clear that Sally was able to exploit this in order to research and obtain the means to end her life whilst a sectioned and detained patient.
Staff at Meadowfield lacked any practical ability or means to know of, monitor or respond to Sally’s internet use. Whilst encouraged to express curiosity with patients as to their use of the internet, there were no technical means to control or monitor use, other than removal of devices or denial of internet access. However, this obviously risked a negative effect on Sally’s wellbeing and progress due to the wider impact of denying contact or information which would help and support her recovery (there was evidence that Sally was in contact with online support for her mental health).
I heard evidence from the Trust as to revision of their policy and improved steps to try and prevent access to harmful or malign internet sites, but – rightly – such steps have to be balanced against the patient’s right to privacy, including communication. Those improved steps include blocking certain search terms and sites when using Trust wi-fi, identifying any attempted access by noting URLs, further restricting the time available for use, and heightening staff vigilance and awareness. However, the blocks can be easily circumvented by using 4G or 5G, and – as I know you will be aware – malign sites and searches often use euphemisms or seemingly innocent language and descriptions to avoid detection.
I noted that the revised policy as regards patients under 18 includes only permitting phones which do not have internet access and/or that internet access is only available via public equipment which can obviously be monitored and checked after use.
As such, my concern remains that permitting adult patients who have been detained under section access to the internet clearly provides an opportunity for them to be exposed to malign influences, and to obtain the means and methods to cause serious self-harm .
I fully accept the difficulty and balance in recognising a patient’s right to a private life and how the least restrictive regime possible (including permitting communication) is intended to facilitate their recovery. I also accept and unreservedly accept the impossible task of policing the internet, but I identify that clearer and stricter rules, guidance and investment in technology (perhaps including AI) at a national level may be needed, to enable Trusts to be able to act consistently and uniformly in at least reducing the potential for patients to secure the means to end their lives whilst detained.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 monitor and control detained patients’ internet use
Wider context from the report “Whilst the Trust applied its policy on mobile phone use and internet access to Sally Burr correctly, it was clear that Sally was able to exploit this in order to research and obtain the means to end her life whilst a sectioned and detained patient.
Staff at Meadowfield lacked any practical ability or means to know of, monitor or respond to Sally’s internet use. Whilst encouraged to express curiosity with patients as to their use of the internet, there were no technical means to control or monitor use , other than removal of devices or denial of internet access. However, this obviously risked a negative effect on Sally’s wellbeing and progress due to the wider impact of denying contact or information which would help and support her recovery (there was evidence that Sally was in contact with online support for her mental health).
I heard evidence from the Trust as to revision of their policy and improved steps to try and prevent access to harmful or malign internet sites, but – rightly – such steps have to be balanced against the patient’s right to privacy, including communication. Those improved steps include blocking certain search terms and sites when using Trust wi-fi, identifying any attempted access by noting URLs, further restricting the time available for use, and heightening staff vigilance and awareness. However, the blocks can be easily circumvented by using 4G or 5G , and – as I know you will be aware – malign sites and searches often use euphemisms or seemingly innocent language and descriptions to avoid detection .
I noted that the revised policy as regards patients under 18 includes only permitting phones which do not have internet access and/or that internet access is only available via public equipment which can obviously be monitored and checked after use.
As such, my concern remains that permitting adult patients who have been detained under section access to the internet clearly provides an opportunity for them to be exposed to malign influences, and to obtain the means and methods to cause serious self-harm.
I fully accept the difficulty and balance in recognising a patient’s right to a private life and how the least restrictive regime possible (including permitting communication) is intended to facilitate their recovery. I also accept and unreservedly accept the impossible task of policing the internet, but I identify that clearer and stricter rules, guidance and investment in technology (perhaps including AI) at a national level may be needed, to enable Trusts to be able to act consistently and uniformly in at least reducing the potential for patients to secure the means to end their lives whilst detained.
” 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 Publish principles and practical suggestions for using digital technologies safely and least restrictively in mental health inpatient care.
Verbatim wording from the response “We do, however, recognise that the use of technology within mental health settings is a rapidly moving landscape and that staff need support to be able to make decisions about how to implement new technologies safely and in a least restrictive way. We recently published the Principles for using digital technologies in mental health” Source location Response from NHS England
Open published response
12 Jun 2025 Michael Paul Barry · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1 Lack of commissioned specialist services for safely reducing and withdrawing from prescribed dependency-forming medications View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Paul Barry · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Paul Barry died at Broomfield Hospital from fatal complications of community-acquired pneumonia, with excessive codeine use contributing to his death. The principal concern was the lack of a commissioned specialist service to help patients and GPs safely reduce or withdraw from prescribed dependency-forming medication, creating a risk of avoidable future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of commissioned specialist services for safely reducing and withdrawing from prescribed dependency-forming medications
Wider context from the report “Notwithstanding the positive finding that the specific medication prescribed by Mr Barry’s GP had not been the source of the excessive codeine taken prior to admission to hospital, compelling evidence was received at the inquest from a Partner at the GP Practice (with a particular specialism in this area of dependency-forming medications) that there remains no specialist commissioned service available for GPs to which they might refer their patients to manage reduction of their intake of prescribed dependency-forming medications . This is in contrast to the availability of commissioned services for patients who are dependent on illicit drugs and/or alcohol.
The evidence confirmed that reduction or cessation of dependency-forming medications needs to be very carefully managed due to the risk of withdrawal symptoms and, in the context of the unchallenged evidence received, requires specialist input and training to maximise the prospects of success and to avoid potentially fatal consequences . The evidence, again unchallenged, was that the continuing absence of such a commissioned service gives rise to the risk of avoidable future deaths .
The long-standing and continuing lack of commissioned services in primary or secondary care for assisting people to safely reduce and withdraw from such prescribed medication was confirmed in her evidence by the Director of Pharmacy and Medicines Optimisation within the Mid and South Essex Integrated Care Board (the ICB). This witness helpfully set out important steps currently proposed and/or being taken to educate clinicians and service users alike of the dangers of opiate based prescription medications (alongside their relatively limited benefits in most, though not all, cases) with a view to reducing the size of the cohort of patients at risk of becoming dependent/addicted in the medium and longer term. However, this does not - absent a commissioned service to which GPs and patients may turn for specialist advice and assistance - address the immediate and on-going risk of future deaths to those currently dependant on/addicted to these medications, with the numbers of such patients having significantly increased in the post-COVID 19 period as a consequence of lengthy delays to, for example, chronic pain-relieving surgery.
Precisely this issue was highlighted in a previous PFD Report from 14th November 2019 issued by the former Senior Coroner in this jurisdiction. The response from the (then) Clinical Commissioning Group had indicated an intention to roll-out a Prescribed Opioid Dependence Local Enhanced Service in early 2020, but this was not implemented due to the COVID 19 pandemic.
Since then, including at the date of Mr Barry’s death in November 2023 and through to today, there remains no such, or similar, commissioned service across Essex or, it appears, consistently across England and Wales with only rare pockets around the country where such a service is commissioned.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the framework for personalised care of adults prescribed medicines associated with dependence or withdrawal symptoms.
Verbatim wording from the response “In March 2023, NHS England published ‘Optimising personalised care for adults prescribed medicines associated with dependence or withdrawal symptoms: Framework for action for ICBs and primary care’.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a chronic-pain medicines safety programme to reduce prescribed opioid use and help Integrated Care Systems adopt effective whole-system practice.
Verbatim wording from the response “Other developments” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation ICBs are responsible for commissioning services supporting safe withdrawal from prescribed dependency-forming medicines and should commission appropriate local provision.
Verbatim wording from the response “The commissioning of services to support people with chronic pain (including services to support people to safely withdraw from prescribed medicines that may cause dependence and withdrawal) now lies with ICBs as a delegated specialised service. NHS England expects ICBs to commission appropriate services to meet the needs of the population that each ICB geographically covers. This includes taking due regard of the above national commissioning and clinical guidance. A multi-disciplinary team (MDT) approach is needed with input from, for example, pain specialists, dependence services, mental health services and peer support groups. I note that your Report has also been addressed to Mid and South Essex ICB and trust that they will be able to respond further on this issue.” Source location Response from NHS England
Open published response
12 Jun 2025 Oscar Michael Thomas Keenan · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 3 Inadequacies of the algorithm in assessing ill newborns and infants and identifying significant respiratory problems View source Total reliance on an algorithm that does not direct early clinical input View source Delays and lack of direction in obtaining clinical assessment 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
Oscar Michael Thomas Keenan · 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
Oscar was born with a pelvi-ureteric junction obstruction and later developed a bacterial infection after prescribed antibiotics were not received. On 26 June 2024, he was taken to hospital after a call to NHS 111 about breathing difficulties, was found to have sepsis, and died the same day. Concerns included inadequacies in the algorithm for assessing ill newborns, reliance on the algorithm without early clinical input, and delay or lack of direction in obtaining clinical assessment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequacies of the algorithm in assessing ill newborns and infants and identifying significant respiratory problems
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The apparent inadequacies of the present algorithm in assessing ill newborns/infants, particularly in identifying significant respiratory problems that require early clinical assessment
(2) Total reliance on the algorithm which does not appear to direct early clinical input.
(3) A delay/lack of direction in obtaining clinical assessment.
I have concerns that this is widespread and could occur in other areas.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Total reliance on an algorithm that does not direct early clinical input
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The apparent inadequacies of the present algorithm in assessing ill newborns/infants, particularly in identifying significant respiratory problems that require early clinical assessment
(2) Total reliance on the algorithm which does not appear to direct early clinical input.
(3) A delay/lack of direction in obtaining clinical assessment.
I have concerns that this is widespread and could occur in other areas.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 and lack of direction in obtaining clinical assessment
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The apparent inadequacies of the present algorithm in assessing ill newborns/infants, particularly in identifying significant respiratory problems that require early clinical assessment
(2) Total reliance on the algorithm which does not appear to direct early clinical input.
(3) A delay/lack of direction in obtaining clinical assessment.
I have concerns that this is widespread and could occur in other areas.
” 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 Continuously refine NHS Pathways using clinical feedback and real-world cases to improve infant and family safety.
Verbatim wording from the response “We recognize that the remote assessment of very young babies is inherently challenging, and we continuously refine the system based on clinical feedback and real-world cases. In Oscar’s case – and in accordance with the investigation at SCAS - the review concluded that the algorithm functioned as intended, and no changes were required. However, every case contributes to our ongoing learning and improvement.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The review concluded that the NHS Pathways algorithm functioned as intended in this case and required no changes.
Verbatim wording from the response “We recognize that the remote assessment of very young babies is inherently challenging, and we continuously refine the system based on clinical feedback and real-world cases. In Oscar’s case – and in accordance with the investigation at SCAS - the review concluded that the algorithm functioned as intended, and no changes were required. However, every case contributes to our ongoing learning and improvement.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local services manage the availability of services matched to the NHS Pathways recommended outcome.
Verbatim wording from the response “Health advisors using the NHS Pathways system must have access to clinical support and supervision. They are trained to use probing questions to better understand caller responses. If a call is complex, uncertain, or includes three “not sure” answers, advisors are expected to seek clinical input. This support should be available immediately through a ‘warm transfer’ to a clinician, as required by the system’s Licence. To encourage this, NHS Pathways promotes the motto: “If in doubt, shout.” The system generates a recommended outcome (disposition), which is then matched to services commissioned locally. The availability of these services is managed locally.” Source location Response from NHS England
Open published response
Concerns raised 4 Lack of understanding among non-stroke specialist clinicians about when and where thrombectomy services are available View source Lack of regional mutual aid for thrombectomy View source Lack of a clear plan to deliver a 24/7 thrombectomy service in Lancashire View source Failure to deliver a 24/7 thrombectomy service in Lancashire View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michelle Julie Marie Michaela MASON · 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
Michelle Julie Marie Michaela MASON died on 1 June 2024 at Royal Infirmary, Lancaster, after sudden onset of lack of vision, vomiting and severe pain. She was reviewed around six hours later, when thrombolysis was no longer possible; thrombectomy was considered but no local service was available and transfer was considered too late. Concerns included the absence of a 24/7 thrombectomy service in Lancashire, limited understanding among non-stroke specialists about thrombectomy availability, and a lack of regional mutual aid.
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 understanding among non-stroke specialist clinicians about when and where thrombectomy services are available
Wider context from the report “(2) There is a lack of understanding from non-stroke specialist clinicians in Lancashire as to when and where thrombectomy services are available for patients in Lancashire
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 regional mutual aid for thrombectomy
Wider context from the report “(3) There is no mutual aid regionally , even where thrombectomy is available, clinically appropriate, it is known lack the procedure is likely to result in death and it is anticipated resources are available to complete the procedure.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear plan to deliver a 24/7 thrombectomy service in Lancashire
Wider context from the report “(1) NHS England national service specifications provide for a 24/7 thrombectomy service which is not currently being delivered in Lancashire and there is no clear plan to deliver that 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 deliver a 24/7 thrombectomy service in Lancashire
Wider context from the report “(1) NHS England national service specifications provide for a 24/7 thrombectomy service which is not currently being delivered in Lancashire and there is no clear plan to deliver that service
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue commissioners an urgent recommendation to review North West thrombectomy provision and achieve fully operational 24/7 coverage.
Verbatim wording from the response “Following their visit to the CSCs at Royal Preston Hospital, Salford Royal and the Walton Centre in April 2025, ████████ and ████████ issued a letter in June 2025 to LTH, the Northern Care Alliance NHS Foundation Trust, and the Walton Centre NHS Foundation Trust. This outlined their recommendation that an urgent review of mechanical thrombectomy provision within the North West is undertaken by commissioners, and set out their expectation that a fully operational 24/7 service is achievable and the position set by October 2025.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support an options appraisal of regional nighttime thrombectomy models to improve equal access across the North West.
Verbatim wording from the response “In order to ensure equal access for the population across the North West region, the North West’s Medical Director for Commissioning is supporting an options appraisal to consider the best model that supports outcomes for patients, whilst making the most effective use of resources. As set out above, the options currently being considered are for LTH to move to a 24/7 service or for the population of Lancashire & South Cumbria to have access to the service elsewhere in the region during nighttime hours (10pm to 8am).” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with Lancashire Teaching Hospitals to sustain its seven-day thrombectomy service.
Verbatim wording from the response “Currently, 12 of the 24 CSCs across the 20 ISDNs have a 24/7 thrombectomy service in place. In the North West, NHS England’s Regional Specialised Commissioning Team have been focused on work with Lancashire Teaching Hospitals NHS Foundation Trust (LTH) on the sustainable delivery of a 7 day service. LTH had previously been delivering a 7 day service until April 2024 when, due to staffing issues, they regressed to a Monday to Friday service, moving back to 7 days in August 2024 on a six weekend in eight basis. The Regional Specialised Commissioning Team have, through dialogue and formal contractual levers, been following this up with LTH to improve this position and, as a result, the service has gradually expanded. From May 2025, the service has operated consistently on a 7 day basis (between the hours of 8am and 10pm) and NHS England continues to work with LTH in sustaining this service.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Visit comprehensive stroke centres and issue measurable recommendations to improve thrombectomy access, workforce capacity and inter-centre coordination.
Verbatim wording from the response “visits, led personally by my predecessor ████████ and our National Clinical Director for Stroke Medicine, ████████. During 2024, they visited every CSC in England to understand the local barriers and successes, support quality improvement, bring together the wider thrombectomy stakeholders to discuss collaborative opportunities and provide specific, jointly agreed, measurable actions for each centre. Each CSC was given a list of recommended actions in order to improve access to thrombectomy, focusing on pre-hospital video triage, ensuring timely diagnostic pathways, encouraging training for non-INRs and optimising all training opportunities generally to increase the workforce, developing repatriation policies to ensure that centres always have free beds, collaborating between units, and data accuracy. 12 CSCs have received second visits during 2025, to reflect on the uptake of actions.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtain regional assurance that the thrombectomy communication arrangements have been actioned through regional assurance meetings.
Verbatim wording from the response “LTH implemented a Standard Operating Procedure (SOP) for communication about the availability of thrombectomy services with stakeholders in September 2024, and this was a clinician-led communication.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Since 1 April 2024, Lancashire and South Cumbria ICB is responsible for commissioning regional stroke thrombectomy services, not NHS England.
Verbatim wording from the response “NHS England has liaised with Lancashire & South Cumbria Integrated Care Board (ICB) regarding your Report. Stroke thrombectomy services are now a delegated specialised service and, since 1 April 2024, Lancashire & South Cumbria ICB has been the responsible commissioner for the region rather than NHS England. Whilst NHS England was previously responsible for commissioning (funding) stroke thrombectomy services, the responsibility for providing this service rests with the Trusts in each region.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for providing regional stroke thrombectomy services rests with the relevant provider Trusts, rather than NHS England.
Verbatim wording from the response “NHS England has liaised with Lancashire & South Cumbria Integrated Care Board (ICB) regarding your Report. Stroke thrombectomy services are now a delegated specialised service and, since 1 April 2024, Lancashire & South Cumbria ICB has been the responsible commissioner for the region rather than NHS England. Whilst NHS England was previously responsible for commissioning (funding) stroke thrombectomy services, the responsibility for providing this service rests with the Trusts in each region.” Source location Response from NHS England
Open published response
Concerns raised 2 Failure to transfer comprehensive discharge and ongoing treatment information to community nursing services View source Failure of hospital systems to enable electronic referrals to community nursing services outside the usual geographical area View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Malcolm Morris · 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
Malcolm Morris developed lymphoedema after surgery for penile cancer and died on 5 January 2024 after collapsing with right-thigh pain. The report raises concerns about hospitals being unable to electronically refer patients living outside their usual catchment area to community nursing services, resulting in inadequate discharge information and delayed or absent support for wound and catheter care.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer comprehensive discharge and ongoing treatment information to community nursing services
Wider context from the report “Upon discharge from hospital in Sunderland, staff were unable to refer him electronically to district nursing services in Northumberland. They had to resort to telephoning the service to make a referral and were unable by this route to pass the necessary information to the service .
As a consequence, Mr Morris left hospital requiring catheter care and wound management. He did not initially receive district nursing support. His wound became infected and required readmission to hospital. His catheter bag became full and he, nor his family had any guidance on what action to take.
Evidence I heard at inquest described that hospital systems were unable to communicate with healthcare systems outside of the immediate geographical area and as such efficient referrals to district nursing services were not possible.
This meant detailed information on Mr Morris's discharge arrangements and ongoing treatment could not be passed and ultimately district nurses relied on inadequate brief paper-based discharge documents .
In Mr Morris's case he was supported and cared for by his wife and family. They sought advice and made contact with the district nursing services themselves to affect a referral, after the absence of nursing support following his first discharge from hospital.
My concern is, had Mr Morris been discharged without any support from his family, lived alone or been vulnerable in some way, he may have not been able to access nursing services.
Even with family support, his wound became infected and required readmission to hospital. My concern is other persons may be at risk of death if discharging hospitals cannot efficiently, comprehensively and in a timely fashion refer patients to ongoing care in the community.
The evidence I have heard is this is an issue which is not confined to individual hospital trusts and is based on the ability of technology to ‘talk to each other’ across various NHS services. Given Sunderland Royal Hospital is a regional centre for penile cancer it means patients are treated there who are not living in the usual catchment area for the trust, and as such situations such as this with patients living out of the area must occur regularly.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital systems to enable electronic referrals to community nursing services outside the usual geographical area
Wider context from the report “Upon discharge from hospital in Sunderland, staff were unable to refer him electronically to district nursing services in Northumberland . They had to resort to telephoning the service to make a referral and were unable by this route to pass the necessary information to the service.
As a consequence, Mr Morris left hospital requiring catheter care and wound management. He did not initially receive district nursing support. His wound became infected and required readmission to hospital. His catheter bag became full and he, nor his family had any guidance on what action to take.
Evidence I heard at inquest described that hospital systems were unable to communicate with healthcare systems outside of the immediate geographical area and as such efficient referrals to district nursing services were not possible .
This meant detailed information on Mr Morris's discharge arrangements and ongoing treatment could not be passed and ultimately district nurses relied on inadequate brief paper-based discharge documents.
In Mr Morris's case he was supported and cared for by his wife and family. They sought advice and made contact with the district nursing services themselves to affect a referral, after the absence of nursing support following his first discharge from hospital.
My concern is, had Mr Morris been discharged without any support from his family, lived alone or been vulnerable in some way, he may have not been able to access nursing services.
Even with family support, his wound became infected and required readmission to hospital. My concern is other persons may be at risk of death if discharging hospitals cannot efficiently, comprehensively and in a timely fashion refer patients to ongoing care in the community.
The evidence I have heard is this is an issue which is not confined to individual hospital trusts and is based on the ability of technology to ‘talk to each other’ across various NHS services . Given Sunderland Royal Hospital is a regional centre for penile cancer it means patients are treated there who are not living in the usual catchment area for the trust, and as such situations such as this with patients living out of the area must occur regularly.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and implement the national Booking and Referral Standard to digitise and standardise referrals and bookings across care settings.
Verbatim wording from the response “To further support more consistent interoperability across the NHS, NHS England has developed the ‘Booking and Referral Standard’ (BaRS), which is a national framework designed to help digitise and standardise referrals and bookings across care settings, including urgent and emergency care (UEC), general practice, hospital, and community services.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and lead the Frontline Digitisation Programme to support adoption and safe deployment of electronic patient record systems.
Verbatim wording from the response “Over the past three years, NHS England has developed and led ‘The Frontline Digitisation’ (FLD) Programme, which has supported trusts in adopting electronic patient record (EPR) systems, and which nationally supports increased consistency in digital maturity and improves information sharing between and within organisations.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Interoperability configuration and management are assigned to local provider organisations and regional centres, rather than being led nationally by NHS England.
Verbatim wording from the response “The FLD Programme not only enables organisations to purchase EPRs but also advises on safe and effective deployment. However, whilst FLD enhances local digital capabilities, interoperability (i.e. how different digital systems communicate with one another) is typically configured and managed at a local level, rather than being led nationally by NHS England. This will be based on local arrangements between provider organisations and regional centres, will be cognisant of the wider catchment area and will depend on the range of technology suppliers. As such, interoperability will vary depending on local infrastructure and information governance arrangements.” Source location Response from NHS England
Open published response
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