19 May 2025 John Charles Spencer · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 1 Failure of GP out-of-hours surgeries to access key GP medical history information after patient consent View source
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AI-generated summary
John Charles Spencer · 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 Charles Spencer became unwell on 17 May 2024 and died on 21 May 2024 after a bowel perforation caused by obstruction within a recurrent right inguinal hernia, resulting in purulent peritonitis. The principal concern was that the GP out-of-hours surgery could not access his relevant GP medical history because different computer systems prevented the exchange of information, potentially affecting the examinations undertaken when patients do not report relevant history.
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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 of GP out-of-hours surgeries to access key GP medical history information after patient consent
Wider context from the report “(1) The GP medical history summary, populated by the GP that a patient is registered to, is not always accessible to a GP out of hours surgery. Evidence was given that there are various reasons for this, including the patient not providing consent for the exchange of this information. However, on some occasions, even when a patient has consented, the patient record systems utilised by the GP registered practice and the GP out of hours surgery, insofar as being different computer systems or for whatever other technological reason, prevented the exchange of information into the GP out of hours surgery. In this case, evidence was heard that the GP practice was using the EMIS system and that the urgent treatment centre (GP out of hours surgery) was using SystmOne. That fact caused the GP out of hours surgery to not be able to access Mr Spencer’s GP medical summary. This situation generates a concern that, providing the patient has consented, key medical information may not be conveyed to the GP out of hours surgery which should be accessible to allow the appropriate exchange of medical information to inform what examinations should take place in an out of hours setting . This concern is particularly significant in circumstances where the patient does not say and/or present with the points in the medical history relevant to the GPs determination about what further examinations should occur flowing from the medical history of the patient.
” 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 Support greater integration and awareness of record sharing between in-hours and out-of-hours providers.
Verbatim wording from the response “NHS England is aware of the challenge in sharing medical records between providers during the in-hours and out-of-hours period and the variability between areas using different technologies. We are also aware that use of the NCRS is variable across different care settings.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the Shared Care Records Programme to support wider access to relevant patient information.
Verbatim wording from the response “We are therefore working across the health system to support greater integration and awareness of record sharing between in-hours and OOH providers. We are also working with the ShCR Programme to support wider access to relevant patient information.” Source location Response from NHS England
Open published response
Concerns raised 4 Failure to routinely obtain and listen to parents’ or guardians’ information about children with profound disabilities View source Lack of guidance for managing children with profound disabilities in hospital settings View source Failure to recognise and act on parents’ ongoing concerns about children on hospital wards View source Failure to routinely offer learning disability liaison nurse support in the emergency department View source See 1 more concern
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Rose Annie Harfleet · 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
Rose Annie Harfleet, aged 12, died in hospital on 30 January 2024 after presenting with abdominal pain and vomiting, later identified as a caecal volvulus causing intestinal obstruction and bowel ischaemia. The report raised concerns about failures to recognise and respond to her deterioration, obtain and act on information from her mother, provide appropriate monitoring and surgical review, and offer learning disability liaison support. It also identified a lack of guidance for managing and consulting with children with profound disabilities in hospital settings.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely obtain and listen to parents’ or guardians’ information about children with profound disabilities
Wider context from the report “2. Guidelines - consultation with parents and guardians of children with profound disabilities within a hospital setting
Rose’s mother was devoted to Rose and was very able to advocate on Rose’s behalf as well as being best placed to provide the vital information about her signs and symptoms given Rose was unable to do this for herself. The importance of obtaining this information was not understood by the paediatric consultant who took no history from Rose’s mother and underestimated the severity of her signs and symptoms. The consequence of this was that Rose’s voice – through her mother as her advocate – was not heard and she was not therefore able to actively participate in the care and management that was provided to Rose, the corollary of which resulted in poor clinical decision making which contributed to Rose’s death. This gives rise to a concern that by not listening to parents or guardians as a matter of course leads to discrimination of disabled children.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for managing children with profound disabilities in hospital settings
Wider context from the report “1. The management of children with profound disabilities within a hospital setting
Rose was a deeply loved child who brought great joy to her mother, wider family and all that knew her. During the inquest hearing no national or local guidance was forthcoming to assist medical and nursing staff, within a conventional hospital setting, to appropriately manage patients such as Rose who had a global developmental delay and was wholly reliant on her mother to advocate on her behalf . This gives rise to a concern that this omission adversely impacts the care that patients such as Rose receive.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and act on parents’ ongoing concerns about children on hospital wards
Wider context from the report “3. Nursing and Medical care on the ward
In the absence of local and national guidelines, the importance of listening and responding to Rose’s mothers ongoing concerns about her daughter when she was transferred to the ward were not recognised by the nursing and medical staff and consequently not acted upon thereby contributing to Rose’s death. There appears to be a prevailing culture that in the absence of a patient being able to explain their symptoms themselves the voice of the parent or guardian is not given the significance it should be for the most vulnerable in a hospital setting.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely offer learning disability liaison nurse support in the emergency department
Wider context from the report “4. LeDeR Role
Rose’s admission was during the working week, yet there was no consideration or offer given to Rose or her mother during her time in the Emergency Department to being introduced to a learning Disability Liaison Nurse . This led to Rose’s mother being unsupported during this admission or for a nursing professional to be able to liaise and advocate for Rose and her mother with medical and nursing staff in the emergency department. This again gives rise to a concern that patients such as Rose and her mother are adversely impacted on the care that they receive in the absence of local and national guidelines that this should be routinely available and offered as a matter of course.
” 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 Health and Care Passport guidance and a template supporting personalised hospital care for people with learning disabilities and autistic people.
Verbatim wording from the response “In June 2024, NHS England published a Health and Care Passport guidance and template which aims to support personalised care for people with a learning disability and autistic people, including when they go into an acute hospital.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a national competency framework for learning disability liaison nurses.
Verbatim wording from the response “NHS England is due to publish a national competency framework for learning disability liaison nurses, which will help to strengthen some of the processes which determine when the input of liaison nurses should be sought. In addition, it will help to address some of the gaps which have been observed whereby, in some instances, learning” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A national protocol for engaging learning disability liaison nurses is not considered necessary because hospitals have varied referral processes and should retain autonomy.
Verbatim wording from the response “From the standpoint of learning disability liaison nurses, there is currently no national accepted protocol for how and when liaison nurses should be engaged in someone’s care. This is due to the fact that different hospitals have a variety of processes for enacting secondary referrals and, to a degree, they should be afforded this autonomy. However, when it is clearly specified and evident that a patient has a specific diagnosis and particular needs arising from their disability then, in accordance with the Trust’s duties under the Equality Act 2010, they should endeavour to make ‘reasonable adjustments’. In cases such as Rose’s, the provision of learning disability liaison nurses is one such adjustment, affording patients and their families a level of assurance that their care will be ‘adjusted’ as needed.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust is responsible for determining how patients access reasonable adjustments, including learning disability liaison nurse support, through local processes.
Verbatim wording from the response “The Trust’s services will still need to determine how they ensure access to reasonable adjustments, such as the input of learning disability liaison nurse support. As above, I note that your Report has also been addressed to the Trust and I would refer you to their response for further information on their local processes. NHS England will also consider their response in due course.” Source location Response from NHS England
Open published response
Concerns raised 1 Failure of the ambulance triage system to distinguish abdominal complaints and assign timely hospital-conveyance dispositions View source
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AI-generated summary
John Stephen England · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Stephen England developed abdominal pain and increasing distention while on holiday in Cornwall on 12 March 2023, after a history of recurrent sigmoid volvulus. Delays occurred in ambulance arrival, transfer into hospital, and escalation of the CT findings; he underwent surgery for ischaemic and gangrenous bowel and died in hospital on 15 March 2023 after an acute collapse during placement of a naso-gastric tube. The principal concern was whether the ambulance dispatch system could distinguish surgical emergencies requiring conveyance within an appropriate timeframe.
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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 the ambulance triage system to distinguish abdominal complaints and assign timely hospital-conveyance dispositions
Wider context from the report “1) At the time of the initial call to South West Ambulance Service Trust, Mr England reported that he thought he had a ‘twisted bowel.’ This had happened to him on five previous occasions in Gloucester when medical intervention had been required four times to decompress a sigmoid volvulus.
The call handler, using the MDPS system, reached a Category 5 disposition. Two experts who gave evidence at inquest, ████████, a Consultant Surgeon, and ████████, a Consultant Gastroenterologist, both felt Mr England needed to be conveyed to hospital within two hours which I believe would have required a Category 3 disposition.
As both the fact of a delay and its causative relevance were admitted by the Trust, the detail of the call and the questions asked to reach a disposition were not enquired into at inquest. Evidence was heard, however, that upon audit it was felt the call handler had achieved a high degree of compliance with expected standards.
This raises a concern whether the system is sufficiently nuanced to distinguish between different types of abdominal complaints and to ensure that those who need to be recognised as a surgical emergency receive a disposition resulting in a patient being conveyed to hospital within an appropriate timeframe .
” 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 Discuss the abdominal pain case within the AMPDS clinical coding subgroup with PDC to identify opportunities to improve assessment and differentiation of surgical emergencies.
Verbatim wording from the response “To respond directly to the Coroner’s concerns on abdominal pain, NHS England has obtained the specific details of this case from SWASFT, which will be discussed within the NHS England AMPDS clinical coding sub-group, in collaboration with PDC, to determine if there are opportunities to improve the assessment and differentiation of abdominal pain presentations within the AMPDS triage system. NHS England has additionally shared the Coroner’s concerns with PDC, who have outlined that they welcome the opportunity to review any dispatch-specific, non-visual interrogation suggestions to further improve the discovery of surgical emergencies associated with the complaint of abdominal pain.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual ambulance services are responsible for processes and timescales enabling timely clinical navigation and validation of calls requiring further assessment.
Verbatim wording from the response “During this clinical assessment, the patient’s current condition should be explored as well as considering the past medical history to be able to determine if an ambulance response is required. At the conclusion of the clinical assessment, additional information can be provided to the clinician to the caller about what actions to take if the patient’s condition appears to be worsening or there are any other concerns. Individual ambulance services should have appropriate processes in place to facilitate the timely clinical navigation and validation of all calls that require further clinical assessment. It is critical that services consider their clinical navigation and validation timescales and processes in full to prevent patients from experiencing delays in receiving clinical assessment to identify the appropriate outcome required to meet their clinical needs.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Telephone triage cannot make differential diagnoses requiring visual, historical and diagnostic information unavailable during the call.
Verbatim wording from the response “symptoms of severe blood loss, such as a decreased level of consciousness, fainting or near fainting, or an ash-grey colour, are prioritised. Moreover, patients within a common cardiac age range (patients aged 35 years and older) are further assessed and coded based on their age and the location of the pain. However, whilst the AMPDS system’s Abdominal Pain Protocol is able to identify and prioritise based on priority symptoms, triage systems are not designed to make differential diagnoses that would require additional visual, historic and diagnostic information that cannot be provided via telephone triage.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Priority Dispatch Corp manages AMPDS protocols and questions, including responsibility for making changes to the commercial international system.
Verbatim wording from the response “• As regards to SWASFT being users of the AMPDS system, the Priority Dispatch Corp (PDC) is responsible for and manages the commercial international AMPDS system, including making any changes to the protocols and questions asked. This may be on the basis of a recommendation from NHS England’s ECPAG, or as part of PDC’s own improvement and triage development work, which draws on its international user base.” Source location Response from NHS England
Open published response
2 May 2025 Sarah Frances BOYLE · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 8 Failure to respond reliably to expressions of self harm or suicidality View source ACCT observations failing to provide therapeutic support View source Insufficient mental health input for women not case loaded to the mental health team View source Delays in transferring women requiring mental health inpatient treatment View source Insufficient staffing capacity to complete ACCT checks and documentation View source Inconsistent completion of the ACCT process View source Insufficient mental health team capacity for women awaiting assessment or inpatient beds View source Insufficient mental health training and time for prison officers conducting meaningful ACCT conversations View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Sarah Frances BOYLE · 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
Sarah Boyle was detained at HMP Styal and was monitored under the ACCT process after expressing thoughts of self-harm or suicide and making several ligature attempts. On 14 July 2024, she was found with a ligature around her neck, suffered irreversible brain damage, and died in hospital on 20 July 2024. The report raises concerns that the ACCT process at HMP Styal was not working effectively, citing high levels of self-harm, complex mental-health needs, understaffing, missed checks, and inconsistent completion of the process.
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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 respond reliably to expressions of self harm or suicidality
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed ;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation ACCT observations failing to provide therapeutic support
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming . Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient mental health input for women not case loaded to the mental health team
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best , and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring women requiring mental health inpatient treatment
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team . The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing capacity to complete ACCT checks and documentation
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime . It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed ;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inconsistent completion of the ACCT process
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process ”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient mental health team capacity for women awaiting assessment or inpatient beds
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do . It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient mental health training and time for prison officers conducting meaningful ACCT conversations
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” Open source report
1 May 2025 Peter Michael ANZANI · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Failure to properly complete patient records View source Inadequate workforce staffing capacity View source Lack of adequate staff training View source Delays in patient reviews and treatments View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Peter Michael ANZANI · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter Michael Anzani died in Birmingham Heartlands Hospital on 23 November 2024 from a pulmonary embolism after being admitted with community-acquired pneumonia. He had a spinal cord injury resulting in tetraplegia and had experienced falls and chest infections. Concerns included inadequate recording of clinical observations, possible staff training issues, and prolonged patient waiting lists linked to staffing and funding difficulties.
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 properly complete patient records
Wider context from the report “1. I considered evidence from a ████████ who indicated at paragraphs 20-21 of his statement, “I did not see any record of his pulse, blood pressure or oxygen saturation. The normal practice is to complete these observations, and I would expect this to be done, especially with him presenting with chest issues. However, I am unable to comment why this was not recorded or confirm that these were carried out. (21) This is a learning point for the department, and I have taken steps to ensure this learning is taken forward by the Trust. I have alerted the Sister in charge of the Spinal Injuries Outpatients’ Department and requested that adequate measures are taken to ensure that all observations made are recorded in the outpatient forms ...”.
2. It was unclear whether this was a single one-off event involving human error or indicative of a wider and systemic issue involving a lack of training. There was no evidence before the court that this “learning point” had been actioned or that any adequate steps had been taken to ensure proper and accurate recording of records by staff.
3. There is a real risk of future deaths occurring where staff do not have adequate training and that patient records are not being properly completed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 workforce staffing capacity
Wider context from the report “1. I heard evidence that The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (”The Trust”) have been experiencing difficulties with patient waiting lists - due to both an increase in the quantity of patients being treated and staffing shortages - which has led to patients waiting longer than is reasonable or necessary for reviews and treatments. As part of the inquest, there was evidence that Peter Anzani himself had been waiting for nearly a year for a follow-up review, which should have been carried out after no more than 6 months.
2. I heard evidence from representatives of the Trust that they have repeatedly requested additional funds for workforce development and expansion to assist with cutting patient waiting lists and waiting times. I understand that an initial Workplace Funding Review was submitted in 2023 but was rejected by NHS England due to a funding shortage. I understand that a further Workplace Funding Review was submitted in the Autumn of 2024, but in February/March of this year, NHS England indicated that the same would again be rejected under a "no growth policy".
3. Whilst naturally I am aware of the pressures on the public purse and on the NHS generally, it is concerning to hear that the Trust do not appear to be being adequately supported financially by NHS England, and do not currently appear to be able to address their workplace staffing issues without additional financial support (which does not appear to be forthcoming).
4. It is obvious that where patients are waiting for longer than is reasonable or necessary for treatment or review, there is a real risk of deaths occurring. No patient should be waiting longer than absolutely necessary for treatment.
5. In light of HM Government's decision on 13 March 2025 to abolish NHS England and for its role to be subsumed within the Department of Health and Social Care, this report is being sent to both Agencies to consider, as it relates to issues of both a local and national significance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate staff training
Wider context from the report “1. I considered evidence from a ████████ who indicated at paragraphs 20-21 of his statement, “I did not see any record of his pulse, blood pressure or oxygen saturation. The normal practice is to complete these observations, and I would expect this to be done, especially with him presenting with chest issues. However, I am unable to comment why this was not recorded or confirm that these were carried out. (21) This is a learning point for the department, and I have taken steps to ensure this learning is taken forward by the Trust. I have alerted the Sister in charge of the Spinal Injuries Outpatients’ Department and requested that adequate measures are taken to ensure that all observations made are recorded in the outpatient forms...”.
2. It was unclear whether this was a single one-off event involving human error or indicative of a wider and systemic issue involving a lack of training . There was no evidence before the court that this “learning point” had been actioned or that any adequate steps had been taken to ensure proper and accurate recording of records by staff.
3. There is a real risk of future deaths occurring where staff do not have adequate training and that patient records are not being properly completed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in patient reviews and treatments
Wider context from the report “1. I heard evidence that The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (”The Trust”) have been experiencing difficulties with patient waiting lists - due to both an increase in the quantity of patients being treated and staffing shortages - which has led to patients waiting longer than is reasonable or necessary for reviews and treatments . As part of the inquest, there was evidence that Peter Anzani himself had been waiting for nearly a year for a follow-up review, which should have been carried out after no more than 6 months.
2. I heard evidence from representatives of the Trust that they have repeatedly requested additional funds for workforce development and expansion to assist with cutting patient waiting lists and waiting times. I understand that an initial Workplace Funding Review was submitted in 2023 but was rejected by NHS England due to a funding shortage. I understand that a further Workplace Funding Review was submitted in the Autumn of 2024, but in February/March of this year, NHS England indicated that the same would again be rejected under a "no growth policy".
3. Whilst naturally I am aware of the pressures on the public purse and on the NHS generally, it is concerning to hear that the Trust do not appear to be being adequately supported financially by NHS England, and do not currently appear to be able to address their workplace staffing issues without additional financial support (which does not appear to be forthcoming).
4. It is obvious that where patients are waiting for longer than is reasonable or necessary for treatment or review, there is a real risk of deaths occurring . No patient should be waiting longer than absolutely necessary for treatment.
5. In light of HM Government's decision on 13 March 2025 to abolish NHS England and for its role to be subsumed within the Department of Health and Social Care, this report is being sent to both Agencies to consider, as it relates to issues of both a local and national significance.
” 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 Complete an internal review of the Coroner’s findings and formal workforce funding requests for the SCI service.
Verbatim wording from the response “NHS England was not given Interested Party status or asked to provide any witness evidence during the inquest into Peter’s death. The Coroner’s findings have resulted in an internal NHS England review and we have not identified any specific formal workforce funding requests that have been rejected by NHS England for the SCI service at RJAH with regard to outpatient services.” 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 No formal workforce funding requests for RJAH’s outpatient spinal injury service were identified as having been rejected by NHS England.
Verbatim wording from the response “NHS England’s Specialised Commissioning funds RJAH’s SCI service as part of a block funded commissioning system to cover the complete costs for the service, including inpatient and outpatient activity with inflationary finance being applied to all NHS England contracts annually since 2020. As a Foundation Trust, RJAH take organisational decisions on individual service spends, including workforce, to deliver services as identified in the national service specification. In June 2024, a Trust internal workforce review was shared for information with NHS England and we understand this is being updated at this current time. No formal requests for funding have been received through the contract review meeting process between RJAH and NHS England, to support the findings of the RJAH internal review.” 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 RJAH, as a Foundation Trust, makes organisational decisions about workforce spending within its block-funded spinal injury service.
Verbatim wording from the response “NHS England’s Specialised Commissioning funds RJAH’s SCI service as part of a block funded commissioning system to cover the complete costs for the service, including inpatient and outpatient activity with inflationary finance being applied to all NHS England contracts annually since 2020. As a Foundation Trust, RJAH take organisational decisions on individual service spends, including workforce, to deliver services as identified in the national service specification. In June 2024, a Trust internal workforce review was shared for information with NHS England and we understand this is being updated at this current time. No formal requests for funding have been received through the contract review meeting process between RJAH and NHS England, to support the findings of the RJAH internal review.” Source location Response from NHS England
Open published response
24 Apr 2025 Jacqueline Anne Potter · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 5 Failure to restrict in-patient access to self-harm websites through secure unit Wi-Fi View source Failure to provide families with codified risk and safety planning information for first overnight leave View source Insufficient availability of specialist menopausal practitioners in primary and Trust-wide care View source Lack of mandatory menopausal training for relevant clinical practitioners View source Failure to recognise the clinical importance of menopausal symptoms and care View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jacqueline Anne Potter · 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
Jacqueline Anne Potter, known as Anne, died on 5 December 2022 after taking a car and deliberately driving into the path of an HGV tanker on the A303 during overnight leave from a psychiatric unit. The report raises concerns about families not receiving a codified risk and safety planning document for a patient’s first overnight leave, unrestricted access to self-harm websites through secure unit Wi-Fi, and inadequate recognition and provision of menopausal care and training.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict in-patient access to self-harm websites through secure unit Wi-Fi
Wider context from the report “(2) It transpired during the Inquest that if an in-patient (detained or voluntary) accesses the secure unit Wi-Fi there are no algorithms or ‘search detection features’ to prevent access to websites pertaining to self harm and so these can be readily accessed by a group who are already vulnerable due to their acute mental health presentation with some element of inherent risk of suicide . It was noted, quite rightly, by legal representatives that workplace organisations can block access to certain sites they deem it undesirable for their workforce to access (such as sites relating to gambling, sexually inappropriate content etc) which shows that it is possible to limit access to certain websites and content when using a Wi-Fi provider. By allowing an already vulnerable group to have unfettered access to websites dedicated to self harm creates a risk of further deaths .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide families with codified risk and safety planning information for first overnight leave
Wider context from the report “(1) Anne was not sent home for her first overnight leave with any codified ‘Risk’ and ‘Safety Planning’ document. Whilst it was widely accepted in this case that Anne’s husband was well versed and knowledgeable about his wife’s risks and the measures that might be necessary to help keep her safe whilst she was at home, not all families are as involved in their loved one’s psychiatric care, despite the Trust following the Triangle of Care principles.
Whilst families are not mental health practitioners and are not expected to adopt that role within the community there appears to be an opportunity to supply families with a short, codified document dealing with salient points of risks and safety planning when a patient goes for their first overnight leave since being detained . This may equip families with the knowledge to spot signs of declining mental presentation and/or risk and provide them with the knowledge and/or tools to take appropriate steps to assist in safeguarding their loved ones whilst they are in the community.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of specialist menopausal practitioners in primary and Trust-wide care
Wider context from the report “(ii) I was told that the Trust has just one ‘menopause specialist’ (a GP) who covers the entire Trust operations . Not all GP surgeries have a menopause specialist practitioner (or access to one) despite a GP usually being the first port of call for women in the community when seeking primary care. Those GP Surgeries who do have a practitioner who acts as a ‘specialist’ is often a GP with a personal interest who has taken the initiative to go on courses and broaden their learning and understanding, rather than any mandatory requirement for a Surgery [or group with multiple surgeries] to have an available community ‘front-line’ specialist .
I was told that the Trust does not have an “expert” in this field and it would be difficult to have one as menopause isn’t a disease or an illness. Whilst I do not dispute that is it not a disease, menopause is a condition; it does have symptoms and it does have recognised presentations, yet there appears to be a failure to recognise this condition as having equal importance to other ailments or diagnoses.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 mandatory menopausal training for relevant clinical practitioners
Wider context from the report “(i) Certain elements of medicine and clinical practice training are compulsory but having heard evidence at the Inquest around mandatory and statutory training modules I learnt that this covers areas such as GDPR training and disposal of sharp objects such as syringes. I was surprised to learn that menopausal training is not mandatory in any area of clinical practice or specialism . I am concerned that there is no requirement to undertake essential compulsory menopausal training for those working in ‘relevant’ clinical practices such as Mental Health Practice, Obstetrics and Gynaecology and Oncology, or even general as a general GP.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the clinical importance of menopausal symptoms and care
Wider context from the report “I was told during a previous PFD Response relating to menopausal knowledge and care within the NHS that “It is important to ensure that women understand common symptoms such as anxiety, stress and depression which they might experience during the menopause and where and when to seek help. The NHS website has resources….” This emphasises my concerns entirely; the lack of importance given to menopausal symptoms . If someone has concerns about heart disease, a worrying lump, a broken bone etc they expect to be able to consult a medically qualified professional who has a knowledge and understanding of their condition or presentation and can diagnose and treat accordingly; not just [and I paraphrase] ‘have a look at a website to help’.
I appreciate that each and every woman will experience perimenopause and menopause differently, their individual experience is unique to them and this, to some degree, creates difficulties as a ‘one size fits all’ approach (which is perhaps achievable in other medical specialisms and disciplines) cannot be offered, but the lack of recognition of the importance of this condition remains a significant concern . I had previously been told (back in a 2024 PFD response) of a roll-out of specialist menopausal care and upskilling of GPs but there was little evidence during the inquest that this has happened/is happening and women continue to approach and navigate the menopause without the support of expert clinicians or practitioners who understand and can treat the symptoms they are experiencing .
” 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 Work with regions and Integrated Care Boards to improve nationwide access to good menopause care.
Verbatim wording from the response “There is often variation between GPs and practices in the level of complexity of care they are able to provide. Women’s Health Hubs were piloted in 2023/2024, seeking to reduce the variations in reproductive healthcare which women reported receiving. They provide the option for women to be referred to more specialist reproductive health care (including menopause care) if the GP needs further advice. Women’s Health Hubs have yet to achieve full coverage, but have the potential to fill the gap in care where this is more complex. NHS England is working closely with its regions and Integrated Care Boards (ICBs) to ensure that every woman can access good menopause care wherever they are in the country.” 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 menopause educational resources to enhance practice nurses’ learning.
Verbatim wording from the response “Practice nurses also have a significant role in menopause care and are often the first port of call for some women experiencing difficulties, or who may have the opportunity to proactively enquire about the menopause. In 2024, NHS England published specific” 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 a toolkit supporting menopause information events and group consultations in local areas.
Verbatim wording from the response “A toolkit that supports local areas to provide menopause information events and group consultations is under development to improve access and also to provide a forum for learning for other healthcare professionals. NHS England is working on menopause workforce support packages for employees and employers and developing a range of tools to upskill, including two e-learning packages (Menopause Awareness – e-learning for healthcare and Menopause and people professionals eLearning for healthcare), decision support tools and a self-care factsheet to empower women to understand and self-manage their perimenopause and menopause symptoms, and to point them towards further sources of credible information.” 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 menopause workforce support packages and tools, including decision support and self-care resources.
Verbatim wording from the response “A toolkit that supports local areas to provide menopause information events and group consultations is under development to improve access and also to provide a forum for learning for other healthcare professionals. NHS England is working on menopause workforce support packages for employees and employers and developing a range of tools to upskill, including two e-learning packages (Menopause Awareness – e-learning for healthcare and Menopause and people professionals eLearning for healthcare), decision support tools and a self-care factsheet to empower women to understand and self-manage their perimenopause and menopause symptoms, and to point them towards further sources of credible information.” 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 Promote high-quality and equitable menopause care coverage for all.
Verbatim wording from the response “Anne’s tragic death has highlighted important gaps in the care of women experiencing perimenopause or menopause and the potential for improvements. NHS England will continue to promote high quality and equitable coverage of menopause care for all.” 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 Launch menopause awareness sessions and related e-learning packages for healthcare and people professionals.
Verbatim wording from the response “In recent years, the NHS England National Menopause programme has also launched a series of awareness sessions, including the ‘Menopause awareness’ and ‘Menopause and people professionals’ e-learning packages referenced earlier on in this response, as well as e-learning on ‘Menopause and occupational health’.” 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 Employing organisations determine locally mandated menopause training according to their priorities and patient needs.
Verbatim wording from the response “2. Locally mandated – each employing organisation will determine what should be mandated to all or most of their staff to meet priorities and patient needs. This training varies between organisations, with some similarities.” 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 Professions and royal colleges determine profession- or role-specific menopause training standards and curricula.
Verbatim wording from the response “3. Profession or role specific mandated – this is determined by the respective professions and royal colleges and will form part of standards for professional development and curriculum for future trainees.” Source location Response from NHS England
Open published response
16 Apr 2025 Abdulrahman AlAjmi · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 3 Absence of systems or structures for safe receipt and treatment of patients arriving in the UK for medical treatment View source Lack of a set procedure for UK hospital acceptance of patients from other countries View source Failure to ensure accurate and updated clinical information for referral acceptance and patient transfer 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
Abdulrahman AlAjmi · 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
Abdulrahman AlAjmi died at the London Clinic on 7 August 2024 from multiorgan failure after arriving in the UK for medical treatment in a substantially poorer condition than had been reported. The report found that the flight probably contributed to his death by exacerbating serious pre-existing medical conditions. Concerns included the absence of uniform systems for accepting and transferring overseas patients, ensuring that receiving services have accurate and up-to-date medical information, and safely treating patients who arrive more unwell than anticipated.
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 Absence of systems or structures for safe receipt and treatment of patients arriving in the UK for medical treatment
Wider context from the report “5. The evidence showed an absence of systems or structures to ensure that patients arriving in the UK for medical treatment are able to be received (by the ambulance transferring them and the hospital treating them) safely and be properly treated : with a full understanding of the accurate and up to date medical position.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 set procedure for UK hospital acceptance of patients from other countries
Wider context from the report “1. In the course of the evidence it was confirmed that there is no set procedure regarding the acceptance by hospitals in the UK of patients for treatment from other countries .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure accurate and updated clinical information for referral acceptance and patient transfer
Wider context from the report “2. It was stated in evidence that patients often arrive in a substantially different (often worse) condition to that described to the receiving clinicians when they accepted the referral and agreed that they were able to provide treatment. This means that UK health providers may receive for treatment individuals who are more unwell than anticipated, potentially requiring expertise that is not held by the receiving treatment providers (albeit in this case they had an ICU team who were able to provide the necessary treatment).
3. The evidence provided showed that it is up to each individual hospital to determine whether they are willing and able to accept a referral and agree the process for transfer of the patient. The evidence indicated that process is not uniform and relies heavily on the accuracy of the information received from the referring medical staff, as well as it being appropriately updated should circumstances change .
” 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 concerns about procedures for accepting foreign patients fall outside NHS England’s remit.
Verbatim wording from the response “The concerns raised in your Report do not sit within NHS England’s remit. NHS England notes that the Coroner has also addressed your Report to the Department of Health and Social Care (DHSC) and the Foreign, Commonwealth and Development Office (FCDO) who are the more appropriate organisations to respond to your concerns. Where we are able to, NHS England will be happy to support these organisations in addressing the concerns raised.” 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 Acceptance of foreign patients by NHS hospitals is governed by existing local procedures rather than a national procedure.
Verbatim wording from the response “While we note that, in this case, the receiving hospital was private and not under NHS jurisdiction, it is currently the case that any acceptance of a foreign patient by an NHS hospital would be subject to local procedures. We have therefore ensured that North West London Integrated Care Board (NWL ICB), the host ICB for the London Clinic, are aware of Abdulrahman’s case and the concerns raised in your Report for assurance purposes.” 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 DHSC and FCDO are identified as the more appropriate organisations to respond to concerns about accepting foreign patients for treatment.
Verbatim wording from the response “The concerns raised in your Report do not sit within NHS England’s remit. NHS England notes that the Coroner has also addressed your Report to the Department of Health and Social Care (DHSC) and the Foreign, Commonwealth and Development Office (FCDO) who are the more appropriate organisations to respond to your concerns. Where we are able to, NHS England will be happy to support these organisations in addressing the concerns raised.” Source location Response from NHS England
Open published response
7 Apr 2025 Sandra Ann MILLARD · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 1 Failure to apply additional caller enquiries when a person is unable to move from any position View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sandra Ann MILLARD · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sandra Ann Millard called 111 on 19 May 2024 because she was unable to move from her chair. A clinician could not reach her by telephone, no ambulance was dispatched, and she was found deceased by a neighbour the following day; the cause of death was recorded as sepsis from infected leg ulcers, with ischaemic heart disease, coronary artery atheroma and chronic kidney disease also noted. The concern was that additional enquiries and support arrangements used for people lying on the floor were not applied to people unable to move from other positions, such as a chair.
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 apply additional caller enquiries when a person is unable to move from any position
Wider context from the report “I heard that when SCAS call takers using the NHS Pathways triage tool exit a module indicating a person is lying on the floor with no reported injuries they are prompted to ask additional questions of the caller; including whether someone else is with the caller; whether the caller can provide a number for next of kin or other person who may be able to attend the caller whilst they wait for an ambulance. This is due to the likely delay of a number of hours before an ambulance can attend.
This same procedure is not applied when someone reports that they are stuck in situ, for example they are unable to move from their chair.
My concern is that the additional risks of a long lie, for example rhabdomyolysis, may well apply when someone in unable to move from any position.
SCAS agreed to change their standard operating procedures to incorporate additional enquiries in these circumstances. I am pleased that they have agreed to amend their procedures swiftly.
However this matter has wider significance and should be considered by other users of the NHS Pathways triage tool.
” 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 Maintain NHS Pathways functionality for assessing patients unable to move from their current position.
Verbatim wording from the response “Between 2017 and 2018, NHS Pathways collaborated with its ambulance service stakeholders to enhance the assessment of patients who may not have fallen but are nonetheless unable to move from their current position. Since 2018, the system has included functionality to assess patients in this situation, regardless of whether their immobility is due to disability, frailty, weakness, pain, or another factor.” Source location Response from NHSE
Open published response
Concerns raised 1 Lack of available British Sign Language interpreters for Deaf patients with mental health difficulties View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Imogen Alice NUNN · 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
Imogen Alice NUNN was found deceased at her home on 1 January 2023 after leaving a party and being reported as a high-risk missing person; the circumstances text states that she had consumed a substance bought online. The principal concern was the lack of available British Sign Language interpreters for Deaf patients receiving mental health support, particularly for urgent assessments when patients were in crisis.
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 available British Sign Language interpreters for Deaf patients with mental health difficulties
Wider context from the report “During the course of the Inquest (which has yet to be concluded) I heard evidence that there was a lack of availability of British Sign Language Interpreters able to help support Deaf patients in the community who were being treated with mental health difficulties . This was particularly apparent when mental health staff were seeking an interpreter at short notice for a patient who was in crisis . The lack of interpreters available has meant that urgent assessments are being carried out with no interpreters present .
The overall lack of British Sign Language Interpreters has also meant that this Inquest has itself had to be delayed/adjourned for two months due to there being no available Interpreters to interpreter for two deaf witnesses over the two week period of the Inquest.
” 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 Hold a stakeholder meeting to brief stakeholders on the plan to publish a refreshed Accessible Information Standard.
Verbatim wording from the response “loss. The AIS was co-designed with stakeholders such as Sign Health and the British Deaf Association. A meeting will be held by NHS England later in May 2025 to brief stakeholders on the plan to publish a refreshed version of the AIS. The revised AIS is expected to ensure that BSL interpreters are suitably qualified, and that their provision is a requirement for families and carers, as well as patients.” 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 Integrated Care Boards are responsible for commissioning community mental health services and ensuring adequate BSL interpreter provision.
Verbatim wording from the response “NHS England recognises that the provision of interpreters within community mental health services is important, both to support patients and to ensure that comprehensive mental health assessments take place in a timely manner. Commissioning of community mental health services is the responsibility of Integrated Care Boards (ICBs), and this includes responsibility for ensuring there is adequate provision of BSL interpreters to support deaf patients in the community. Should a Trust or local provider experience challenges in booking interpreters, they would be expected to identify this as a risk and work with their commissioner (ICB) to resolve the issue.” Source location Response from NHS England
Open published response
Concerns raised 20 Failure to grade fatal severe harm correctly View source Failure to examine the Trust's own clinical governance processes View source Unreliability of Trust safety and complaints data View source Failure to ensure midwives complete current mandatory training View source Failure of harm-only reporting to identify underlying safety problems View source Failure to notify external and internal patient-safety bodies of serious incidents View source Lack of a system of remedial training View source Inconsistent categorisation of harm for cooled babies with hypoxic injury View source Lack of document version control and audit View source Failure to learn from identified safety issues and themes View source Lack of a culture of candour View source Lack of assured ongoing funding for MSNI investigations View source Insufficiently skilled and trained clinical governance personnel View source Failure of clinical reporting to provide a holistic and complete account of evidence View source Failure to categorise a death-causing harm event correctly View source Inadequate Trust investigations failing to identify safety issues View source Failure to investigate senior staff roles in disputed safety-report decisions View source Failure to provide relevant information transparently and openly View source Chaotic clinical governance arrangements View source Untrained clinical governance staff View source See 17 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ida Jean Lock · 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
Ida Jean Lock died on 16 November 2019 after suffering a lack of oxygen during delivery on 9 November 2019, resulting in severe hypoxic-ischaemic brain damage. The report describes missed opportunities for enhanced care and obstetric input, delays in responding to fetal distress, and initially ineffective neonatal resuscitation. The principal concerns include the Trust’s alleged lack of candour and transparency, deficient clinical and maternity governance, inadequate investigations, gaps in mandatory and remedial training, and inappropriate grading of the harm suffered.
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 grade fatal severe harm correctly
Wider context from the report “14. The Trust graded Ida’s level of harm as “moderate”, even after her death . This grading should have been adjusted to "severe" by the Trust before Ida was transferred to Royal Preston Hospital as the consultant paediatrician identified that she had sustained a severe hypoxic ischaemic encephalopathy due to fetal bradycardia.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 examine the Trust's own clinical governance processes
Wider context from the report “7. As a result of the Trust's deficient processes, the Trust did not undertake any examination of its own clinical governance processes , which were a principle area of concern and which was identified to the Trust five months before the inquest commenced. The Trust's clinical governance arrangements were extracted piecemeal during the course of the inquest. The deficiencies included lack of version control and audit of documents, untrained staff, chaotic clinical governance arrangements, defensive attitudes and inappropriate self-congratulation. The clinicians' reports to the inquest only answered the questions they were asked rather than trying to assist with a holistic view of the evidence, did not provide relevant information until it was extracted from the witness in testimony, that resulted in rolling disclosure of documents and additional witness evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unreliability of Trust safety and complaints data
Wider context from the report “5. Trust figures to the Board provided in 2025 stated that there were no complaints over 6 months old when the Trust at the time of the inquest have not responded to ████████ and ████████'s 1 June 2020 complaint., Together with the Trust's failure to categorise Ida's death as only "Moderate Harm" (see point 4 above) cause me also to have concern about the reliability of Trust's data .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 midwives complete current mandatory training
Wider context from the report “11. The Band 5 midwife supporting ████████ in Labour had not undertaken her required mandatory training and this fact had not been provided and was only revealed at the inquest as part of the evidence of the Head of Midwifery in March 2025. I was also concerned to learn that in 2025 non-completion of mandatory training was still an issue as ████████ had not completed her mandatory training.
12. It concerns me that the Trust do not have robust systems in place to ensure that any midwife who has not completed her mandatory training is subject to immediate action to ensure that all mandatory training is completed and is in date .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 harm-only reporting to identify underlying safety problems
Wider context from the report “15. The 2024 NHSE Learn from patient safety events (LFPSE) guidance that replaced the National Reporting and Learning System (NRLS) confirms that the recording and analysis of patient safety events that occur in healthcare support the NHS to improve learning from patient safety events to help make care safer. There is a significant risk that if reporting is graded on harm alone , clinical care that resulted in hypoxic brain damage during delivery and which was prevented by therapeutic cooling, will not adequately identify the problems that caused the harm during the delivery .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to notify external and internal patient-safety bodies of serious incidents
Wider context from the report “4. The Trust did not disclose that they had failed to notify the external bodies namely the CQC and the then CCG [ICB] via STEIS and the Trust's internal Serious Incidents Reporting Investigation panel , none of which was noted by the Trust's Patient Safety Summits .The matter was reported to the Coroner a year after Ida's death by the family after the Trust took no action to do so, despite being on notice of failures in treatment from the HSIB report Ida’s harm was at no point categorised by the Trust as a harm event that caused “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 a system of remedial training
Wider context from the report “13. There was no remedial training was put in place for either the midwives involved in Ida's delivery and resuscitation or for the paediatric SHO after Ida’s death. This raises a significant concern that the Trust do not operate a system of remedial training when this inquest has identified remedial training was required for ████████, ████████, ████████ and ████████
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inconsistent categorisation of harm for cooled babies with hypoxic injury
Wider context from the report “16. ████████ confirmed that nationally there is inconsistency in categorisation of harm for babies who sustain a hypoxic injury due to fetal bradycardia in labour and who require cooling and clarification and guidance would assist prevent further maternity deaths and ensure full and proper investigation of hypoxic injuries sustained in labour.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 document version control and audit
Wider context from the report “7. As a result of the Trust's deficient processes, the Trust did not undertake any examination of its own clinical governance processes, which were a principle area of concern and which was identified to the Trust five months before the inquest commenced. The Trust's clinical governance arrangements were extracted piecemeal during the course of the inquest. The deficiencies included lack of version control and audit of documents , untrained staff, chaotic clinical governance arrangements, defensive attitudes and inappropriate self-congratulation. The clinicians' reports to the inquest only answered the questions they were asked rather than trying to assist with a holistic view of the evidence, did not provide relevant information until it was extracted from the witness in testimony, that resulted in rolling disclosure of documents and additional witness evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 learn from identified safety issues and themes
Wider context from the report “2. ████████s evidence to the inquest was that a deep-seated and endemic culture within the Trust leads to denial and a failure to learn . ████████'s Investigation report was published in 2015, the Trust is ten years on and still issues and themes identified in 2015 were very much in issue in 2019 and still exist at the Trust as identified by Ida’s inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a culture of candour
Wider context from the report “1. I am concerned that there is not a culture of candour within University Hospitals of Morecambe Bay NHS Foundation Trust (Trust) and the impact that this has on safety, learning and implementing required changes to prevent deaths. Urgent action is required by the Trust to meaningfully embed the Duty of Candour
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 assured ongoing funding for MSNI investigations
Wider context from the report “18. The MSNI is now hosted by the CQC with funding secured for the next two years but no certainty as to ongoing funding after this date . These independent investigations by specialist skilled investigators into the most serious of events is an essential safeguard to the lives of mothers and unborn children.
19. Without an assurance that funding will continue beyond 2027 I am concerned that significant harm events to mothers and babies and deaths such as Ida's will go unrecorded and lessons that should be learned to prevent future maternal and baby deaths will go unnoticed, and there will be a risk of future maternity deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficiently skilled and trained clinical governance personnel
Wider context from the report “6. I consider the clinical governance arrangements at the Trust require urgent review to ensure the appropriate personnel are in place, with the necessary training and skills to deliver robust clinical governance to ensure patient safety in maternity 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 clinical reporting to provide a holistic and complete account of evidence
Wider context from the report “7. As a result of the Trust's deficient processes, the Trust did not undertake any examination of its own clinical governance processes, which were a principle area of concern and which was identified to the Trust five months before the inquest commenced. The Trust's clinical governance arrangements were extracted piecemeal during the course of the inquest. The deficiencies included lack of version control and audit of documents, untrained staff, chaotic clinical governance arrangements, defensive attitudes and inappropriate self-congratulation. The clinicians' reports to the inquest only answered the questions they were asked rather than trying to assist with a holistic view of the evidence , did not provide relevant information until it was extracted from the witness in testimony , that resulted in rolling disclosure of documents and additional witness evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 categorise a death-causing harm event correctly
Wider context from the report “4. The Trust did not disclose that they had failed to notify the external bodies namely the CQC and the then CCG [ICB] via STEIS and the Trust's internal Serious Incidents Reporting Investigation panel, none of which was noted by the Trust's Patient Safety Summits .The matter was reported to the Coroner a year after Ida's death by the family after the Trust took no action to do so, despite being on notice of failures in treatment from the HSIB report Ida’s harm was at no point categorised by the Trust as a harm event that caused “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 Inadequate Trust investigations failing to identify safety issues
Wider context from the report “9. All investigations conducted by the Trust to date in respect of Ida’s death have been unskilled, superficial, brief, failed to identify issues and left the family without answers and were all features identified by the 2015 Kirkup Report. In view of the continuing culture at the Trust, this cause a significant concern that issues of safety and safeguarding are not properly considered, transparently engaged with and then addressed formally in respect of a child fatality and serious injury by the Trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate senior staff roles in disputed safety-report decisions
Wider context from the report “8. ████████ is now Head of Compliance and Assurance at the Trust but that there has been no investigation into her role in respect of reneging on the Trust's acceptance of the HSIB report at senior management level and with the family as was indicated by her approval of the July 2021 position statement. Similarly, ████████ is now Head of Midwifery at the Trust and there has been no investigation in respect of her disputing the HSIB findings and submission of challenge to the HSIB report in Ida’s case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide relevant information transparently and openly
Wider context from the report “3. The Trust's approach to the inquest has been one of a lack of transparency and openness, failure to provide relevant information and a failure to identify with candour the defective clinical governance processes that have operated at the Trust from 2019 to present day.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Chaotic clinical governance arrangements
Wider context from the report “7. As a result of the Trust's deficient processes, the Trust did not undertake any examination of its own clinical governance processes, which were a principle area of concern and which was identified to the Trust five months before the inquest commenced. The Trust's clinical governance arrangements were extracted piecemeal during the course of the inquest. The deficiencies included lack of version control and audit of documents, untrained staff, chaotic clinical governance arrangements , defensive attitudes and inappropriate self-congratulation. The clinicians' reports to the inquest only answered the questions they were asked rather than trying to assist with a holistic view of the evidence, did not provide relevant information until it was extracted from the witness in testimony, that resulted in rolling disclosure of documents and additional witness evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Untrained clinical governance staff
Wider context from the report “7. As a result of the Trust's deficient processes, the Trust did not undertake any examination of its own clinical governance processes, which were a principle area of concern and which was identified to the Trust five months before the inquest commenced. The Trust's clinical governance arrangements were extracted piecemeal during the course of the inquest. The deficiencies included lack of version control and audit of documents, untrained staff, chaotic clinical governance arrangements , defensive attitudes and inappropriate self-congratulation. The clinicians' reports to the inquest only answered the questions they were asked rather than trying to assist with a holistic view of the evidence, did not provide relevant information until it was extracted from the witness in testimony, that resulted in rolling disclosure of documents and additional witness evidence.
” Open source report
Concerns raised 3 Lack of clear cross-sector guidance on when and in what circumstances patients may be returned to care homes View source Failure to ensure that discharge to a non-nursing care home is appropriate for a patient's condition and care needs View source Failure of discharge letters to communicate clinically significant sedation and oxygen requirements View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Winnie Harrop · 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
Winnie Harrop collapsed at a care centre on 12 August 2024, was treated in hospital after sustaining facial fractures, and was discharged back to the care centre with a new oxygen requirement but without oxygen. She became drowsy and unresponsive, was readmitted on 13 August, and died in hospital on 16 August 2024. The principal concerns were unclear health and social care guidance about discharge to a care home, discharge while overly sedated, and a discharge letter that did not record the sedation level or new oxygen requirement.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of clear cross-sector guidance on when and in what circumstances patients may be returned to care homes
Wider context from the report “(1) There is no clear guidance between health and social care as to when and in what circumstances it is appropriate to send a patient back to a care home . Ms Harrop was discharged back to the care home less than 24 hours following her admission despite being overly sedated. The care home was not a nursing home. Ms Harrop’s discharge letter failed to refer to the level of sedation provided or that there was a new oxygen requirement.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that discharge to a non-nursing care home is appropriate for a patient's condition and care needs
Wider context from the report “(1) There is no clear guidance between health and social care as to when and in what circumstances it is appropriate to send a patient back to a care home. Ms Harrop was discharged back to the care home less than 24 hours following her admission despite being overly sedated . The care home was not a nursing home . Ms Harrop’s discharge letter failed to refer to the level of sedation provided or that there was a new oxygen requirement.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of discharge letters to communicate clinically significant sedation and oxygen requirements
Wider context from the report “(1) There is no clear guidance between health and social care as to when and in what circumstances it is appropriate to send a patient back to a care home. Ms Harrop was discharged back to the care home less than 24 hours following her admission despite being overly sedated. The care home was not a nursing home. Ms Harrop’s discharge letter failed to refer to the level of sedation provided or that there was a new oxygen requirement .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clear health and social care discharge guidance and discharge documentation concerns fall outside NHS England’s remit.
Verbatim wording from the response “Your Report raised a concern around there being no clear guidance between health and social care as to the circumstances in which it is appropriate to send a patient back to a care home following a hospital admission. You also raised that Winnie’s discharge letter failed to refer to the level of sedation provided or that there was a new oxygen requirement. This particular concern falls outside of NHS England’s remit and should be raised locally with Tameside and Glossop Integrated Care NHS Foundation Trust, should the Coroner require any further information beyond what is set out in this response.” Source location Response from NHSE
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 Further information about discharge guidance and documentation should be sought locally from Tameside and Glossop Integrated Care NHS Foundation Trust.
Verbatim wording from the response “Your Report raised a concern around there being no clear guidance between health and social care as to the circumstances in which it is appropriate to send a patient back to a care home following a hospital admission. You also raised that Winnie’s discharge letter failed to refer to the level of sedation provided or that there was a new oxygen requirement. This particular concern falls outside of NHS England’s remit and should be raised locally with Tameside and Glossop Integrated Care NHS Foundation Trust, should the Coroner require any further information beyond what is set out in this response.” Source location Response from NHSE
Open published response
Concerns raised 2 Failure of the Special Allocation Scheme to meet the needs of autistic patients View source Lack of appropriate care and support for autistic people in crisis without a treatable mental health condition View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Benjamin Robert Compton · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Benjamin Robert Compton, who had autism, experienced a deterioration in his physical and mental wellbeing and escalating distress. In the early hours of 1 February 2022, he left his supported accommodation and was hit by a lorry on the M5. The substantive concerns included gaps in support for autistic people in crisis and the inability of the Special Allocation Scheme to meet Benjamin’s needs.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of the Special Allocation Scheme to meet the needs of autistic patients
Wider context from the report “(2) Benjamin was removed from his GP practice due to violent behaviour and allocated to the Special Allocation Scheme. This scheme was not able to meet the needs of a patient such as Benjamin with a diagnosis of Autism Spectrum disorder .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate care and support for autistic people in crisis without a treatable mental health condition
Wider context from the report “(1) The evidence reveals that there was a gap in the provision of care for individuals suffering with autism and in crisis, that remains the case today both in Devon and nationally . Evidence was heard that a gap exists with autistic people in distress and or dysregulation with no treatable mental health condition and there is a grey area around treatment. This is beyond the skills of social care providers . And unless the individual meets the criteria for treatment under the Mental Health Act there is very little support .
” 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 national guidance for Integrated Care Boards and providers on accessible, autism-informed mental health care.
Verbatim wording from the response “In December 2023, NHS England published Meeting the Needs of Autistic Adults in Mental Health Services, which provides guidance to Integrated Care Boards and health providers on delivering accessible, autism-informed care. Key areas of relevance to your Report include:” 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 Implement an online SAS referral prompt reminding GP practices to undertake careful consideration before referral.
Verbatim wording from the response “b) Implement a prompt to GP practices when completing the online referral on the need for careful consideration (Status: in the process of implementation).” 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 Update the Primary medical services policy and guidance manual to remind practices to consider protected characteristics, medical history, learning disability and neurodiversity before SAS referrals.
Verbatim wording from the response “The PGM was updated on 15 July 2024 to include the following key updates in the SAS section:” 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 Include an action request for commissioners to consider initial appropriateness assessments in commissioned SAS services, subject to commissioning reviews and funding availability.
Verbatim wording from the response “c) An action request for commissioners to consider establishing and embedding initial appropriateness assessments into all commissioned SAS services. This would be subject to consideration when new services are commissioned or when existing services are reviewed, as well as funding availability.” 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 Establishing initial Special Allocation Scheme appropriateness assessments is subject to funding availability.
Verbatim wording from the response “c) An action request for commissioners to consider establishing and embedding initial appropriateness assessments into all commissioned SAS services. This would be subject to consideration when new services are commissioned or when existing services are reviewed, as well as funding availability.” 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 responding to concerns about care provision within Devon.
Verbatim wording from the response “Your Report raises concerns over a gap in the provision of care nationally for individuals suffering with autism and in mental health crisis. It is for NHS Devon Integrated Care Board, who I note you have also sent your Report to, to respond to your concerns regarding provision of care within Devon.” 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 Commissioners are responsible for considering and establishing initial appropriateness assessments in commissioned Special Allocation Scheme services.
Verbatim wording from the response “c) An action request for commissioners to consider establishing and embedding initial appropriateness assessments into all commissioned SAS services. This would be subject to consideration when new services are commissioned or when existing services are reviewed, as well as funding availability.” Source location Response from NHS England
Open published response
13 Mar 2025 Mr Paul Timothy Dunne · Prevention of Future Deaths report South London
View report summary
Concerns raised 12 Failure of Mental Health Trust leadership to recognise serious professional knowledge and judgment deficits View source Failure to direct staff to the need for 1:1 monitoring View source Failure to apply A&E risk assessment and staffing policies to mental health staff View source Absence of audit of absconsions and mental health liaison in A&E View source Failure to recognise high-risk mental health patients View source Incorrect understanding of Mental Health Act assessment criteria View source Failure to acknowledge communicated patient risk View source Failure to complete required duplicate A&E clinical record entries by mental health staff View source Lack of shared access to mental health and A&E clinical records View source Failure to document mental health assessments when no recording location is available View source Inconsistent risk assessment documentation and training across departments View source Gaps in mental health professionals’ knowledge and clinical judgment View source See 9 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
Mr Paul Timothy Dunne · 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
Mr Paul Dunne was brought to A&E after a paracetamol overdose and was considered at high risk of suicide, but did not receive continuous 1:1 observation. He absconded several times and was found dead after suspending himself in a nearby children's playground. Concerns included failures in risk assessment, observation, communication, documentation and escalation, as well as separate clinical-record systems used by mental health and A&E staff.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of Mental Health Trust leadership to recognise serious professional knowledge and judgment deficits
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 direct staff to the need for 1:1 monitoring
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need . When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 A&E risk assessment and staffing policies to mental health staff
Wider context from the report “2. The Mental Health Trust
• Staff and it appears the director even at the time of the inquest did not appreciate that the A&E policies (Missing Persons, Shared Care) which required risk assessment after an absconsion and alerting managers to the need for extra temporary staff if 1:1 monitoring was needed, also applied to MH staff.
• Evidence was heard that staff in KCH A&E and Oxleas NH Trust had been trained on different risk assessment documents. Although meetings had been reinstated between departments, there had been no audit of absconsions or MH liaison in A&E.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Absence of audit of absconsions and mental health liaison in A&E
Wider context from the report “2. The Mental Health Trust
• Staff and it appears the director even at the time of the inquest did not appreciate that the A&E policies (Missing Persons, Shared Care) which required risk assessment after an absconsion and alerting managers to the need for extra temporary staff if 1:1 monitoring was needed, also applied to MH staff.
• Evidence was heard that staff in KCH A&E and Oxleas NH Trust had been trained on different risk assessment documents. Although meetings had been reinstated between departments, there had been no audit of absconsions or MH liaison in A&E.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise high-risk mental health patients
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk , despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Incorrect understanding of Mental Health Act assessment criteria
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 acknowledge communicated patient risk
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to complete required duplicate A&E clinical record entries by mental health staff
Wider context from the report “3. MH staff and A&E staff write their clinical records in different systems and hospital staff do not have access to MH Rio records. MH staff attending A&E departments are asked to make a double entry in the A&E records as well. Here that was omitted, potentially with fatal risks. Moving to a combined electronic system (now identified as EPIC) has long been the aim of the local health providers, but evidence was heard that the pace of introduction, which is very slow, is in the hands of national NHS leadership.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 shared access to mental health and A&E clinical records
Wider context from the report “3. MH staff and A&E staff write their clinical records in different systems and hospital staff do not have access to MH Rio records . MH staff attending A&E departments are asked to make a double entry in the A&E records as well. Here that was omitted, potentially with fatal risks. Moving to a combined electronic system (now identified as EPIC) has long been the aim of the local health providers, but evidence was heard that the pace of introduction, which is very slow, is in the hands of national NHS leadership.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to document mental health assessments when no recording location is available
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment , as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inconsistent risk assessment documentation and training across departments
Wider context from the report “2. The Mental Health Trust
• Staff and it appears the director even at the time of the inquest did not appreciate that the A&E policies (Missing Persons, Shared Care) which required risk assessment after an absconsion and alerting managers to the need for extra temporary staff if 1:1 monitoring was needed, also applied to MH staff.
• Evidence was heard that staff in KCH A&E and Oxleas NH Trust had been trained on different risk assessment documents. Although meetings had been reinstated between departments, there had been no audit of absconsions or MH liaison in A&E.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Gaps in mental health professionals’ knowledge and clinical judgment
Wider context from the report “1. Individual mental health professionals appeared to have gaps in knowledge and judgment. The director who was spokesperson for the Mental Health Trust did not appear to appreciate the seriousness of these deficits.
• A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will, having just expressed suicidal ideation, made a previous attempt, with alcohol intoxication and absconsion, as at the time he denied suicidality. Even in retrospect in court she did not acknowledge her misjudgement. She also asserted incorrectly that a patient who has mental capacity cannot be assessed under the Mental Health Act.
• A mental health nurse of 9 years standing in the Home Treatment Team who acknowledged the risk to the patient’s life could hardly be higher, failed to document his assessment, as he could not find anywhere to write it before going on his break. No staff acknowledged that he had informed them of the risk. He assumed the patient would get 1:1 monitoring, but did not direct anyone to the need. When asked what he would have done if he had known there were no staff to conduct 1:1 monitoring, he said that he could perhaps hang around for a bit longer.
” 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 Advance national interoperability between Shared Care Records across England.
Verbatim wording from the response “footprint, through their local Shared Care Record (ShCR). ShCR supplies must be assured against the Professional Record Standards Body’s (PRSB) Core Information Standard, which has been specified by NHS England. Where local ShCRs are used therefore, the core information standard will be available. Building on this and recognising the clinical need, an initiative has been set to achieve national interoperability between SHCRs across England. This initiative has been commenced but does not have a defined timeframe as it is dependent on funding which has not yet been confirmed. It aims to enable any authorised health and care professionals to have access to safe, reliable and accurate records, regardless of the patient’s location or where care is provided.” 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 Provide funding to ensure NHS Trusts have electronic patient records implemented.
Verbatim wording from the response “NHS England is committed to improving the maturity and quality of Electronic Patient Records (EPRs) across all NHS Trusts. NHS England has provided funding to ensure all NHS Trusts have an EPR implemented. It is, however, up to individual NHS Trusts to effectively procure and implement their chosen EPR system, and to agree and progress any convergence of EPR systems within their local systems.” 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 Specify the Core Information Standard and support sharing critical clinical information through local Shared Care Records.
Verbatim wording from the response “NHS England is also committed to supporting the sharing of critical clinical information across NHS organisations. Since 2021, all primary and secondary care organisations have been able to share a subset of the patient information they hold (known as the core information standard) between providers within their own Integrated Care System” 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 care organisations and NHS Trusts are responsible for agreeing additional shared information and negotiating local data-sharing arrangements.
Verbatim wording from the response “It is, however, up to local care organisations and participating NHS Trusts to agree what information, in addition to the core information standard, is held and shared through the local ShCR. It is also up to individual NHS Trusts to negotiate data sharing protocols and agreements to enhance localised information sharing outside of the local ShCR.” 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 procuring, implementing and locally converging their chosen electronic patient record systems.
Verbatim wording from the response “NHS England is committed to improving the maturity and quality of Electronic Patient Records (EPRs) across all NHS Trusts. NHS England has provided funding to ensure all NHS Trusts have an EPR implemented. It is, however, up to individual NHS Trusts to effectively procure and implement their chosen EPR system, and to agree and progress any convergence of EPR systems within their local systems.” 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 National interoperability between shared care records has no defined timeframe because the required funding has not yet been confirmed.
Verbatim wording from the response “footprint, through their local Shared Care Record (ShCR). ShCR supplies must be assured against the Professional Record Standards Body’s (PRSB) Core Information Standard, which has been specified by NHS England. Where local ShCRs are used therefore, the core information standard will be available. Building on this and recognising the clinical need, an initiative has been set to achieve national interoperability between SHCRs across England. This initiative has been commenced but does not have a defined timeframe as it is dependent on funding which has not yet been confirmed. It aims to enable any authorised health and care professionals to have access to safe, reliable and accurate records, regardless of the patient’s location or where care is provided.” Source location Response from NHS England
Open published response
Concerns raised 1 Insufficient funding for urgent mechanical thrombectomy provision outside daytime hours View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Barry Myers · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Barry Myers died at Royal Sussex County Hospital on 28 January 2024 after suffering an ischaemic cerebral artery stroke. The report describes that a mechanical thrombectomy was not available outside departmental operational hours, and notes insufficient funding for urgent thrombectomy provision between 4 pm and 8 am, as well as missed opportunities for transfer to another centre.
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 funding for urgent mechanical thrombectomy provision outside daytime hours
Wider context from the report “The court heard there is insufficient funding in place for patients to be provided with an urgent mechanical thrombectomy between the hours of 4 pm and 8 am at University Hospitals Sussex NHS Foundation Trust.
” 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 Continue supporting the Trust to develop evening and weekend mechanical thrombectomy operating hours.
Verbatim wording from the response “NHS England continues to work with UHSx to support the development of services to expand their operating hours, to include evenings and weekends (operating seven days a week). This is possible within the current level of funding received by the Trust, however it is recognised that the current financial position of the Trust means that there are significant challenges to being able to identify the funds internally to expand the service at this time.” 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 development of mutual aid arrangements with other centres so patients can access out-of-hours mechanical thrombectomy when the local service is unavailable.
Verbatim wording from the response “Over the past year, NHS England has been supporting UHSx with developing mutual aid arrangements with other centres offering mechanical thrombectomy services, for when the UHSx service is not available. Alternative pathways have recently been agreed for patients in the west of Sussex (accessing care from St Richard’s Hospital and Winchester Hospital) to be referred directly to University Hospital Southampton NHS Foundation Trust for out of hours mechanical thrombectomies. Patients from other part of Sussex (accessing care under East Sussex Healthcare NHS Trust, or University Hospitals Sussex NHS Foundation Trust (UHS) Eastbourne, Brighton and Hove) are referred to the University College London Hospital (UCLH) out of hours. Both the UCLH and UHS service are currently operating 24/7.” 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 Fund the purchase of a second bi-plane scanner to support extended hours and faster access when the existing scanner is occupied.
Verbatim wording from the response “share the learning from other centres who have expanded their services over recent years. NHS England has also funded the purchase of a second bi-plane scanner to allow extended operating hours and enable more rapid access to mechanical thrombectomy when the current bi-plane scanner is being used for other elective treatments.” 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 existing block funding is sufficient to expand UHSx mechanical thrombectomy operating hours.
Verbatim wording from the response “NHS England continues to work with UHSx to support the development of services to expand their operating hours, to include evenings and weekends (operating seven days a week). This is possible within the current level of funding received by the Trust, however it is recognised that the current financial position of the Trust means that there are significant challenges to being able to identify the funds internally to expand the service at this time.” 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 UHSx cannot yet expand mechanical thrombectomy hours because of operational, workforce and internal funding challenges.
Verbatim wording from the response “UHSx has not been able to expand their operating hours from the initial hours they started the service with (Monday-Friday, 08:00-16:00) due to operational and workforce challenges. Whilst there has been an increase in the number of mechanical thrombectomies undertaken each year at UHSx, the levels of activity are not yet at the value set within the block funding arrangement.” Source location Response from NHS England
Open published response
Concerns raised 5 Failure of some mental healthcare trusts to accept referrals for homeless prisoners on release View source Unavailability of National Record Locator access for South West ambulance care in Dorset View source Lack of guidance and tools for assessing violence risk in MOSOVO-managed offenders View source Lack of a process for sharing remanded prisoners’ risk information with sentencing courts View source Lack of practical national guidance for continuity of prisoners’ healthcare on release View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Marta Elena Vento · 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
Marta Elena Vento was working alone as a hotel receptionist in Bournemouth when she was fatally beaten in an unprovoked attack on 9 December 2020. The report raises concerns about the sharing of remand prisoners’ risk information with sentencing courts, continuity of mental healthcare after release from prison, risk assessment of violent offenders managed by MOSOVO units, and access to patient information through the National Record Locator.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of some mental healthcare trusts to accept referrals for homeless prisoners on release
Wider context from the report “Evidence was given that this is not the process nationally in that some mental healthcare trusts will not accept a referral if a person is homeless . There is no national guidance about the continuity of care for prisoners upon release from prison when homeless .
I am concerned that this lack of continuity of care could lead to future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unavailability of National Record Locator access for South West ambulance care in Dorset
Wider context from the report “Evidence was given by the Head of Clinical Development and Organisational Development at South West Ambulance Service NHS Foundation Trust (SWAST) that in the South West region all Integrated Care Boards (ICBs), apart from the ICB in Dorset, NHS Dorset, are at some stage of implementing the use of NRL so that SWAST can access this information to assist in the provision of care to those they treat.
Evidence was given that as this would limit the information SWAST had access to about a patient in Dorset , this would impact upon the care provided to those in Dorset by SWAST which could lead to a future 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 guidance and tools for assessing violence risk in MOSOVO-managed offenders
Wider context from the report “The risk assessments detailed in the guidance are aimed at the assessment of the sexual risk of offenders and evidence was given that there is no bespoke risk assessment tool or guidance to assess the violence of such offenders to assist staff within MOSOVO units to undertake their role . There is, therefore, a lack of guidance on how to risk assess and manage offenders who are managed under MOSOVO when they present with the risk of violence, or an escalating risk of violence .
I am concerned that this will result in a failure to identify the risk of violence, or the increasing risk of violence, in those being managed by MOSOVO which may lead to a further 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 a process for sharing remanded prisoners’ risk information with sentencing courts
Wider context from the report “Evidence was given by the Head of the Offender Management Unit (OMU) at HMP Winchester, a Senior Probation Officer, that there is currently no formal process or guidance in place for the sharing of information by a prison with the Criminal Courts to provide an update of the person's behaviour in prison which may increase their risk of harm or risk offending .
It was explained that the person who could enquire about this at Court, if asked, would be the duty Probation Officer, and that this is especially more challenging to complete when a fast delivery report is requested.
There is currently no process from a prison perspective to share information to the sentencing Court other than that contained within the Prison Escort Record (PER), which is not provided to the sentencing Judge, the lawyers at Court or Probation staff .
I am concerned that the full extent of a remanded prisoner’s risk of harm to the public may not be appreciated by the sentencing Judge, which could impact upon the sentence imposed upon a prisoner and I am concerned that this lack of sharing of information could lead to future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of practical national guidance for continuity of prisoners’ healthcare on release
Wider context from the report “There is a lack of national guidance to assist all healthcare providers to ensure continuity of care for a prisoner with health care needs, whether physical or mental health needs, upon release from prison . There are national standards of care and NICE guidelines in place, however none of these provide practical guidance around the delivery of care to ensure continuity of care .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider developing national pathway guidance with adult mental health services for people leaving prison.
Verbatim wording from the response “At present, there is no specific national pathway guidance setting out what an individual on release can expect from their local Community Mental Health Team (CMHT). The guidance relating to the Adult Mental Health Team is generic rather than focused on the prison population.” 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 and refresh the prison mental health service specification, using case learning to strengthen continuity and transfer of care.
Verbatim wording from the response “While there are no plans currently to develop national pathway guidance, NHS England will be considering this in the longer-term, working with the Adult Mental Health Team to ensure services are able to fully support those leaving prison.” 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 Provide RECONNECT care-after-custody support and release planning to improve continuity of care for people leaving prison.
Verbatim wording from the response “To support this approach when individuals are leaving prison, there are services in place such as RECONNECT, a non-clinical ‘care after custody’ service that seeks to improve the continuity of care of individuals with identified health needs, by working with them before they leave the secure estate. RECONNECT supports transition to community-based services, enabling the safeguarding of health gains made whilst in the secure estate, with the aim of helping to reduce inequalities and address health-related drivers of offending behaviours.” 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 There are currently no plans to develop specific national pathway guidance for people leaving prison, although this may be considered longer-term.
Verbatim wording from the response “At present, there is no specific national pathway guidance setting out what an individual on release can expect from their local Community Mental Health Team (CMHT). The guidance relating to the Adult Mental Health Team is generic rather than focused on the prison population.” Source location Response from NHS England
Open published response
Concerns raised 5 Failure of PSII actions to achieve effective safety improvement View source Failure of continuous training to achieve effective learning View source Lack of national guidelines on severe invasive soft tissue infections View source National lack of knowledge of severe invasive soft tissue infections View source Failure to maintain an audit trail for omitted medication doses View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Christopher Granville Bradbury · 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 Granville Bradbury fell at home, sustained a cut to his right foot, and was admitted to hospital several days later with diarrhoea, vomiting, collapse, and swelling of the right leg. He was diagnosed with a severe invasive soft tissue infection and underwent a below-the-knee amputation, but died the following day. Concerns included a lack of national knowledge and guidelines for these infections, ineffective training and learning measures, and the absence of an audit trail when medication was omitted because it was unavailable or for another reason.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of PSII actions to achieve effective safety improvement
Wider context from the report “ii) The evidence given was that, training is being delivered continuously, and the actions from the PSII have been carried out but this is not making significant inroads , it had not been effective at all , and it is thought that this will happen again.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 continuous training to achieve effective learning
Wider context from the report “ii) The evidence given was that, training is being delivered continuously , and the actions from the PSII have been carried out but this is not making significant inroads , it had not been effective at all , and it is thought that this will happen again.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidelines on severe invasive soft tissue infections
Wider context from the report “i) A national lack of knowledge of Severe Invasive Soft Tissue Infections, that are not (but are closely related to) necrotising fasciitis combined with a lack of national Guidelines on this . This being exacerbated by the large number of Drs expected to specialise in this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation National lack of knowledge of severe invasive soft tissue infections
Wider context from the report “i) A national lack of knowledge of Severe Invasive Soft Tissue Infections, that are not (but are closely related to) necrotising fasciitis combined with a lack of national Guidelines on this. This being exacerbated by the large number of Drs expected to specialise in this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an audit trail for omitted medication doses
Wider context from the report “iii) When signing medication out, at the hospital, if the medication is not available, no signature is required when choosing option 5 “omitted dose” . This means that there is no audit train , if a patient is not given their medication, because it is unavailable, or omitted for some other reason .
” 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 Seek to emphasise escalation of deteriorating patients in revised infection prevention and control training.
Verbatim wording from the response “There is an opportunity this year to revisit statutory and mandatory training for infection and prevention control and my Antimicrobial Resistance colleagues will seek to ensure emphasis on escalation of deteriorating patients.” 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 UHNM or Royal Stoke University Hospital should respond to concerns about the effectiveness of Patient Safety Incident Investigation actions.
Verbatim wording from the response “Your second concern was that actions identified in the Patient Safety Incident Investigation (PSII) have not made significant inroads or been effective. I note that you have also sent your Report to the Royal Stoke University Hospital and it is appropriate that they or University Hospitals of North Midlands (UHNM) NHS Trust to respond to your regarding this concern. NHS England regional colleagues are also in the process of engaging with Staffordshire and Stoke-on-Trent Integrated Care Board (ICB), the commissioner of UHNM, on the concerns raised by your Report for assurance purposes.” 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 Responsibility for clinical guidance rests with NICE, so further guidance concerns should be directed to NICE.
Verbatim wording from the response “The responsibility for clinical guidance sits with the National Institute for Health and Care Excellence (NICE) and the current relevant guidance is available here: https://www.nice.org.uk/guidance/conditions-and-diseases/infections/skin-infections/products?GuidanceProgramme=guidelines. NICE have also produced a Clinical Knowledge Summary (CKS) on impetigo and cellulitis, which include treatment options for severe infection and referral/escalation criteria for specialist input.” 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 Further NHS England comment on the reported concerns is not possible based on the information provided.
Verbatim wording from the response “It is not possible for NHS England to provide further comment based on the information provided in your Report.” 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 Relevant guidance for severe soft-tissue infections already exists, disputing the reported national lack of guidance.
Verbatim wording from the response “The first matter of concern raised in your Report was that there is a national lack of knowledge and guidelines of severe invasive soft tissue infections, that are not necrotising fasciitis.” 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 Electronic prescribing systems and existing nursing record requirements address accountability and escalation risks for omitted medication doses.
Verbatim wording from the response “Electronic Prescribing and Medicines Administration (EPMA) systems eliminate the lack of signature and accountability issue raised by the Coroner because a person would need to be logged into the system to record a missed dose and there would therefore be the requirement of a digital signature. Within EPMAs there is also the facility to include alerts that would prompt the person recording a missed dose if this were a critical drug that shouldn’t usually be omitted.” Source location Response from NHS England
Open published response
Concerns raised 2 Failure to record prescribed-drug counselling and safety advice View source Lack of provision to record actions when patients lack capacity to understand medication explanations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
William Stephen GREEN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
William Stephen Green was admitted to hospital after a seizure and was prescribed Lamotrigine. He was later readmitted with a collapse and rash, developed Stevens-Johnson Syndrome, and died on 9 July 2023 from toxic epidermal necrolysis secondary to Lamotrigine, with alcohol dependent disease contributing to his death. The concerns were that patients were not given or recorded as receiving counselling about drug side effects and complications, and that there was no provision to record what should happen when a patient lacked capacity to understand such an explanation.
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 record prescribed-drug counselling and safety advice
Wider context from the report “(1) Once any patient at The Royal Shrewsbury Hospital is initiated on a new prescribed drug during an admission, no written record is ever made anywhere by anyone including pharmacy; nurses; doctors or consultants explaining or counselling the patient upon the possible side-effects or complications as a result of taking a specific prescribed drug; nor is there any written record on what to look out for and what to do in such circumstances and where they can get assistance .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 provision to record actions when patients lack capacity to understand medication explanations
Wider context from the report “(2) No provision seems to be in place to record what should happen when the patient lacks capacity to understand such an explanation even when it is offered .
” 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 Take concerns about medication counselling and written records to an appropriate forum for discussion and consideration of necessary actions.
Verbatim wording from the response “However, NHS England will take your concern about counselling, and keeping a written record of such counselling, to an appropriate forum for further discussion and consideration of any actions we need to take.” Source location Response from NHSE
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 guidance, the Mental Capacity Act and local medicines policies provide an existing framework for treating patients who lack capacity.
Verbatim wording from the response “Regarding the capacity of patients, there is clear NHS guidance on how to proceed with treatment when someone may lack capacity. There is also legislation (The Mental Capacity Act 2005), which provides a framework for decision-making on behalf of people who lack capacity. We would expect Trusts to have their own local policies on the administration of new medications, and most Trusts’ Medicines Policies will contain guidance on counselling patients. However, as above, they may not direct that this counselling needs to be recorded in the patient’s notes, as this is not standard practice.” Source location Response from NHSE
Open published response
Concerns raised 10 Failure to clearly explain and differentiate the Physician Associate role from medically qualified practitioners View source Lack of updated guidelines for rapid sequence induction of anaesthesia in emergency surgery View source Inadequate medical supervision of Physician Associates managing undifferentiated Emergency Department patients View source Unavailability of promptly accessible suction for aspiration during rapid sequence induction View source Failure to inform patients and families that Physician Associates are not medically qualified View source Lack of public understanding of the Physician Associate role View source Lack of guidance on TIVA dosing and timing for rapid sequence induction View source Lack of updated guidance on cricoid pressure and other airway-protection measures during rapid sequence induction View source Failure to prevent Physician Associates undertaking roles outside their competency View source Lack of regulated scope-of-practice guidance and recognised training for Physician Associates View source See 7 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
Pamela Anne Marking · 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
Pamela Anne Marking was admitted with abdominal symptoms, was diagnosed with a nosebleed by a Physician Associate and discharged without medical review or direct medical supervision. She later returned with small bowel obstruction caused by an incarcerated femoral hernia and aspirated feculent fluid during induction of anaesthesia for emergency surgery, subsequently dying from respiratory failure and sepsis. The concerns included the Physician Associate’s role, supervision and scope of practice, and the absence of updated guidance for rapid sequence induction, TIVA and airway protection.
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 clearly explain and differentiate the Physician Associate role from medically qualified practitioners
Wider context from the report “1. The term ‘Physician Associate’ is misleading to the public
Mrs Marking’s son was under the mistaken belief that the Physician Associate was a doctor by this title in circumstances where no steps were taken by the Emergency Department or the Physician Associate to explain or clearly differentiate their role from that of medically qualified practitioners .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 updated guidelines for rapid sequence induction of anaesthesia in emergency surgery
Wider context from the report “6. Lack of ‘Updated’ National Guidelines for Rapid Sequence Induction (RSI) of Anaesthesia for emergency surgery
Mrs Marking required a rapid sequence induction to protect her airway from aspiration of bowel contents as a consequence of small bowel obstruction. The consultant anaesthetist gave evidence that the ‘traditional’ use of consecutive syringes of induction agent and muscle relaxant was obsolete, and it was common practice locally and nationally to routinely undertake a RSI with Total Intravenous Anaesthesia, in the absence of updated local or national guidelines to support this practice .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequate medical supervision of Physician Associates managing undifferentiated Emergency Department patients
Wider context from the report “5. Lack of guidelines for direct supervision and consideration of an appropriate level of autonomy for Physician Associates
Whilst there were discussions with the ‘supervising’ consultant the Physician Associate was effectively acting independently in the diagnosis, treatment, management and discharge of Mrs Marking without independent oversight by a medical practitioner . This gives rise to a concern that inadequate supervision or excessive delegation of undifferentiated patients in the Emergency Department to Physician Associates compromises patient safety.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unavailability of promptly accessible suction for aspiration during rapid sequence induction
Wider context from the report “8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic
Evidence was heard that cricoid pressure was ineffective it was not routinely applied for a RSI intubation. After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to inform patients and families that Physician Associates are not medically qualified
Wider context from the report “3. The right of patients and family to seek a second opinion
The lack of public knowledge that a Physician Associate is not medically qualified has the potential to hinder requests by patients and their relatives who would wish to seek an opinion from a medical practitioner. It also raises issues of informed consent and protection of patient rights if the public are not aware or have not been properly informed that they are being treated by a Physician Associate rather than a medically qualified doctor.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 public understanding of the Physician Associate role
Wider context from the report “2. Lack of public understanding of the role of Physician Associate
Witnesses from the Trust gave evidence that a Physician Associate was clinically equivalent to a Tier 2 resident doctor without evidence to support this belief. This blurring of roles without public knowledge and understanding of the role of a Physician Associate has the potential to devalue and undermine public confidence in the medical profession whilst allowing Physician Associates to potentially undertake roles outside of their competency thereby compromising patient safety.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on TIVA dosing and timing for rapid sequence induction
Wider context from the report “7. Lack of ‘Updated’ National Guidelines to support the use of TIVA for RSI
Other than empirically increasing the rate of infusion of TIVA agents (Propofol and Remifentanil) no evidence was forthcoming as to the target range required to ensure and confirm an adequate depth of anaesthesia for patients or the length of time required prior to and following the administration of a muscle relaxant (Rocuronium) to facilitate intubation. This is despite TIVA being known to provide a slower onset of anaesthesia and approximately 50% of all anaesthetic related deaths are due to aspiration (NAP 4).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 updated guidance on cricoid pressure and other airway-protection measures during rapid sequence induction
Wider context from the report “8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic
Evidence was heard that cricoid pressure was ineffective it was not routinely applied for a RSI intubation . After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 Physician Associates undertaking roles outside their competency
Wider context from the report “2. Lack of public understanding of the role of Physician Associate
Witnesses from the Trust gave evidence that a Physician Associate was clinically equivalent to a Tier 2 resident doctor without evidence to support this belief. This blurring of roles without public knowledge and understanding of the role of a Physician Associate has the potential to devalue and undermine public confidence in the medical profession whilst allowing Physician Associates to potentially undertake roles outside of their competency thereby compromising patient safety .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of regulated scope-of-practice guidance and recognised training for Physician Associates
Wider context from the report “4. Lack of national and local guidelines and regulation of the scope of practice for a Physician Associate
A diagnosis of epistaxis was made by the Physician Associate without appreciating the relevance of the vomiting and lower abdominal discomfort and in the absence of understanding the need to undertake palpation of the groins in an abdominal examination in a patient who was unable to give a proper clinical history because of short term memory loss. No evidence was presented that the management of Mrs Marking was subject to a reflective practice review. Given their limited training and in the absence of any national or local recognised hospital training for Physician Associates once appointed , this gives rise to a concern they are working outside of their capabilities .
” 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 Engage medical Royal Colleges to facilitate broad aligning principles for physician associate and anaesthesia associate specialty scopes of practice.
Verbatim wording from the response “The GMC has published the generic and shared learning outcomes that PAs and AAs must be registered by them as the professional regulator. Taken with the PA curriculum, these documents will describe what all newly qualified physician associates must know and be able to do.” Source location Response from NHSE
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 a summary of existing guidance on deploying medical associate professionals.
Verbatim wording from the response “NHS England has published a summary of existing guidance on the deployment of medical associate professions for NHS organisations. This guidance makes it clear that all staff should introduce themselves and their role clearly and be supported by their employer to do so. This is in accordance with National Institute for Health and” Source location Response from NHSE
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 Updated national RSI anaesthesia guidelines fall outside NHS England’s remit.
Verbatim wording from the response “Your Report also raises concerns around the lack of updated national guidelines relevant to rapid sequence induction (RSI) of anaesthesia, but these issues fall outside of NHS England’s remit and would be best addressed by the Royal College of Anaesthetists and other associated organisations named in your Report. NHS England will give due consideration to their responses to the Coroner.” Source location Response from NHSE
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 Royal College of Anaesthetists and other named organisations should address updated national RSI anaesthesia guidelines.
Verbatim wording from the response “Your Report also raises concerns around the lack of updated national guidelines relevant to rapid sequence induction (RSI) of anaesthesia, but these issues fall outside of NHS England’s remit and would be best addressed by the Royal College of Anaesthetists and other associated organisations named in your Report. NHS England will give due consideration to their responses to the Coroner.” Source location Response from NHSE
Open published response
21 Feb 2025 Mr Luke Alexander Worrell · Prevention of Future Deaths report London South
View report summary
Concerns raised 2 Lack of clinical staff awareness of Clozapine's potential fatal side effects View source Inappropriate use of community treatment orders where sufficient evidence supports retention on a Mental Health Act section 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
Mr Luke Alexander Worrell · 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
Mr Luke Alexander Worrell, who had treatment-resistant schizophrenia and was taking Clozapine, developed persistent vomiting, dehydration and an ileus before suffering a ruptured oesophagus and dying in hospital on 2 January 2021. The report identified concerns about clinical staff failing to recognise the potentially fatal gastrointestinal side effects of Clozapine and about the inappropriate use of a community treatment order instead of continued detention under a mental health section. The inquest narrative also described failures to recognise the need for face-to-face psychiatric assessment after his deterioration following discharge.
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 clinical staff awareness of Clozapine's potential fatal side effects
Wider context from the report “1. The lack of awareness by a series of clinical staff of the potential fatal side effects of Clozapine
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inappropriate use of community treatment orders where sufficient evidence supports retention on a Mental Health Act section
Wider context from the report “2. Inappropriate use of community treatment order , when there was sufficient evidence to keep on a MHA section .
” 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 Raised clinician awareness of clozapine side effects by communicating associated risks to mental health chief pharmacists and health communities.
Verbatim wording from the response “NHS England has undertaken considerable work to highlight to clinicians and colleagues the importance of keeping people safe from the side effects of Clozapine, which are well-recognised.” 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 information provided does not enable assessment of whether discharge onto a community treatment order was appropriate rather than detention or Section 17 leave.
Verbatim wording from the response “NHS England are unable to comment on whether there was sufficient evidence for the responsible clinician to keep Luke under a mental health section or Section 17 (S17) leave, rather than discharging him onto a community treatment order (CTO), based on the information provided in your Report, but this is an available option to inpatient mental health teams.” Source location Response from NHS England
Open published response
Concerns raised 2 Failure to promptly review and escalate deteriorating patients View source Failure to provide 1:1 registered nurse staffing in the Emergency Department resuscitation area 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
Philip John UNWIN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Philip John Unwin, aged 68, was admitted to hospital with fever, shortness of breath and chest pain, and was later confirmed to have sepsis secondary to pneumonia. His condition deteriorated while he remained in the Emergency Department resuscitation area, and he died in hospital on 3 April 2024 from multi-organ failure secondary to pneumonia. Concerns included delayed medical review and escalation to intensive care, staffing in the resuscitation area not complying with national guidance, and recommendations from an internal investigation not having been acted upon in this respect.
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 promptly review and escalate deteriorating patients
Wider context from the report “Although the conclusion of the inquest was one of Natural Causes there was evidence of a failure for medical teams to respond to concerns that the patient was deteriorating whilst awaiting assessment in the resuscitation area of the Emergency Department of Royal Stoke University Hospital . It was accepted by witnesses from the hospital that the patient should not have deteriorated to a 'moribund' state within that area of the hospital when concerns had been raised by staff and family, and that review and escalation to intensive care should have been initiated sooner (albeit the evidence was that this did not more than minimally contribute to the death).
As a result of the concerns raise by hospital staff regarding missed opportunities to escalate care in a timely manner the hospital undertook a Patient Safety Incident Investigation (PSII). As a result of that investigations a number of recommendations were made with assurances given to the report author that work is being undertaken to review and amend policies and procedures focused on reviewing, escalating and referring deteriorating patients.
However, the inquest was told that although the Emergency Department Resuscitation area was where the illest patients were placed awaiting review, staffing levels were not in compliance with national guidance. The Royal College of Emergency Medicine (RCEM) “Nursing Workforce Standards for Type 1 Emergency Departments” (Appendix 5) states “There will be a minimum of Registered Nurse to each patient in the resuscitation area”. The recommendation continued that there should be a named nurse allocated to each patient which should be 1:1 as per National Guidance.
The concern is that the current model of staffing within the Emergency Department Resus area is not in compliance with national guidance and the recommendations following internal investigation into the care afforded to the deceased have not been acted upon in this respect.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 1:1 registered nurse staffing in the Emergency Department resuscitation area
Wider context from the report “Although the conclusion of the inquest was one of Natural Causes there was evidence of a failure for medical teams to respond to concerns that the patient was deteriorating whilst awaiting assessment in the resuscitation area of the Emergency Department of Royal Stoke University Hospital. It was accepted by witnesses from the hospital that the patient should not have deteriorated to a 'moribund' state within that area of the hospital when concerns had been raised by staff and family, and that review and escalation to intensive care should have been initiated sooner (albeit the evidence was that this did not more than minimally contribute to the death).
As a result of the concerns raise by hospital staff regarding missed opportunities to escalate care in a timely manner the hospital undertook a Patient Safety Incident Investigation (PSII). As a result of that investigations a number of recommendations were made with assurances given to the report author that work is being undertaken to review and amend policies and procedures focused on reviewing, escalating and referring deteriorating patients.
However, the inquest was told that although the Emergency Department Resuscitation area was where the illest patients were placed awaiting review, staffing levels were not in compliance with national guidance . The Royal College of Emergency Medicine (RCEM) “Nursing Workforce Standards for Type 1 Emergency Departments” (Appendix 5) states “There will be a minimum of Registered Nurse to each patient in the resuscitation area ”. The recommendation continued that there should be a named nurse allocated to each patient which should be 1:1 as per National Guidance .
The concern is that the current model of staffing within the Emergency Department Resus area is not in compliance with national guidance and the recommendations following internal investigation into the care afforded to the deceased have not been acted upon in this respect.
” 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 Trust does not consider that insufficient nursing staff caused the failure to recognise Philip’s deterioration.
Verbatim wording from the response “UHNM advise that having a Named Nurse in the ED has been tried previously at the Royal Stoke University Hospital, but a ‘team approach’ has been found to work better in the Resuscitation area of the ED rather than care falling to one medical professional. Trauma patients are always nursed 1:1 and this is due to the professional judgement required and the ability to flex staff around the department and into resuscitation with the support of an Operating Department Practitioner (ODP), the (supernumerary) Nurse in Charge and any outreach support for trauma calls. UHNM have asked us to note that the PSII identified that there was clear escalation by relevant nursing staff, and that it is not their belief that a lack of nursing staff led to the failure to recognise Philip’s deterioration.” 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 Trust is responsible for providing further comments and information on actions taken since the inquest concerning the Coroner’s concerns.
Verbatim wording from the response “It is appropriate that UHNM provide any further comment regarding the Coroner’s concerns. It is NHS England’s understanding that they will be providing further information on actions taken by the Trust since the inquest into Philip’s death in their response to the Coroner.” 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 A team approach, supported by flexible staffing and specialist support, is considered more effective than assigning a Named Nurse in the resuscitation area.
Verbatim wording from the response “UHNM advise that having a Named Nurse in the ED has been tried previously at the Royal Stoke University Hospital, but a ‘team approach’ has been found to work better in the Resuscitation area of the ED rather than care falling to one medical professional. Trauma patients are always nursed 1:1 and this is due to the professional judgement required and the ability to flex staff around the department and into resuscitation with the support of an Operating Department Practitioner (ODP), the (supernumerary) Nurse in Charge and any outreach support for trauma calls. UHNM have asked us to note that the PSII identified that there was clear escalation by relevant nursing staff, and that it is not their belief that a lack of nursing staff led to the failure to recognise Philip’s deterioration.” Source location Response from NHS England
Open published response
17 Feb 2025 Diana FAIRWEATHER-PURKIS · Prevention of Future Deaths report Teesside and Hartlepool
View report summary
Concerns raised 2 Insufficient ambulance service availability or resources for timely patient attendance View source Delays in ambulance crew release following hospital attendance 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
Diana FAIRWEATHER-PURKIS · 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
Diana Fairweather-Purkis waited 9 hours and 56 minutes for an ambulance after calling the 111 Service, was admitted to hospital, and died on 3 October 2022 due to multi-organ failure secondary to urosepsis. The report identifies insufficient ambulance availability, delays in releasing ambulance crews after hospital attendance because of patient handover delays, and delays in prescribing and administering antibiotics as substantive concerns or contributing factors.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient ambulance service availability or resources for timely patient attendance
Wider context from the report “1. There is insufficient Ambulance Service availability/resource to enable Ambulances to attend to patients in a timely manner and in accordance with relevant target attendance times .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance crew release following hospital attendance
Wider context from the report “2. There are excessive delays in Ambulance crews being released following attendance at hospital , due to delays in patients being handed over to hospital staff .
” 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 Prioritise improvements to Category 2 ambulance response times and urgent and emergency care services.
Verbatim wording from the response “NHS England recognises the significant pressures on all NHS services, including ambulance services, and has been prioritising improvements to Category 2 response times and urgent and emergency care (UEC) services. Improvements to Category 2 response times will have a positive impact across ambulance performance generally, including Category 3 responses.” Source location Response from NHSE
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with commissioners, integrated care boards, acute providers and ambulance services to implement plans improving ambulance handovers.
Verbatim wording from the response “NHS England’s regional teams are continuing to work closely with commissioners, Integrated Care Boards (ICBs), acute NHS providers and ambulance services to implement plans to continue to improve patient handovers. The 2025/26 priorities and operational planning guidance sets out that the NHS should improve ambulance response times and Accident and Emergency (A&E) waiting times compared to 2024/25, and that Category 2 ambulance response times should average no more than 30 minutes across 2025/26. The guidance also sets out some immediate tasks for 2025/26, including to reduce avoidable ambulance dispatches and conveyances and reduce handover delays.” Source location Response from NHSE
Open published response
Concerns raised 4 Failure to implement planned reforms to ASD assessments View source Failure of bridge safety measures to meet current guidance for preventing pedestrian jumping or falling View source Delays in ASD assessments View source Lengthy waiting times for ASD assessments in Hertfordshire View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Joshua Jay Weavers · 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
Joshua Jay Weavers died on 4 March 2021 after jumping from a railway bridge and being struck by a high-speed train. The report raises concerns about lengthy waits for autism spectrum disorder assessments, delays in implementing assessment-service reforms, and bridge safety measures that did not meet current guidance.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to implement planned reforms to ASD assessments
Wider context from the report “2. That whilst the local mental health Trust has plans to reform the manner in which ASD assessments for patients under their care are undertaken, the implementation of those plans awaits input from the Integrated Care Board . This means that waiting times for ASD assessments in Hertfordshire remain lengthy which in turn gives rise to a risk of future deaths occurring for the reasons set out 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 of bridge safety measures to meet current guidance for preventing pedestrian jumping or falling
Wider context from the report “3. That the safety measures in place on the ████████ to guard against pedestrians either jumping or falling from the bridge do not meet current guidance , and therefore gives rise to a risk of future deaths occurring.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in ASD assessments
Wider context from the report “1. That, nationally, waiting times for ASD assessments are very long . Such assessments are important in guiding effective care and treatment, as well as being a potential gateway to access other relevant services. This combined with the fact of an increased risk of suicidal behaviour amongst those who receive a diagnosis of ASD, gives rise to a concern that future deaths may occur on account of the delays in ASD assessment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lengthy waiting times for ASD assessments in Hertfordshire
Wider context from the report “2. That whilst the local mental health Trust has plans to reform the manner in which ASD assessments for patients under their care are undertaken, the implementation of those plans awaits input from the Integrated Care Board. This means that waiting times for ASD assessments in Hertfordshire remain lengthy which in turn gives rise to a risk of future deaths occurring for the reasons set out above.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue supporting local systems to implement national autism assessment, mental health, and suicide prevention guidance across commissioned services.
Verbatim wording from the response “I hope that the publication of the above guidance in 2023 and 2025 provides assurance to the Coroner and Joshua’s family that actions have been taken since Joshua’s death across the NHS to help address the concerns raised. NHS England continues to support local systems to implement the guidance across their commissioned services. Further information on the work and progress of our Learning Disability and Autism Programme can be found here: https://www.england.nhs.uk/learning-disabilities/” 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 Hertfordshire and West Essex Integrated Care Board is responsible for delivering local autism assessment pathway improvements and providing further information on them.
Verbatim wording from the response “I note that your Report has also been addressed to Hertfordshire and West Essex Integrated Care Board (ICB). NHS England has been sighted on their response to the Coroner and notes the work being undertaken to make improvements across service providers, with key elements including:” 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 guidance requires mental-health support and interventions to continue while people await autism assessment, addressing risks from diagnostic delays.
Verbatim wording from the response “In April 2023, NHS England published the National Framework and Operational Guidance for Autism Assessment Services. This framework sets out a clear expectation that autism assessment pathways must not operate in isolation from wider services. Critically the operational guidance for Integrated Care Boards states:” Source location Response from NHS England
Open published response
Concerns raised 2 Lack of national guidelines and a standard operating procedure for Bone Marrow Aspirate and trephine biopsy methodology View source Lack of a database to record Bone Marrow Aspirate and trephine biopsy procedures and outcomes 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
Amelia Alexandra Anuszka RIDOUT · 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
Amelia Ridout, a six-year-old girl with suspected aplastic anaemia, died after a bone marrow aspirate and trephine procedure under general anaesthetic caused internal bleeding from an iliac artery injury. Despite prolonged resuscitation and emergency surgery, the bleeding could not be stopped. The concerns identified were the development and publication of national guidelines and a standard operating procedure for these procedures, including recommended methodology, and the development of a database to record procedures and outcomes.
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 national guidelines and a standard operating procedure for Bone Marrow Aspirate and trephine biopsy methodology
Wider context from the report “To consider the development and publication of a national guidelines and standard operating procedure for the carrying out of Bone Marrow Aspirate (BMA) and trephine biopsy to include recommended methodology .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 database to record Bone Marrow Aspirate and trephine biopsy procedures and outcomes
Wider context from the report “To consider the development of a data base to record these procedures and their outcomes .
” 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 Communicate support to the British Society for Haematology for developing national bone marrow aspiration and trephine biopsy guidance.
Verbatim wording from the response “NHS England have however communicated to the BSH that it would be supportive of them developing the relevant national guidance for clinicians. Our national Patient Safety Team have advised that they would consider issuing a National Patient Safety Alert (NatPSA) to support awareness of key recommendations, although this would have to be weighed against the existing NatPSA criteria. We are aware that the BSH has already published a demonstration video on ‘How to perform bone marrow aspiration and trephine biopsy’.” Source location Response from NHSE
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 Developing national clinical guidelines or SOPs for bone marrow aspiration and trephine biopsy falls outside NHS England’s remit.
Verbatim wording from the response “It would not sit within the remit of NHS England to produce the relevant clinical guidelines or SOP for BMA and trephine biopsy, although we have engaged with the National Institute for Health and Care Excellence (NICE) and the British Society for Haematology (BSH) on the concerns raised in HM Coroner’s Report and have been sighted on the responses from NICE and the BSH to the Coroner.” Source location Response from NHSE
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 England does not consider developing a registry for bone marrow aspiration and trephine biopsy necessary at this point.
Verbatim wording from the response “Regarding the development of a database to record BMA and trephine biopsy procedures and their outcomes, my colleagues with responsibility for national databases and registries have considered this, together with your Report. NHS England do not consider there is a need for us to develop a registry at this point, however we will undertake to:” Source location Response from NHSE
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 British Society for Haematology, as the responsible professional society, is undertaking relevant guidance and procedure-safety work.
Verbatim wording from the response “We also note many of the actions being undertaken by the BSH, as the responsible professional society for the procedure, and outlined in their response to you which include improving existing consent processes, their exploration of the possibility of a registry of complications and establishing an audit process for Trusts.” Source location Response from NHSE
Open published response
Concerns raised 6 Failure to take urgent safeguarding steps to remove children from an unsafe family home View source Delays in convening multi-agency safeguarding meetings View source Lack of shared access to safeguarding records across agencies View source Inadequate assessment of risk to children presenting with safeguarding and mental health concerns View source Failure to provide agencies with access to all relevant cross-sector safeguarding information View source Lack of a mechanism to convene urgent multi-agency safeguarding meetings 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
Ella Louise Murray · 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
Ella Louise Murray was 13 years old when she died at Kings College hospital on 15 November 2023 following an episode of hanging, after a period of self-harm, suicidal ideation and deteriorating mental health. The report raised concerns about the adequacy of her risk assessment and the failure to take urgent protective action, including removing her from home or convening an urgent multi-agency response. It also identified the lack of shared information and records across health, social care and education services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to take urgent safeguarding steps to remove children from an unsafe family home
Wider context from the report “(1)During the course of the inquest it became clear that Ella was a child in a complex family situation and showing signs of deterioration of her mental health. Her school had raised concerns about her with social services and taken steps to make sure she was seen by healthcare professionals when she indicated to staff at school she wanted to end her life on 13 November 2023. She was assessed by mental health nursing staff and accepted to the caseload of the Intensive Home Treatment Team. She was seen the following day and told the staff nurse who saw her that she was frightened of her stepfather and had run away from home barefoot and police called but she was brought back home by her mother who “grabbed her face” the morning she was seen. She told the nurse that she did not want to be in the family home and would rather go to prison and would harm herself or others is she had to stay at home.
(2) This disclosure led to the nurse making a Safeguarding Referral but this was made after she left Ella’s home and no urgent steps were taken to remove Ella either to a hospital bed or to ask social services to consider if she should be removed from the family home . Her school had raised concerns about her and she herself had indicated she wished to end her life. Evidence heard at the inquest was that this was the procedure in place and there is no shared access to records for all agencies and no way to convene an urgent multi-agency meeting to determine if Ella was safe to remain at home. Had steps been taken to share information between her school, social services and the mental health providers when she attend the emergency department on 13 November 2023 or early the following day rather than leave her at home she may have been removed from her home and may still be alive today.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in convening multi-agency safeguarding meetings
Wider context from the report “(3) Whilst there were concerns about the level of risk assessment undertaken on 14 November 2023 senior staff at the Trust gave evidence that she did not meet the criteria for admission to a hospital bed. This was difficult to reconcile with the documentary evidence as she was clearly crying out for help and her school had recognised this. No one agency involved had access to all the relevant information and concerns about Ella across the health, social care and education arenas. Evidence given suggested that shared records would assist but the ability to respond to urgent concerns would require a system change.
(4)It was brought to the court’s attention that the new Children’s Wellbeing and Schools bill includes a duty to share information to promote safeguarding. In addition the local authority may convene a strategy meeting under s47 of the Children Act 1989 although the speed of convening a meeting would depend on availability and would obviously not be as swift as for example attending an accident and emergency department . If a multiagency meeting had been convened this may have prevented Ella’s death and such action may reduce the risk of death for other children being in a similar position.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 shared access to safeguarding records across agencies
Wider context from the report “(1)During the course of the inquest it became clear that Ella was a child in a complex family situation and showing signs of deterioration of her mental health. Her school had raised concerns about her with social services and taken steps to make sure she was seen by healthcare professionals when she indicated to staff at school she wanted to end her life on 13 November 2023. She was assessed by mental health nursing staff and accepted to the caseload of the Intensive Home Treatment Team. She was seen the following day and told the staff nurse who saw her that she was frightened of her stepfather and had run away from home barefoot and police called but she was brought back home by her mother who “grabbed her face” the morning she was seen. She told the nurse that she did not want to be in the family home and would rather go to prison and would harm herself or others is she had to stay at home.
(2) This disclosure led to the nurse making a Safeguarding Referral but this was made after she left Ella’s home and no urgent steps were taken to remove Ella either to a hospital bed or to ask social services to consider if she should be removed from the family home. Her school had raised concerns about her and she herself had indicated she wished to end her life. Evidence heard at the inquest was that this was the procedure in place and there is no shared access to records for all agencies and no way to convene an urgent multi-agency meeting to determine if Ella was safe to remain at home. Had steps been taken to share information between her school, social services and the mental health providers when she attend the emergency department on 13 November 2023 or early the following day rather than leave her at home she may have been removed from her home and may still be alive today.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 assessment of risk to children presenting with safeguarding and mental health concerns
Wider context from the report “(3) Whilst there were concerns about the level of risk assessment undertaken on 14 November 2023 senior staff at the Trust gave evidence that she did not meet the criteria for admission to a hospital bed. This was difficult to reconcile with the documentary evidence as she was clearly crying out for help and her school had recognised this. No one agency involved had access to all the relevant information and concerns about Ella across the health, social care and education arenas. Evidence given suggested that shared records would assist but the ability to respond to urgent concerns would require a system change.
(4)It was brought to the court’s attention that the new Children’s Wellbeing and Schools bill includes a duty to share information to promote safeguarding. In addition the local authority may convene a strategy meeting under s47 of the Children Act 1989 although the speed of convening a meeting would depend on availability and would obviously not be as swift as for example attending an accident and emergency department. If a multiagency meeting had been convened this may have prevented Ella’s death and such action may reduce the risk of death for other children being in a similar position.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 agencies with access to all relevant cross-sector safeguarding information
Wider context from the report “(3) Whilst there were concerns about the level of risk assessment undertaken on 14 November 2023 senior staff at the Trust gave evidence that she did not meet the criteria for admission to a hospital bed. This was difficult to reconcile with the documentary evidence as she was clearly crying out for help and her school had recognised this. No one agency involved had access to all the relevant information and concerns about Ella across the health, social care and education arenas. Evidence given suggested that shared records would assist but the ability to respond to urgent concerns would require a system change.
(4)It was brought to the court’s attention that the new Children’s Wellbeing and Schools bill includes a duty to share information to promote safeguarding. In addition the local authority may convene a strategy meeting under s47 of the Children Act 1989 although the speed of convening a meeting would depend on availability and would obviously not be as swift as for example attending an accident and emergency department. If a multiagency meeting had been convened this may have prevented Ella’s death and such action may reduce the risk of death for other children being in a similar position.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 to convene urgent multi-agency safeguarding meetings
Wider context from the report “(1)During the course of the inquest it became clear that Ella was a child in a complex family situation and showing signs of deterioration of her mental health. Her school had raised concerns about her with social services and taken steps to make sure she was seen by healthcare professionals when she indicated to staff at school she wanted to end her life on 13 November 2023. She was assessed by mental health nursing staff and accepted to the caseload of the Intensive Home Treatment Team. She was seen the following day and told the staff nurse who saw her that she was frightened of her stepfather and had run away from home barefoot and police called but she was brought back home by her mother who “grabbed her face” the morning she was seen. She told the nurse that she did not want to be in the family home and would rather go to prison and would harm herself or others is she had to stay at home.
(2) This disclosure led to the nurse making a Safeguarding Referral but this was made after she left Ella’s home and no urgent steps were taken to remove Ella either to a hospital bed or to ask social services to consider if she should be removed from the family home. Her school had raised concerns about her and she herself had indicated she wished to end her life. Evidence heard at the inquest was that this was the procedure in place and there is no shared access to records for all agencies and no way to convene an urgent multi-agency meeting to determine if Ella was safe to remain at home . Had steps been taken to share information between her school, social services and the mental health providers when she attend the emergency department on 13 November 2023 or early the following day rather than leave her at home she may have been removed from her home and may still be alive today.
” 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 Actions taken by the Integrated Care Board, social services and local authority fall outside the national policy or programme remit.
Verbatim wording from the response “My response to the Coroner focuses on those areas of concern that sit within NHS England’s national policy or programme remit. It would not be appropriate at this juncture for NHS England to provide comment on actions taken by Kent & Medway Integrated Care Board, Kent Social Services or the Local Authority involved in Ella’s care.” 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 Integrated Care Board is responsible for providing a separate system-level response detailing local actions taken.
Verbatim wording from the response “Ella’s case includes learnings for teams across NHS England and local organisations, as well as more broadly. It is NHS England’s understanding that Kent and Medway Integrated Care Board will be responding to the Coroner separately with a system-level response detailing the local actions taken. NHS England will consider the ICB’s response in due course. My colleagues from national NHS England teams have also provided the below input.” Source location Response from NHS England
Open published response
7 Feb 2025 Anthony Binfield and 2 others · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 14 Inadequate basic training, supervision and mentoring of prison staff View source Inadequate prison and healthcare staffing levels View source Failure to act with candour in post-death investigations View source Use of inaccessible email channels for risk pertinent information View source Failure to identify and share risk pertinent information between prison and healthcare staff View source Insufficient safety scrutiny during prison contract transfer View source Failure to reduce isolation of foreign national prisoners View source Failure to embed learning from deaths and monitor safety culture View source Failure to provide a nurse during night state View source Unreliable and delayed access to interpretation services for foreign national prisoners View source Lack of an effective system for gathering, retaining, reviewing and disclosing investigation material View source Failure to retain sufficient experienced prison and healthcare staff View source Lack of effective NPS-specific drug policy View source Lack of a formal prison-to-prison transfer management system View source See 11 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
Anthony Binfield and 2 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Anthony Binfield, David William Richards and Rolandas Karbauskas died at HMP Lowdham Grange in March 2023 after using ligatures; Anthony’s and Rolandas’s deaths were suicides, while David’s death was accidental. The report identified missed opportunities to recognise and share risk information, shortcomings in prison and healthcare staffing, training and systems, and concerns about prisoner transfers, isolation, the prison contract transfer, and learning from previous 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 Inadequate basic training, supervision and mentoring of prison staff
Wider context from the report “All of the prison staff had completed the ITC programme, and yet there was widespread evidence of failures to do the basics . Staff failed to ensure the welfare of prisoners at roll count, failed to challenge flagrant breaches of Prison rules such as passing items under cell doors, and did not know how to properly deal with obscured cell observation hatches.
This calls into question the adequacy of their basic training, and the system for supervision and mentoring during the early years of practice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequate prison and healthcare staffing levels
Wider context from the report “The inadequate prison and healthcare staffing levels led to a restricted regime and healthcare provision. The prison was unable to offer keywork to all men, and the mental health team could no longer offer a named nurse service. Both of these aspects of care are fundamental to supporting the most vulnerable prisoners.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 with candour in post-death investigations
Wider context from the report “The Healthcare Trust are subject to a statutory duty of candour. HMPPS, Serco and Sodexo failed to embrace the same ethos during these investigations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Use of inaccessible email channels for risk pertinent information
Wider context from the report “I am also concerned by the use of email to convey risk pertinent information . In this case, prison staff communicated their concerns about Anthony’s mental health to individual nursing Sodexo email inboxes, which the nurses were not expected to regularly access . The use of email means that such concerns are not accessible to other members of staff as they would be if they were recorded in PNOMIS or Systemone.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and share risk pertinent information between prison and healthcare staff
Wider context from the report “There was a complete breakdown in the system of risk identification and information sharing . Prison and healthcare staff did not routinely consider information captured within the electronic systems , nor did they update the systems with risk pertinent information gathered during interactions with the prisoners .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 safety scrutiny during prison contract transfer
Wider context from the report “Safety was not front and centre of the Mobilisation and Transfer project.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 reduce isolation of foreign national prisoners
Wider context from the report “I heard evidence that the Big Word translation service did not work on multiple occasions across multiple sites within the prison. Staff gave evidence that even when the system did connect, they could be waiting in a queue for up to an hour to access an appropriate interpreter.
There was no plan to seek to reduce Rolandas’ obvious isolation , and seemingly no provision for expediting his induction so that he could be housed with fellow Lithuanian speakers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 embed learning from deaths and monitor safety culture
Wider context from the report “I heard evidence that many of the contributory factors leading to the deaths of Anthony, David and Rolandas, had been raised as issues in the investigations following previous deaths in custody at HMP Lowdham Grange.
While Serco no longer manage HMP Lowdham Grange, they continue to manage prisons, and there is a risk of future deaths if the organisation is unable to create a robust culture of seeking to identify issues early, adopt learning, and continually monitor culture to ensure any action taken is embedded to reduce the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a nurse during night state
Wider context from the report “For months prior to the deaths, the Trust failed to fulfil its commissioned obligations to provide a nurse during night state . Prison staff have only basic first aid training and lacked the expertise of a medical professional when attempting to provide CPR to Anthony.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unreliable and delayed access to interpretation services for foreign national prisoners
Wider context from the report “I heard evidence that the Big Word translation service did not work on multiple occasions across multiple sites within the prison . Staff gave evidence that even when the system did connect, they could be waiting in a queue for up to an hour to access an appropriate interpreter .
There was no plan to seek to reduce Rolandas’ obvious isolation, and seemingly no provision for expediting his induction so that he could be housed with fellow Lithuanian speakers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective system for gathering, retaining, reviewing and disclosing investigation material
Wider context from the report “HMPPS have no effective system for gathering, retaining, reviewing and disclosing potentially relevant material so that the issues relevant to death can be identified and learning put in place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to retain sufficient experienced prison and healthcare staff
Wider context from the report “I am concerned by the failure to retain experienced prison officers and healthcare staff . The private prison operator and the Authority were focused on the number of staff, rather than the skill sets or experience of the staffing body as a whole .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of effective NPS-specific drug policy
Wider context from the report “There is no requirement for prisons to have an NPS specific drug policy and I am concerned that generic drug reduction strategies are ineffective against this particular threat .
NPS is highly dangerous and carries a risk of death. I am concerned that more young men will die in custody as a result of NPS use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal prison-to-prison transfer management system
Wider context from the report “I heard evidence that there is no formal policy framework or system for managing the progress of prison-to-prison transfers , including a lack of expected response times or formal escalation plan if a prison fails to provide any response.
” 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 and support implementation of best-practice nursing preceptorship guidance for adult prison healthcare.
Verbatim wording from the response “To help address workforce demands within prisons, nursing within the criminal justice system (CJS) needs to be widely promoted as a career option and NHS England is supporting this promotion with the ‘We Are Prison Nurses’ campaign and nursing preceptorship (a period of structured transition where newly qualified nurses are supported by an experienced practitioner).” 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 Promote prison nursing recruitment through the ‘We Are Prison Nurses’ campaign and its recruitment resources.
Verbatim wording from the response “To help address workforce demands within prisons, nursing within the criminal justice system (CJS) needs to be widely promoted as a career option and NHS England is supporting this promotion with the ‘We Are Prison Nurses’ campaign and nursing preceptorship (a period of structured transition where newly qualified nurses are supported by an experienced practitioner).” 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 Maintain prison healthcare quality measures and monitor compliance through quarterly contract review meetings with clinical quality oversight.
Verbatim wording from the response “To support the quality performance assurance and oversight of prison healthcare providers, there are quality measures in place. The measures identified and included are aligned to standard NHS contract quality measures, to ensure consistency in approach, while avoiding increasing the burden of any reporting.” 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 Implement the Information Sharing Position Statement to guide health-information sharing and consent decisions across the criminal justice system.
Verbatim wording from the response “In 2023, NHS England’s national quality function for health and justice developed the Information Sharing Position Statement (ISPS). This supports a common understanding between NHS England and partners across the CJS about patient confidentiality and the sharing of health information (UK GDPR) which is considered more sensitive and therefore amounts to ‘special category’ data.” 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 Urgent information sharing involving safety risks should follow local safeguarding processes rather than the routine information-sharing statement.
Verbatim wording from the response “The ISPS only relates to the general and routine sharing of health information for purposes connected with the care of individuals in the CJS and is not intended to cover the sharing of health information in situations where there is an urgent need to share” 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 health needs assessment did not support continuing 24-hour healthcare at HMP Lowdham Grange.
Verbatim wording from the response “In September 2022, a Health Needs Assessment focused on the provision of 24-hour healthcare across the prison estate in the East Midlands was undertaken. The findings for HMP Lowdham Grange did not support continuation of this service, with funding invested to support a longer core day to enable patients to access healthcare services prior to the prison entering night state.” 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 Out-of-hours prison healthcare is commissioned by the Nottingham and Nottinghamshire Integrated Care System.
Verbatim wording from the response “Healthcare services are commissioned based on patient need and there should be equivalence to services available in the community. Healthcare services outside of the core working day are commissioned by Nottingham & Nottinghamshire Integrated Care System (ICS). In January 2018, 24-hour healthcare was implemented when there was an escalation in the use of psychoactive substances at HMP Lowdham Grange and this was continued as a response to the Covid-19 pandemic, to reduce the healthcare impact on the wider health community.” 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