31 May 2024 Frazer Charlie Williams · Prevention of Future Deaths report Dorset
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Concerns raised 17 Lack of guidance on transferring prisoners under healthcare-team care between establishments View source Lack of national guidance for management and operational staff on pre-transfer prisoner handover View source Lack of consultation with receiving-prison healthcare teams about care capability View source Lack of national guidance for healthcare handover to receiving prisons View source Failure to deliver the keyworker scheme in line with national guidance View source Lack of process for recording and involving prisoners’ next of kin View source Lack of NHS and joint HMPPS guidance on identifying, managing and treating self-neglect in prisons View source Delays in transferring prisoners requiring mental health hospital admission View source Lack of a national directory of healthcare facilities and provision at individual prisons View source Lack of guidance requiring consultation with prison doctors before transferring prisoners receiving medical care View source Lack of automatic flagging of missed ACCT reviews View source Lack of ACCT quality assurance between day 7 and post-closure review View source Failure to make an immediate ambulance call when a code blue or red is raised View source Failure to invite relevant individuals such as key workers to ACCT reviews View source Lack of national specification for prison healthcare units View source Failure of the email-a-prisoner system to facilitate contact after unrecognised prisoner transfers View source Camouflaging similarity between cell-door and bedsheet colours View source See 14 more concerns
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AI-generated summary
Frazer Charlie Williams · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Frazer Charlie Williams was found deceased on 7 March 2022 in his cell at HMP Guys Marsh, suspended by a ligature. The report identifies concerns about delays transferring prisoners requiring mental health hospital care, inadequate arrangements for managing self-neglect and healthcare handovers, shortcomings in ACCT monitoring and reviews, and other prison care and safety processes. The inquest concluded that he died by suicide in circumstances where there was inadequate assessment and monitoring of his risks of self-harm and suicide prior to his death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on transferring prisoners under healthcare-team care between establishments
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold . There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care, whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold. Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 guidance for management and operational staff on pre-transfer prisoner handover
Wider context from the report “vi. There is lack of national guidance for both senior management and operational prison staff in relation to the handover of a prisoner in advance of their transfer , not specific to, but especially those with complex needs, when transferring between prisons.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 consultation with receiving-prison healthcare teams about care capability
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold. There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care, whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold. Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 guidance for healthcare handover to receiving prisons
Wider context from the report “iv. There is a lack of national guidance for healthcare teams working in prisons around the handover of healthcare of a prisoner to the receiving prison when they are transferred to another prison.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to deliver the keyworker scheme in line with national guidance
Wider context from the report “x. The keyworker scheme is not being delivered in line with national guidance at HMP Guys Marsh.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 process for recording and involving prisoners’ next of kin
Wider context from the report “xiii. There is a lack of process regarding the recording of a prisoner’s next of kin and involvement of them at HMP Guys Marsh.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 NHS and joint HMPPS guidance on identifying, managing and treating self-neglect in prisons
Wider context from the report “ii. There is a lack of NHS guidance, and joint guidance with HMPPS, on the identification, management, and treatment of someone with self neglect in the prison 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 Delays in transferring prisoners requiring mental health hospital admission
Wider context from the report “i. There is inequity within the system of the treatment of a person with mental illness in the prison setting compared to an individual in the community, due to the fact that in the community a person would be placed in a hospital setting on the day they were deemed to require hospital admission, however in prison there are delays in transferring a prisoner in the same situation to hospital .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 national directory of healthcare facilities and provision at individual prisons
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales , and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold. There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care, whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold. Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 requiring consultation with prison doctors before transferring prisoners receiving medical care
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold. There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care , whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold . Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 automatic flagging of missed ACCT reviews
Wider context from the report “viii. There is lack of automatic flagging of a missed ACCT review at HMP Guys Marsh and this could also be a national problem.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 ACCT quality assurance between day 7 and post-closure review
Wider context from the report “vii. The lack of ACCT quality assurance, or audit, between day 7 of the ACCT and the post closure review .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to make an immediate ambulance call when a code blue or red is raised
Wider context from the report “xii. PSI 03/2013 is not being followed at HMP Guys Marsh as there is no immediate call to the ambulance service when a code blue or red is raised .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 invite relevant individuals such as key workers to ACCT reviews
Wider context from the report “ix. Relevant individuals, such as key workers are not being invited to attend ACCT reviews at HMP Guys Marsh in line with ACCT 6 guidance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 specification for prison healthcare units
Wider context from the report “v. There is a lack of national specification in respect of prison healthcare units .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 email-a-prisoner system to facilitate contact after unrecognised prisoner transfers
Wider context from the report “xiv. The email a prisoner system is dependant on the person wanting to contact the prisoner knowing their location , so if the prisoner is transferred to another prison and the person contacting them is not aware, contact which can be a protective factor particularly in a prisoner’s mental health care, will not be facilitated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Camouflaging similarity between cell-door and bedsheet colours
Wider context from the report “xi. The colour of the cell doors and bedsheets at HMP Guys Marsh, and possibly at other prisons nationally, being very similar can camouflage ligatures .
” 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 Use a clinical template to record and monitor referrals, assessments and transfers under sections 47 and 48 of the Mental Health Act.
Verbatim wording from the response “A new clinical template for improving data collection and monitoring has been developed and is now in place, to record the referral, assessment and transfer process for prisoners and detainees, under sections 47 and 48 of the Mental Health Act (MHA)” 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 Review mental health pathway processes, communication and information sharing, then develop a proposed pathway and programme plan addressing identified gaps and priorities.
Verbatim wording from the response “A review of processes, communication and information sharing around mental health concerns is also underway and will be completed by February 2025. This review is calling “Health and Justice Mental Health Pathway”. Work on the development of a Mental Health Pathway aims to:” 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 Share ACCT process concerns with regional commissioners and request monitoring through contract reviews and feedback to the Health and Justice Oversight Delivery Group.
Verbatim wording from the response “7. The lack of Assessment Care in Custody and Teamwork (ACCT) quality assurance or audit between day 7 of the ACCT and post closure review.” Source location Response from NHS England
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Respond directly to concerns identified in the thematic review of delays transferring mentally unwell prisoners.
Verbatim wording from the response “I would like to reassure you that NHS England consistently strives for equality in mental health healthcare provision. To address the specific concerns about Frazer’s care, there are several cross party workstreams underway.” Source location Response from NHS England
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Gather transfer-timeliness data and work with commissioners to improve the quality and completeness of existing data collection.
Verbatim wording from the response “1983. This template is for use within the health and justice information system (HJIS) in prisons (current SystemOne). NHS England is working to use the information generated to gather data on the timeliness of transfers, whilst also proactively working with Health and Justice commissioners to improve data quality and completeness of existing manual collection.” 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 Existing prison mental health service specifications provide clear guidance for mental healthcare provision within prisons.
Verbatim wording from the response “5. There is a lack of national specification in respect of prison healthcare units.” 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 HMPPS should respond to the absence of a national prison healthcare directory and related prisoner-transfer guidance.
Verbatim wording from the response “i. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold.” Source location Response from NHS England
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation HMPPS is responsible for overseeing the ACCT process, including establishment-level training, and is responding independently to ACCT concerns.
Verbatim wording from the response “The points above relating to the ACCT process (annex-to-psi-64-2011-acct .docx (live.com)) will be shared with NHS England’s regional Health and Justice commissioners, with a request that they monitor this in contract review meetings and feedback via the Health and Justice Oversight Delivery Group (HJODOG).” Source location Response from NHS England
Open published response
29 May 2024 George Barry Broadhurst · Prevention of Future Deaths report Manchester South
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Concerns raised 3 Delayed review of radiology reports against clinical notes View source Delays in specialist reporting of X rays View source Insufficient training of community and primary care teams to recognise deterioration in healing fractures 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
George Barry Broadhurst · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
George Barry Broadhurst sustained a vertebral fracture in an accidental fall, which was not identified on an initial x-ray review. He later deteriorated with a collapsed lung, pulmonary embolism and an infected fractured vertebra, and died in hospital on 10 October 2023. The principal concerns were delays in radiology reporting and review, and insufficient recognition and escalation of concerning pain and deterioration in the community.
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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 Delayed review of radiology reports against clinical notes
Wider context from the report “2. The knock-on impact of the delay in reporting is that once the radiology reports are available they then have to be reviewed in conjunction with the notes by a consultant days after the attendance to ensure the treatment given fits with the reported findings. This is a significantly more time-consuming process than them being looked at in real time and results in ED consultant resource being diverted away from the day to day demands of ED. Thus, placing a greater strain on clinicians in ED and stretching resources more thinly.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 specialist reporting of X rays
Wider context from the report “1. The inquest heard evidence that the delay in reporting of X rays by radiologists is not unique to Tameside but is a national picture caused by a shortage of radiologists and trained reporting radiographers . The impact of the shortage is that ED doctors are interpreting x rays in highly pressured situations without specialist input and with a consequential risk of missing more subtle fractures. This means that patients are discharged with fractures rather than appropriate treatment or conversely are given unnecessary treatment that then has to be reversed once a specialist review takes 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 Insufficient training of community and primary care teams to recognise deterioration in healing fractures
Wider context from the report “3. The evidence given was that the level of pain that Mr Broadhurst still had in the community after 1st October was not in keeping with a healing fracture. The inquest was told that it was important that community/primary care teams were trained to understand how “normal” pain, in the context of a fracture being managed in the community, would present and what was a red flag/ deteriorating situation . Training on expectations around healing fractures would ensure what was a life-threatening deterioration was picked up and escalated at the earliest possible point .
” 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 international recruitment of radiologists to support diagnostic capacity, with demand planning underway for further recruitment.
Verbatim wording from the response “A programme of international recruitment also ran in 2023/24 to enable Community Diagnostic Centres (CDCs) to deliver diagnostics and achieve the benefits in access, recovery and transformation of care. During 2023/24, 21 Radiologists were appointed through the programme. Further international recruitment is planned for 2024/25, with demand planning currently underway.” Source location Response from NHSE
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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 Deliver the Long Term Workforce Plan, including expanded domestic education, training and recruitment and workforce retention measures.
Verbatim wording from the response “NHS England is also working at a national level to deliver the Long-Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of” Source location Response from NHSE
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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 Expand Clinical Radiology specialty training places to increase the trained reporting workforce.
Verbatim wording from the response “Following additional investment through spending review settlements in 2021/22 and 2022/23, the NHS has observed a significant and sustained expansion in recruitment to specialty training places. Clinical Radiology recruitment increased from an average of 234 trainees per year (between 2016 and 2020) to an average of 328 (between 2021 and 2022), meaning an expansion of around 100 specialty trainee places per year.” Source location Response from NHSE
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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 NHS Trusts are responsible for ensuring safe staffing levels in hospitals’ current day-to-day operations.
Verbatim wording from the response “people, with the right skills and support in place, to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years. These actions will aim to close anticipated staffing shortfalls in the NHS in the long term, however NHS Trusts have a responsibility to ensure safe staffing levels in the current day to day operation of their hospitals.” Source location Response from NHSE
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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 Requesting doctors and clinical teams are responsible for reading, acting on, and safely managing imaging reports and alerts.
Verbatim wording from the response “On behalf of the Royal College of Radiologists, the Academy of Medical Royal Colleges (AoMRC) published ‘Alerts and notification of imaging reports’ in October 2022, which makes clear that the referrer is required to act on the report issued by imaging, and that it is the responsibility of the requesting doctor and/or their clinical team to read and act upon the report findings and fail-safe alerts as quickly and efficiently as possible. This extends to ensuring robust mechanisms are in place and that there are suitable resources to cover leave within clinical teams or practices.” Source location Response from NHSE
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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 Local A&E procedures require follow-up of X-ray reports because general X-rays may not receive 24/7 imaging-service reporting.
Verbatim wording from the response “Accident & Emergency (A&E) departments are required to have local procedures in place to ensure that they follow up X-ray reports, based on the formal report being finalised, as pathologies can be missed via A&E routes and imaging services do not support/deliver 24/7 reporting of general X-rays.” Source location Response from NHSE
Open published response
23 May 2024 Jada Monoja · Prevention of Future Deaths report Inner South London
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Concerns raised 3 Failure to clearly date and signpost revisions within compound risk assessments View source Failure to systematically review and update risk indicators at relevant patient events View source Failure to maintain detailed patient risk assessments as clear, well-signposted and dated assessments 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
Jada Monoja · 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
Jada Monoja, who had a history of chronic paranoid and delusional thinking, disclosed suicidal thoughts on 15 November 2020 and was assessed by mental health services before being accepted by the Home Treatment Team. In the early hours of 17 November 2020, he was found unresponsive after leaving home and could not be resuscitated; the inquest concluded that he died by suicide, likely while experiencing delusional and paranoid thoughts. The principal concerns relate to the use of the online risk assessment tool, including assessments being incomplete, insufficiently dated or signposted, and difficult to identify within chronological records.
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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 clearly date and signpost revisions within compound risk assessments
Wider context from the report “Multiple witnesses indicated that the Risk Assessment Tool on the online system (EPJS) is not used in line with policy (i.e. that a new assessment in that tool is undertaken at the time of each admission/discharge/major risk event etc.), and, if updated, may only be updated in so far as additional narrative is added to the last such narrative in a previously completed assessment.
Further, the evidence was that rather than be used for a detailed assessment per the indicators set out in the tool at the time of each relevant event, it was reviewed to instead access any past assessment in order (only) to establish quickly a benchmark against which the gauge a patient’s current presentation when considering their risks. The detailed indicators informing the risk assessment were not updated.
Although it was submitted that patient risk was nonetheless assessed and recorded in the EPJS, and acknowledged that benchmarking/comparison is useful, I am concerned that:
(1) if the risk indicators set out in the tool are not systematically reviewed or reconsidered, then the assessment of risk that follows will then be based on incomplete, and therefore misleading, information; and
(2) absent the above, and dating of revisions within a compound document, it is not clear on what indicators any assessment is in fact based
(3) to the extent the risk assessment is used as a benchmarking tool, the impression given to the most recent reviewer is then likely to be incomplete and misleading;
(4) the apparent current use of the tool to establish a point of benchmarking/comparison is in any event lost where the compound narrative assessments are not clearly dated and signposted ;
(5) if the detailed patient assessment is instead placed as a new entry in the general chronological notes, the usefulness of the tool as a clear, well signposted, dated assessment and documentation of the patients of risk(s), is lost, requiring a reviewer to instead review the general chronological log of entries on the EPJS where it is not required to be articulated in the same terms, and may be more difficult to identify in a longstanding patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 systematically review and update risk indicators at relevant patient events
Wider context from the report “Multiple witnesses indicated that the Risk Assessment Tool on the online system (EPJS) is not used in line with policy (i.e. that a new assessment in that tool is undertaken at the time of each admission/discharge/major risk event etc. ), and, if updated, may only be updated in so far as additional narrative is added to the last such narrative in a previously completed assessment.
Further, the evidence was that rather than be used for a detailed assessment per the indicators set out in the tool at the time of each relevant event , it was reviewed to instead access any past assessment in order (only) to establish quickly a benchmark against which the gauge a patient’s current presentation when considering their risks. The detailed indicators informing the risk assessment were not updated.
Although it was submitted that patient risk was nonetheless assessed and recorded in the EPJS, and acknowledged that benchmarking/comparison is useful, I am concerned that:
(1) if the risk indicators set out in the tool are not systematically reviewed or reconsidered , then the assessment of risk that follows will then be based on incomplete, and therefore misleading, information ; and
(2) absent the above, and dating of revisions within a compound document, it is not clear on what indicators any assessment is in fact based
(3) to the extent the risk assessment is used as a benchmarking tool, the impression given to the most recent reviewer is then likely to be incomplete and misleading;
(4) the apparent current use of the tool to establish a point of benchmarking/comparison is in any event lost where the compound narrative assessments are not clearly dated and signposted ;
(5) if the detailed patient assessment is instead placed as a new entry in the general chronological notes, the usefulness of the tool as a clear, well signposted, dated assessment and documentation of the patients of risk(s), is lost, requiring a reviewer to instead review the general chronological log of entries on the EPJS where it is not required to be articulated in the same terms, and may be more difficult to identify in a longstanding patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 detailed patient risk assessments as clear, well-signposted and dated assessments
Wider context from the report “Multiple witnesses indicated that the Risk Assessment Tool on the online system (EPJS) is not used in line with policy (i.e. that a new assessment in that tool is undertaken at the time of each admission/discharge/major risk event etc.), and, if updated, may only be updated in so far as additional narrative is added to the last such narrative in a previously completed assessment.
Further, the evidence was that rather than be used for a detailed assessment per the indicators set out in the tool at the time of each relevant event, it was reviewed to instead access any past assessment in order (only) to establish quickly a benchmark against which the gauge a patient’s current presentation when considering their risks. The detailed indicators informing the risk assessment were not updated.
Although it was submitted that patient risk was nonetheless assessed and recorded in the EPJS, and acknowledged that benchmarking/comparison is useful, I am concerned that:
(1) if the risk indicators set out in the tool are not systematically reviewed or reconsidered, then the assessment of risk that follows will then be based on incomplete, and therefore misleading, information; and
(2) absent the above, and dating of revisions within a compound document, it is not clear on what indicators any assessment is in fact based
(3) to the extent the risk assessment is used as a benchmarking tool, the impression given to the most recent reviewer is then likely to be incomplete and misleading;
(4) the apparent current use of the tool to establish a point of benchmarking/comparison is in any event lost where the compound narrative assessments are not clearly dated and signposted ;
(5) if the detailed patient assessment is instead placed as a new entry in the general chronological notes , the usefulness of the tool as a clear, well signposted, dated assessment and documentation of the patients of risk(s), is lost , requiring a reviewer to instead review the general chronological log of entries on the EPJS where it is not required to be articulated in the same terms, and may be more difficult to identify in a longstanding 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 Include risk-assessment and safety-planning principles in national guidance for mental health inpatient services.
Verbatim wording from the response “One of the key actions set out in the Government’s Suicide Prevention Strategy (published on 11 September 2023) was that NHS England would identify opportunities to improve the quality and culture of risk management and safety planning within mental health services. The position regarding risk assessments was included in the NHS England guidance to improve the culture of care for mental health inpatient services in April 2024: Culture of care standards for mental health inpatient services.” Source location Response from NHS England
Open published response
21 May 2024 Emma Louise MORRIS · Prevention of Future Deaths report Cheshire
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Concerns raised 1 Failure to provide access to inpatient mental health beds at the time of clinical need 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
Emma Louise MORRIS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Emma Louise Morris died after deliberately walking in front of a bus on 20 September 2023, following a deterioration in her mental health. A mental health practitioner had assessed that inpatient admission was clinically indicated because of an immediate risk to her safety, but no inpatient bed was available. The concern was that pressure on hospital trusts and the lack of available inpatient mental health beds could put future patients at risk of death when admission is clinically needed.
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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 provide access to inpatient mental health beds at the time of clinical need
Wider context from the report “During the course of the inquest, I heard that there is national pressure on hospital trusts as there is a national increase in people waiting for inpatient beds. I am therefore concerned that there is a risk of future deaths as it is not possible to access inpatient mental health beds at the time of clinical need .
” 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 Make £1.6 billion available through the Better Care Fund to support mental health inpatient services and wider system capacity.
Verbatim wording from the response “To address the wider system issues that impact on health services, a further £1.6 billion has been made available via the Better Care Fund (‘BCF’) from 2023-25. This funding can be used to support both mental health inpatient services as well as the wider system, which should help to reduce pressures on local inpatient services so that those who need to access beds can do so quickly and locally.” Source location Response from NHS England
Open published response
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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 Issue operational planning guidance directing systems to reduce average adult acute mental health ward length of stay and improve access to local beds.
Verbatim wording from the response “In some local areas there is a need for more beds. This is being addressed in part through investment in new units but should also be considered as part of a whole system transformation approach. This is supported by the NHS Long Term Plan (LTP), which is seeing an additional £2.3 billion funding being invested in mental health services from 2019/20 – 2023/24, around £1.3 billion of which is for adult community, crisis and acute mental health services to help people get quicker access to the care they need, and to prevent avoidable deterioration and hospital admission. NHS England’s 2024/25 priorities and operational planning guidance reinforces this focus on improving patient flow as a key priority, with systems directed to reduce the average length of stay in adult acute mental health wards, in order to deliver more timely access to local beds.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest £2.3 billion in mental health services, including approximately £1.3 billion for adult community, crisis and acute services.
Verbatim wording from the response “In some local areas there is a need for more beds. This is being addressed in part through investment in new units but should also be considered as part of a whole system transformation approach. This is supported by the NHS Long Term Plan (LTP), which is seeing an additional £2.3 billion funding being invested in mental health services from 2019/20 – 2023/24, around £1.3 billion of which is for adult community, crisis and acute mental health services to help people get quicker access to the care they need, and to prevent avoidable deterioration and hospital admission. NHS England’s 2024/25 priorities and operational planning guidance reinforces this focus on improving patient flow as a key priority, with systems directed to reduce the average length of stay in adult acute mental health wards, in order to deliver more timely access to local beds.” Source location Response from NHS England
Open published response
20 May 2024 James Furlong and 2 others · Prevention of Future Deaths report Central Criminal Court
View report summary
Concerns raised 6 Failure to maintain and disseminate an adequate intelligence picture View source Failure to provide an adequate and integrated response to identified risk View source Failure to address consequential risks created by inadequate intelligence dissemination View source Failure to provide adequate secondary mental healthcare in prison View source Failure to provide adequate mental healthcare in the community View source Failure to avoid discounting extremist risk because of personality disorder and PTSD symptoms 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
James Furlong 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
James Furlong, Joseph Ritchie-Bennett and David Wails were murdered by Khairi Saadallah in a premeditated attack in Forbury Gardens, Reading, on 20 June 2020. The principal concerns were failures by multiple bodies to assess and share intelligence about Saadallah’s risks, provide an adequate integrated response, and provide adequate mental healthcare in the community and prison; the report states these failures probably or possibly contributed to the three 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 Failure to maintain and disseminate an adequate intelligence picture
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation 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 provide an adequate and integrated response to identified risk
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation 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 address consequential risks created by inadequate intelligence dissemination
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation 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 provide adequate secondary mental healthcare in prison
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation 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 provide adequate mental healthcare in the community
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation 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 avoid discounting extremist risk because of personality disorder and PTSD symptoms
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation Trust)
” 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 Review current mental health service provision for adults in contact with the criminal justice system.
Verbatim wording from the response “The NHS England Mental Health Programme has recently embarked on new work to review the current service provision for adult individuals in contact with the criminal justice system. This has focused on the changes required to provide sustainable and” 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 Mental Health Criminal Justice Pathway through the Health and Justice Mental Health Pathway Expert Working Group.
Verbatim wording from the response “To enable these changes, a Mental Health Criminal Justice Pathway is in development. This Pathway is overseen by a ‘Health and Justice Mental Health Pathway Expert Working Group’ and this work aims to:” 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 Require Integrated Care Boards to review community services for people with serious mental illness who need intensive treatment and follow-up despite engagement challenges.
Verbatim wording from the response “However, NHS England recognises that further national work is needed to ensure that people with severe mental illness, who pose a risk of harm to others when unwell, are properly supported and can access appropriate care to avoid relapses in their mental health. NHS England has therefore asked all Integrated Care Boards to review their community services by September 2024, to ensure that they have clear policies and practices in place for patients with serious mental illness, who require intensive community treatment and follow-up, but where engagement is a challenge. To support system reviews, NHS England has convened an expert advisory group to advise on the development of national guidance, setting out the key principles in this area that should be reflected in local policies and practices.” 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 national guidance on community treatment and follow-up principles through a convened expert advisory group.
Verbatim wording from the response “However, NHS England recognises that further national work is needed to ensure that people with severe mental illness, who pose a risk of harm to others when unwell, are properly supported and can access appropriate care to avoid relapses in their mental health. NHS England has therefore asked all Integrated Care Boards to review their community services by September 2024, to ensure that they have clear policies and practices in place for patients with serious mental illness, who require intensive community treatment and follow-up, but where engagement is a challenge. To support system reviews, NHS England has convened an expert advisory group to advise on the development of national guidance, setting out the key principles in this area that should be reflected in local policies and practices.” 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 Operate the enhanced RECONNECT trauma-informed pathway pilot for high-risk people with complex health needs.
Verbatim wording from the response “Enhanced RECONNECT (ER), which is a trauma informed service working with people from 6 months prior to release until 12 months post release, builds on the RECONNECT service as an enhanced pathway of care, and is NHS England’s response to the management of individuals identified as a high risk of harm to the public and who have complex health needs. The enhanced service is a pilot scheme currently operating in the North East, North West and South West of England. The service works collaboratively with partners (including from other services and organisations) to support any high-risk individual with complex health needs, which may impact on their risk of reoffending.” 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 Operate an integrated primary and secondary prison mental healthcare model with access to health and community mental health records.
Verbatim wording from the response “Further to the above, there is an integrated model of mental health care across both primary and secondary care mental health services, with access to the Health and Justice Information Services (HJIS) records, along with community mental health records, to better support continuity of care and information sharing.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Re-procure and provide secondary mental health services at HMP Bullingdon and HMP Huntercombe through Oxford Health NHS Foundation Trust.
Verbatim wording from the response “Additionally, since the tragic events of 20 June 2020, NHS England’s South East region has re-procured mental health services at HMP Bullingdon and HMP Huntercombe. These services are now provided by Oxford Health NHS Foundation Trust (OHFT) at both sites.” 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 Prioritise increased access to evidence-based talking therapies while developing a more sustainable workforce to deliver them in prisons.
Verbatim wording from the response “The provision of psychological therapies is still commissioned, although recruitment challenges mean there is a longer wait for initial assessment for psychological therapy than is ideal at present. Prison mental health teams do maintain a 5 day wait for routine mental health referrals, however, increasing the availability and accessibility of talking therapies is a priority.” 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 Increase investment in adult and older adult community mental health services by £1 billion annually to support transformed models of care.
Verbatim wording from the response “Additionally, as part of its NHS Long Term Plan commitments to improve mental health care, NHS England has increased the investment in adult and older adult community mental health services by £1 billion per year since 2019/20. This additional funding has meant that over 370,000 people were able to access transformed models of care in 2023/24. These new models, as described in the Community Mental Health Framework (September 2019), are aimed at ensuring that adults and older adults with severe mental health problems are better able to access a high quality of care that meets their clinical and social needs, and that care is easily 'stepped up' or 'stepped down' depending on their needs.” 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 Oxford Health NHS Foundation Trust is required to provide assurance about current practices and psychological services at Bullingdon and Huntercombe prisons.
Verbatim wording from the response “My regional colleagues in the South East have also been asked to engage with BHFT on the concerns raised, and with OHFT who, as set out above, are now providing the secondary mental health services to HMPs’ Bullingdon and Huntercombe. We note that OHFT are required to provide assurance of current practices at these two prisons, including the current position on the level of available psychological services against the background of the previous failure by MPFT to provide these to the perpetrator of the attack whilst he was in prison. We will carefully consider the Trusts’ responses, once sighted on these.” Source location Response from NHS England
Open published response
8 May 2024 Oliver Walter John Stephen BARNETT · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1 Lack of residential substance misuse treatment facilities for children under 18 View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Oliver Walter John Stephen BARNETT · 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
Oliver Barnett, aged 17, died on 8 December 2022 from an overdose of illicitly obtained drugs after experiencing drug dependence and previous overdoses. The report identified the absence of residential substance misuse treatment facilities in England for people under 18, leaving children to receive community treatment and placing them at greater risk of relapse and death by overdose.
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 residential substance misuse treatment facilities for children under 18
Wider context from the report “There are no residential substance misuse treatment facilities for children and young persons under the age of 18 in England. If a child is acutely unwell through substance misuse, they will be treated in hospital and then discharged home to receive treatment in the community. Parents/guardians must manage the detoxification programme, and the risk of relapse, supported by substance misuse agencies. There is a disparity between the treatment offered to adults and children, and the absence of residential substance misuse facilities places children at greater risk of relapse and death by overdose .
” 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 Residential substance misuse treatment for children and young people is outside NHS England’s remit.
Verbatim wording from the response “Treatment for substance misuse is not something that comes under NHS England’s remit, although my colleagues from our national Mental Health, Prevention and Children and Young People Teams have been sighted on 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 The Department of Health and Social Care is responsible for responding to the concerns about residential substance misuse treatment.
Verbatim wording from the response “I note that you have also addressed your Report to the former Secretary of State for Health and Social Care, Victoria Atkins MP. The Department of Health and Social Care is the appropriate organisation to respond to your concerns.” Source location Response from NHS England
Open published response
7 May 2024 David RILEY · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 5 Failure to specify and disseminate learning from the DOAC pausing incident View source Failure to coordinate pericardiocentesis timing with the duration of DOAC interruption View source Lack of clear guidance for clinicians on pausing DOACs View source Failure to communicate, recognise and act on time-critical DOAC directions View source Inconsistent understanding and application of DOAC pausing decisions View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
David RILEY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Riley developed a pericardial effusion after atrial fibrillation ablation and later suffered a stroke before dying on 10 June 2023. Concerns included inconsistent decisions about pausing Apixaban, delays in restarting it, inadequate communication and continuity of care, and difficulties using computerised clinical records.
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 specify and disseminate learning from the DOAC pausing incident
Wider context from the report “Although the Warwick hospital conducted a Root Cause Analysis Investigation Report (RCAIR) of 6 July 2023 which indicated that the pausing of the DOAC was a lesson learned, it did not indicate what was learned . The only further action was limited to the incident being presented at the Grand Round, but this had not taken place at the time of the inquest, some 9 months after publication of the RCAIR . There are remaining outstanding matters of concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 coordinate pericardiocentesis timing with the duration of DOAC interruption
Wider context from the report “2. Effective communication
From the evidence, there was a failure to effectively communicate, recognise and act on directions that were time critical, such as restarting the DOAC as directed. It does not appear that there was any consideration as to the timing of the pericardiocentesis to ensure that the DOAC was paused for a short a time as possible . The evidence suggested that this may be due to lack of continuity of care and the difficulties in the way in which computerised clinical/pharmacy records are updated and accessed. Clear communication between medical staff is essential to patient 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 Lack of clear guidance for clinicians on pausing DOACs
Wider context from the report “1. Decisions regarding pausing of DOACs.
It was not clear if there is national guidance available to clinicians regarding the pausing of DOACs and the considerations to be applied in making that decision . If there is such guidance, it is not widely understood or on the evidence given, followed consistently from hospital to hospital or within different teams. The inconsistency of approach appears from the evidence to increase the risk of misunderstanding and to put patients with atrial fibrillation at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate, recognise and act on time-critical DOAC directions
Wider context from the report “2. Effective communication
From the evidence, there was a failure to effectively communicate, recognise and act on directions that were time critical, such as restarting the DOAC as directed . It does not appear that there was any consideration as to the timing of the pericardiocentesis to ensure that the DOAC was paused for a short a time as possible. The evidence suggested that this may be due to lack of continuity of care and the difficulties in the way in which computerised clinical/pharmacy records are updated and accessed. Clear communication between medical staff is essential to patient 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 Inconsistent understanding and application of DOAC pausing decisions
Wider context from the report “1. Decisions regarding pausing of DOACs.
It was not clear if there is national guidance available to clinicians regarding the pausing of DOACs and the considerations to be applied in making that decision. If there is such guidance, it is not widely understood or on the evidence given, followed consistently from hospital to hospital or within different teams . The inconsistency of approach appears from the evidence to increase the risk of misunderstanding and to put patients with atrial fibrillation at risk .
” 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 Review the Report and consider whether learning should be shared across Midlands integrated care boards.
Verbatim wording from the response “The Regional Chief Pharmacist in the Midlands has also been asked to review your Report and consider whether any learnings need to be shared across the ICBs within the Midlands region.” 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 Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share their learning nationally and regionally.
Verbatim wording from the response “I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of David, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.” 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 Publishing national clinical guidance on pausing direct oral anticoagulants is outside NHS England’s remit.
Verbatim wording from the response “It is not within NHS England’s remit to publish the relevant clinical guidance on this matter. We would refer you to the National Institute for Health and Care Excellence (NICE), who we note you have also addressed your Report to, and who have published national guidance on the use of Apixaban, which was last updated in April 2024. The guidance states that patients may need to temporarily stop taking Apixaban if they require surgery or any other invasive procedure, and this depends on the patient’s risk of having a thromboembolic event along with the bleeding risk associated with the procedure. For “procedures with a high bleeding risk, the last dose of apixaban should be taken 3 days before the procedure”.” 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 Warwick Hospital is best placed to address local communication, continuity-of-care and clinical-record concerns.
Verbatim wording from the response “You also raised the concern that there was a failure to effectively communicate, recognise and act on time critical directions, including restarting the DOAC, and that this may be due to a lack of continuity of care and difficulties in accessing and updating the computerised clinical / pharmacy records. We note that your Report has also been sent to Warwick Hospital (falling under the South Warwickshire University NHS Foundation Trust), and they would be best placed to address these concerns and their local arrangements.” 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 NICE is responsible for relevant national guidance on pausing Apixaban and direct oral anticoagulants.
Verbatim wording from the response “It is not within NHS England’s remit to publish the relevant clinical guidance on this matter. We would refer you to the National Institute for Health and Care Excellence (NICE), who we note you have also addressed your Report to, and who have published national guidance on the use of Apixaban, which was last updated in April 2024. The guidance states that patients may need to temporarily stop taking Apixaban if they require surgery or any other invasive procedure, and this depends on the patient’s risk of having a thromboembolic event along with the bleeding risk associated with the procedure. For “procedures with a high bleeding risk, the last dose of apixaban should be taken 3 days before the procedure”.” Source location Response from NHS England
Open published response
3 May 2024 Michael Clarke · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to account for actual category 3 ambulance response times when accepting call categorisation View source Lack of specific sepsis trigger questions on the ambulance pathway View source Delays in category 3 ambulance responses View source Failure of suspected sepsis indications to trigger a faster ambulance response View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Michael Clarke · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Clarke, who had multiple underlying health conditions including end stage renal failure, developed suspected urosepsis after a cystoscopy and died in hospital on 30 July 2023. The report raised concerns about delays in category 3 ambulance responses, the categorisation of a call where sepsis was suspected, and the absence of specific sepsis trigger questions on the ambulance pathway.
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 account for actual category 3 ambulance response times when accepting call categorisation
Wider context from the report “2. The inquest was told that the initial call to NWAS was made by the out of hours nurse. She made it clear that she felt the ambulance response needed to be within 1 hour. As this was in theory the response time consistent with a category 3 response, she accepted the categorisation. This acceptance did not appear to take into account that on that evening a category 3 call was not going to result in an ambulance within 1 hour .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 specific sepsis trigger questions on the ambulance pathway
Wider context from the report “3. The evidence before the inquest was that there were no specific sepsis trigger questions on the ambulance pathway . The nurse suspected sepsis and gave that indication but that did not trigger a faster response despite the recognition that where sepsis is suspected antibiotics need to commence as a priority.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 category 3 ambulance responses
Wider context from the report “1. The inquest was told that due to significant demand the wait time for an ambulance in category 3 was in excess of 4 hours rather than the target 1 hour . The inquest was told that this was not unusual and was still an ongoing issue . The evidence was that this was not unique to NWAS but the general picture in England. The inquest was told that there had been improvements in category 1 and 2 response times but to achieve this category 3 calls continued to have these significant delays .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 suspected sepsis indications to trigger a faster ambulance response
Wider context from the report “3. The evidence before the inquest was that there were no specific sepsis trigger questions on the ambulance pathway. The nurse suspected sepsis and gave that indication but that did not trigger a faster response despite the recognition that where sepsis is suspected antibiotics need to commence as a priority .
” 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 developing alternative referral pathways, including urgent community response, to provide timely and appropriate care.
Verbatim wording from the response “Whilst ambulance response times have not returned to pre-pandemic levels, there were improvements in ambulance response times nationally during 2023/24. The 2023/24 year-end Category 3 Mean time to respond was 2 hours 4 minutes 14 seconds which is 31 minutes 4 seconds quicker than 2022/23 and the 2023/24 year-end Category 2 Mean was 36 minutes 23 seconds which is 13 minutes 37 seconds quicker than 2022/23. For 2024/25, the Delivery Plan continues to focus on the improvement of ambulance response times, with ambulance services expected to maintain the increases in capacity achieved throughout 2023/24, alongside the continued development of alternative referral pathways (e.g. urgent community response) to ensure that patients receive timely and high-quality care.” Source location Response from NHS England and NHS GMIC
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 ambulance capacity increases achieved during 2023/24 to support improved response times.
Verbatim wording from the response “The plan outlined key actions to recover and improve urgent and emergency care services, including improving ambulance response times, increasing ambulance capacity through growing the workforce (for example, increasing clinical capacity in control rooms), alongside broader system actions to improving flow through hospitals and reducing handover delays, speeding up discharges from hospitals and expanding new services in the community, all of which should help ambulance crews to get back on the road to the next waiting patient more rapidly.” Source location Response from NHS England and NHS GMIC
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 the Delivery Plan for recovering urgent and emergency care services, including actions to improve ambulance response times and capacity.
Verbatim wording from the response “Your first concern is centred on the significant demand and waiting times for a Category 3 ambulance which was more than four hours rather than the one-hour target. NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic, as well as issues associated with handing over ambulance patients in a timely way at some NHS Trusts. NHS England has prioritised improving ambulance performance during 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, which was published in January 2023.” Source location Response from NHS England and NHS GMIC
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 Pathways already considers sepsis through symptom-based assessment and provides an option to identify suspected sepsis.
Verbatim wording from the response “Your third concern raised was regarding there being no specific sepsis questions on the ambulance pathway. The NHS Pathways triage system is a clinical decision support system (CDSS) supporting the assessment of patients presenting to urgent and emergency services, such as ambulance services. The system is owned by the Department for Health and Social Care and delivered by the Transformation Directorate of NHS England.” Source location Response from NHS England and NHS GMIC
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 Category 3 ambulance categorisation was audited and considered safe and appropriate based on the patient’s presentation.
Verbatim wording from the response “You also raised a concern that the initial call to North West Ambulance Service (NWAS) was made by an out of hours Nurse who requested an ambulance within one hour as this is consistent with Category 3 response call-outs. It was not considered then that on that evening a Category 3 call was not going to result in an ambulance attending within one hour.” Source location Response from NHS England and NHS GMIC
Open published response
30 Apr 2024 Jason PULMAN · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 8 Lack of clarity about national gender-service referral mechanisms and available resources View source Insufficient CAMHS resources causing long waits for treatment View source Insufficient specialist workforce capacity within CAMHS and paediatrics for gender identity services View source Failure of CAMHS teams to be aware of enhanced support offered to gender-service patients View source Unavailability of assured mental wellbeing support for young people waiting for gender services View source Long waits for access to gender services View source Failure to refer young people awaiting gender services for specialist psychiatric support from CAMHS View source Delays in access to specialist gender dysphoria treatment while on the GIDS waiting list View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jason PULMAN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jason Pulman, aged 15, was found dead on 19 April 2022 and the inquest concluded that he died by suicide, by hanging. Evidence indicated that he had not received specialist gender dysphoria treatment while waiting for GIDS and was awaiting further CAMHS assessment. The principal concern was that unclear referral mechanisms and inadequate resources for mental health support during waits for gender services could lead to similar circumstances recurring.
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 clarity about national gender-service referral mechanisms and available resources
Wider context from the report “5. I am concerned that if urgent clarity is not provided to CAMHS teams, patients and parents on the appropriate national referral mechanisms for gender services, and the resources available for those services , there is a risk that the circumstances arising prior to Jason’s death could be repeated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 CAMHS resources causing long waits for treatment
Wider context from the report “4. During the inquest, I heard evidence from senior management at the CAMHS run by Sussex Partnership Foundation Trust to the effect that (i) they were unaware that enhanced support was being offered via CAMHS and (ii) due to existing pressures on resources the enhanced support would likely have an impact on the already very long wait times for CAMHS treatment , which in turn would give rise to a risk of patients taking their own lives while waiting for treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Insufficient specialist workforce capacity within CAMHS and paediatrics for gender identity services
Wider context from the report “2. On 10 April 2024, i.e. during the course of the inquest, ████████ published her report on the independent review of gender identity services for children and young people (the Cass review). Her recommendations included that: “a smaller number of secondary services within CAMHS and paediatrics should be identified initially to act as Designated Local Specialist Services (DLSS) within each area. This would increase the available workforce through a flexible, multi-site staff group working between the DLSS and the regional centre, with the opportunity to provide targeted training and upskilling.”
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 CAMHS teams to be aware of enhanced support offered to gender-service patients
Wider context from the report “4. During the inquest, I heard evidence from senior management at the CAMHS run by Sussex Partnership Foundation Trust to the effect that (i) they were unaware that enhanced support was being offered via CAMHS and (ii) due to existing pressures on resources the enhanced support would likely have an impact on the already very long wait times for CAMHS treatment, which in turn would give rise to a risk of patients taking their own lives while waiting for treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Unavailability of assured mental wellbeing support for young people waiting for gender services
Wider context from the report “3. The Arden and GEM has provided an update on its website entitled the “National Referral support Service for the NHS Gender Incongruence Service for Children and Young People”. This states: “The NHS understands it isn’t easy having to wait a long time to be seen by gender services, and young people may need some extra support with their mental wellbeing while they wait . The NHS is offering this support, if needed, through local Children and Young People Mental Health services (CYPMH), also known as Children and Adolescent Mental Health Services (CAMHS). People will be contacted to ask if they are happy for their details to be shared with their local CYPMH / CAMH service so they can speak to a professional about how they are feeling. This support offer is voluntary and the people’s place on the Children and Young People’s Gender Services waiting list will not change. This service will be contacting parents, children and young people on the waiting list by email or post to ask if they wish to access this support between April and May 2024.”
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Long waits for access to gender services
Wider context from the report “3. The Arden and GEM has provided an update on its website entitled the “National Referral support Service for the NHS Gender Incongruence Service for Children and Young People”. This states: “The NHS understands it isn’t easy having to wait a long time to be seen by gender services , and young people may need some extra support with their mental wellbeing while they wait. The NHS is offering this support, if needed, through local Children and Young People Mental Health services (CYPMH), also known as Children and Adolescent Mental Health Services (CAMHS). People will be contacted to ask if they are happy for their details to be shared with their local CYPMH / CAMH service so they can speak to a professional about how they are feeling. This support offer is voluntary and the people’s place on the Children and Young People’s Gender Services waiting list will not change. This service will be contacting parents, children and young people on the waiting list by email or post to ask if they wish to access this support between April and May 2024.”
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to refer young people awaiting gender services for specialist psychiatric support from CAMHS
Wider context from the report “1. I heard evidence at the inquest that Jason did not receive specialist gender dysphoria treatment because he was on the waiting list for the Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Trust. There was also evidence that clinicians did not refer Jason for specialist psychiatric support from Child and Adolescent Mental Health Services (CAMHS) in part because the guidance at the time suggested any specialist gender dysphoria treatment should be provided by GIDS . Jason was awaiting a further assessment from CAMHS at the time of his 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 Delays in access to specialist gender dysphoria treatment while on the GIDS waiting list
Wider context from the report “1. I heard evidence at the inquest that Jason did not receive specialist gender dysphoria treatment because he was on the waiting list for the Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Trust . There was also evidence that clinicians did not refer Jason for specialist psychiatric support from Child and Adolescent Mental Health Services (CAMHS) in part because the guidance at the time suggested any specialist gender dysphoria treatment should be provided by GIDS. Jason was awaiting a further assessment from CAMHS at the time of his death.
” 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 Establish new regional Children and Young People’s Gender Incongruence Services under an interim service specification.
Verbatim wording from the response “Children and Young People’s Gender Incongruence Services” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide additional funding to local mental-health systems to support waiting-list assessments and care.
Verbatim wording from the response “• From April 2024 we have established a process whereby all children and young people who are on the waiting list for CYP gender services are contacted by the NHS and offered an assessment by local NHS mental health services; NHS England has put additional funding into local mental health systems for this purpose. All children and young people who are identified with mental health needs will receive ongoing support by local services while they remain on the waiting list for CYP gender services.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Decide whether to strengthen pre-referral relationships between gender services and local secondary-care services after public consultation.
Verbatim wording from the response “• During the same public consultation, we proposed an enhanced relationship between the Children and Young People’s Gender Service and local secondary care services at the pre-referral stage, so that there is a coordinated approach across the health system in the care of vulnerable children and young people,” 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 Decide whether to require all Children and Young People’s Gender Service referrals to come through NHS secondary care after public consultation.
Verbatim wording from the response “• Additionally, in order to ensure that a child / young person’s mental and physical health needs are addressed at the point of referral to the CYP gender service NHS England has proposed that in the future all referrals to the Children and Young People’s Gender Service must be made through NHS secondary care services – mental health services or general paediatric services. This new arrangement will ensure that concomitant health needs are addressed by secondary care clinicians while the child or young person is waiting to be assessed by the specialist CYP gender service. NHS England will make a final decision on this proposal in June 2024 following a public consultation on the proposal.” 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 Contact all children and young people on the waiting list and offer local NHS mental-health assessment, with ongoing support for identified needs.
Verbatim wording from the response “• From April 2024 we have established a process whereby all children and young people who are on the waiting list for CYP gender services are contacted by the NHS and offered an assessment by local NHS mental health services; NHS England has put additional funding into local mental health systems for this purpose. All children and young people who are identified with mental health needs will receive ongoing support by local services while they remain on the waiting list for CYP gender services.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a substantive service specification strengthening infrastructure and regional links between specialist centres and local services.
Verbatim wording from the response “The two new services that are operational work to an interim service specification pending the outcome of work to build a new substantive service specification in 2024/25, for adoption in April 2025, through a process of stakeholder engagement and public consultation, to reflect the final recommendations of the Cass Report.” 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 Disseminate the waiting-list support initiative to mental-health providers, Integrated Care Boards and relevant services through notifications, webinars and regional meetings.
Verbatim wording from the response “We confirm that formal notification of the initiative has been provided to all NHS mental health providers in England and a number of webinars were held between senior clinicians at NHS England and executive and operational leads of the various mental health providers in March 2024. Colleagues in the NHS England South East Regional Team have confirmed subsequent communications have been shared with all Integrated Care Boards and relevant providers and will continue to be shared for the purpose of supporting mental health providers in their readiness to receive these patients. A series of regional meetings have also been convened to further cascade this information and support implementation.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England strongly refutes the suggestion that assessing gender-service waiting-list patients will pose a risk to other patients.
Verbatim wording from the response “NHS England will be contacting senior Trust representatives directly to understand the concerns further, including the suggestion that this initiative will pose a risk to other patients, which we strongly refute. NHS England has put additional funding into local mental health systems for the purpose of seeing children and young people on the waiting list for CYP gender services, and this initiative was established and overseen under the leadership of two senior clinicians: the NHS National Mental Health Director (Claire Murdoch), and the NHS Medical Director for Specialised Services (Professor James Palmer). The initiative was welcomed by the CEOs of the NHS mental health trusts when the proposal was put to them by the NHS National Mental Health Director in January 2024.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS Arden and Greater East Midlands Commissioning Support Unit will respond separately to concerns within its commissioned waiting-list management role.
Verbatim wording from the response “Your Report raises five matters of concern. Some of these are better addressed by Sussex Partnership NHS Foundation Trust who we note that you have sent your Report to as an interested party. We are also in the process of seeking further information from the Trust. You have also sent your report to NHS Arden and Greater East Midlands Commissioning Support Unit (the CSU) who will respond separately to you, but there is a common position described in the responses made by NHS England and the CSU given that the CSU is commissioned to manage the national waiting list for Children and Young People’s Gender Services on behalf of NHS England.” 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 Expanding clinical capacity is constrained by shortages of suitable workforce potential in children’s and adult gender services, rather than funding.
Verbatim wording from the response “The main constraint in building a new clinical workforce is not funding, it is the shortage of workforce potential for both children’s and adult gender services. NHS England’s overall planned spend on all gender dysphoria services (adults and children) in 2023/24 was £78.17m – up from £33.4m in 2018/19, representing an overall increase in funding of 134% in five years. NHS England’s planning assumption is that the new providers of CYP gender services will begin to draw patients from the waiting list from November 2024, with the priority focus between April and October 2024 being the ongoing care of patients transferred from the Tavistock GIDS.” Source location Response from NHS England
Open published response
Concerns raised 2 Delays in offloading ambulance patients at hospitals View source Failure to provide ambulance responses within the required 40 minutes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sophie HINDMARSH · 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
Sophie HINDMARSH had complex needs and required full-time care. After her father called 999 because she was vomiting brown liquid, felt hot to the touch and had a leaking feeding tube, the ambulance arrived 4 hours and 46 minutes after the call; concerns centred on delays in ambulance response and hospital handovers that reduced available ambulance resources.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in offloading ambulance patients at hospitals
Wider context from the report “The ambulance service was called at 0245 on 21 July 2022 and the call was coded as a Category 2 at 0251 call requiring a response within 40 minutes. The ambulance finally arrived at 0731 on 21 July 2022, 4 hours and 46 minutes after the call.
There was a significant delay in offloading patients at hospitals which tied up ambulance resource on that day and meant they were unable to respond to emergency calls .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 ambulance responses within the required 40 minutes
Wider context from the report “The ambulance service was called at 0245 on 21 July 2022 and the call was coded as a Category 2 at 0251 call requiring a response within 40 minutes . The ambulance finally arrived at 0731 on 21 July 2022, 4 hours and 46 minutes after the call .
There was a significant delay in offloading patients at hospitals which tied up ambulance resource on that day and meant they were unable to respond to emergency calls.
” 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 the Delivery plan for recovering urgent and emergency care services to improve ambulance and urgent-care performance.
Verbatim wording from the response “NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic, as well as issues associated with handing over ambulance patients in a timely way at some NHS Trusts. NHS England prioritised improving ambulance performance during 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, published in January 2023.” Source location Response from NHS England
Open published response
26 Apr 2024 Ellen Mercer · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 2 Failure of policy to clearly define a 24-hour VTE risk assessment period that accounts for emergency department waits View source Failure of current policies to require VTE risk assessment for emergency department patients during prolonged waits 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
Ellen Mercer · 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
Ellen Mercer attended Wexham Park Hospital by ambulance in the early hours of 9 February 2023 after deterioration associated with her mental health, nitrous oxide use, leg injuries and reduced mobility. She died in the emergency department approximately 24 hours after arriving; a post-mortem examination identified bilateral pulmonary artery thromboembolus and deep vein thrombosis. The substantive concerns relate to the absence of a formal VTE risk assessment and uncertainty in hospital policies about when the 24-hour period for such an assessment begins, particularly for patients waiting in emergency departments.
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 policy to clearly define a 24-hour VTE risk assessment period that accounts for emergency department waits
Wider context from the report “1. Patients are unfortunately waiting increasingly longer times in emergency departments – not just in waiting areas, but also after being seen by clinical staff and waiting for admission to a ward or discharge from the hospital. During this time, current policies do not require VTE risk assessment.
2. The policy for this trust suggests that the 24 hour period (during which VTE risk assessment must take place) starts only when a patient is “admitted” to hospital, i.e. when a decision is taken to admit them to a ward – which could be many hours after they have originally attended the emergency department.
3. The policy as currently drafted implies that VTE risk assessment is essentially not relevant for emergency department patients.
4. If current policies require VTE risk assessment to take place within 24 hours, the point at which that 24 hour period starts is not sufficiently clear and does not take long waits in emergency departments into account. I am concerned that policies may need to reflect the current reality on the ground.
5. I suspect that this issue may be a national one.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 current policies to require VTE risk assessment for emergency department patients during prolonged waits
Wider context from the report “1. Patients are unfortunately waiting increasingly longer times in emergency departments – not just in waiting areas, but also after being seen by clinical staff and waiting for admission to a ward or discharge from the hospital. During this time, current policies do not require VTE risk assessment.
2. The policy for this trust suggests that the 24 hour period (during which VTE risk assessment must take place) starts only when a patient is “admitted” to hospital, i.e. when a decision is taken to admit them to a ward – which could be many hours after they have originally attended the emergency department.
3. The policy as currently drafted implies that VTE risk assessment is essentially not relevant for emergency department patients.
4. If current policies require VTE risk assessment to take place within 24 hours, the point at which that 24 hour period starts is not sufficiently clear and does not take long waits in emergency departments into account. I am concerned that policies may need to reflect the current reality on the ground.
5. I suspect that this issue may be a national one.
” 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 Ask NICE to update VTE guidance so assessments occur within 14 hours of a decision to admit.
Verbatim wording from the response “However, to further clarify this issue and acknowledging that there is an ongoing heightened demand in EDs leading to significant waits, NHS England’s national Patient Safety Team have been in touch with NICE to suggest that their guidance is updated to reflect that VTE assessments should be undertaken within 14 hours of a ‘decision to admit’, as opposed to admission. NICE have advised that they will be addressing the issue with their Prioritisation Board.” 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 NICE, rather than NHS England, is responsible for changing national VTE guidance on when assessments should occur.
Verbatim wording from the response “The National Institute for Health and Care Excellence (NICE), who I note you have also addressed your Report to, are responsible for the relevant clinical guidelines [NG89] for VTE risk assessment.” 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 VTE risk assessment remains the admitting specialty team’s responsibility, including when patients remain in the emergency department.
Verbatim wording from the response “We do not think it is likely to be effective to require ED staff, who are already experiencing issues with their capacity, to undertake a specific risk assessment for VTE. This is supported by the Royal College of Emergency Medicine (RCEM), who we note in their response to you, have stated that ‘it is not the role of emergency medicine doctors to be undertaking risk assessments that specifically relate to the hospital admission process’ and that this is the ‘role of the admitting specialty doctors, even when a patient is still in the ED’. The RCEM has issued clinical guidance on the clinical responsibility for patients who are located in the ED but who have been seen and are under the clinical care of another team. The guidance states that ‘Once a patient in the ED is seen by a specialty team, then the patient becomes the responsibility of the speciality team’.” Source location Response from NHS England
Open published response
23 Apr 2024 Ronald Henry SPENCER · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure to maintain sufficient staffing for timely patient medical care View source Inadequate cohesive planning for short-term staffing pressures and longer-term solutions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ronald Henry 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
Ronald Henry Spencer had an oesophageal stent placed on 13 November 2023, which migrated into the small bowel and caused a suspected bowel perforation. He underwent surgery to remove the stent and repair the bowel, initially recovered, then deteriorated and died on 2 December 2023. The report raised concerns about significant staffing issues and resulting delays in treatment, as well as inadequate cohesive planning for short- and long-term staffing pressures; it stated there was no direct evidence that the delays caused or contributed to his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain sufficient staffing for timely patient medical care
Wider context from the report “1. I heard evidence that there were significant staffing issues during the Ronald's period of in-patient care that caused delays to his treatment . Whilst there was no direct evidence at the inquest that these delays caused or contributed to death, any delays in patients receiving medical care due to a lack of staff clearly presents a risk of future deaths occurring.
2. It is recognised that the reasons for delay can be multifactorial, with so called "winter pressures" causing an influx of ill patients and heightened staff absences. "Winter pressures" are now a regular annual event and put significant strain on the NHS. There can be no doubt that patients have died, and will continue to die, from avoidable deaths due to delays caused by these staffing inadequacies .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 cohesive planning for short-term staffing pressures and longer-term solutions
Wider context from the report “5. I remain significantly concerned not only that delays are continuing and that deaths will continue to occur into the future, but also that there is inadequate cohesive forward thinking or planning either in relation short term pressures (eg. "winter pressures") or with a view to finding longer term solutions .
” 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 Issue national winter-planning guidance to Integrated Care Boards and NHS trusts.
Verbatim wording from the response “NHS England continues to plan for and provide support to systems ahead of winter pressures. Further information and links to historic plans and letters to our systems can be found on our winter resilience website pages. For the most recent winter period (2023/24), we sent out a letter to our Integrated Care Boards and Trusts, setting out our national approach to winter planning and our four areas of focus:” 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 Plan for and provide system support ahead of winter pressures through operational, surge, cross-system and workforce preparedness measures.
Verbatim wording from the response “NHS England continues to plan for and provide support to systems ahead of winter pressures. Further information and links to historic plans and letters to our systems can be found on our winter resilience website pages. For the most recent winter period (2023/24), we sent out a letter to our Integrated Care Boards and Trusts, setting out our national approach to winter planning and our four areas of focus:” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the Long-Term Workforce Plan, expanding domestic education, training and recruitment while improving staff culture, leadership and wellbeing.
Verbatim wording from the response “NHS England is working at a national level to deliver the Long-Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years. These actions will aim to close anticipated staffing shortfalls in the NHS in the long term.” 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 Local staffing and workforce arrangements are the responsibility of NHS Birmingham and Solihull ICB and University Hospitals Birmingham NHS Foundation Trust.
Verbatim wording from the response “Trusts do have a responsibility to ensure safe staffing levels in the current day to day operation of their hospitals. This is in line with the Care Quality Commission (CQC) Regulation 18 which states that providers must deploy enough suitably qualified, competent and experienced staff to enable them to meet all other regulatory requirements.” Source location Response from NHS England
Open published response
19 Apr 2024 Dr Richard George Hardman · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of a mechanism for multidisciplinary medical coordination under a single practitioner View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Dr Richard George Hardman · 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
Dr Richard George Hardman had complex swallowing and respiratory problems associated with prior radiotherapy and Parkinson’s disease. He was admitted to hospital on 7 August 2023 with aspiration pneumonia, and the inquest concluded that he died from aspiration pneumonia arising from natural disease and recognised effects of necessary medical treatment. The principal concern was the absence of a mechanism for coordinating care across different medical disciplines and hospital sites under the leadership of a single practitioner.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism for multidisciplinary medical coordination under a single practitioner
Wider context from the report “The absence of any obvious mechanism for the various medical disciplines across different hospital sites to be brought together in complex medical cases under the leadership of a single practitioner in a position to evaluate and co-ordinate the best approach and combination of medical care for the patient.
” 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 Processes for managing complex patients across Greater Manchester specialties are better addressed by the Greater Manchester Integrated Care Board.
Verbatim wording from the response “We note that you have also addressed your Report to the Greater Manchester Integrated Care Board (GM ICB) and they are better placed to address your concern regarding processes across the Greater Manchester system for management of patients with complex medical needs, under the care of different specialties. NHS England has however engaged with GM ICB on the concerns raised.” Source location Response from NHS England and GMIC
Open published response
18 Apr 2024 ALEXANDER LEE REID · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1 Failure of general practice IT systems to validate or challenge potential data input errors at the point of entry 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
ALEXANDER LEE REID · 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
Alexander Lee Reid received the Oxford AstraZeneca Covid-19 vaccine after being invited early because an erroneous BMI in his GP records led him to be identified as vulnerable. He died on 29 June 2021, and the inquest concluded that his death was linked to the vaccination, with the medical cause recorded as cerebral venous sinus thrombosis and Covid-19 vaccine-induced immune thrombotic thrombocytopenia. The principal concern was whether general practice IT systems should validate or challenge potentially erroneous data at the point of entry to improve data reliability and patient safety.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure of general practice IT systems to validate or challenge potential data input errors at the point of entry
Wider context from the report “(2) The inquest heard expert evidence that the combined vaccination monitoring and recall specification designed to identify vulnerable people for the purposes of inviting them to receive their Covid vaccinations early had identified Alex as vulnerable from an incorrect BMI of 68.97 recorded in his GP records on 06/02/2004. The mistake was due to the relevant clinician recording Alex's height as 145cm and his weight as 145kg, giving a BMI of 68.97 for an 11 year old boy whose previously recorded BMI aged 9 had been 14.88.
(3) The inquest heard expert evidence that to have built a system that would validate multiple data items in an individual's GP records for the purposes of ensuring that individuals were not incorrectly identified as vulnerable would not have been feasible within the constraints and context of the Covid-19 programme.
(4) The inquest heard expert evidence that an easier and more appropriate option would be to embed validation rules in general practice IT systems that would check such information at the time of data entry .
(5) If the obviously erroneous BMI had not been recorded or had been challenged at the point of entry by the relevant IT system, Alex would not have been classed as vulnerable, would not have been offered a vaccine before guidance was published that the under 30’s should not receive the Oxford Astra Zeneca vaccine, and would not have died when he did.
(6) The consequences of the data input error in this case give rise to a concern that more might be done by way of specification design to allow for the correction of or challenge to potential data input errors at the point of entry , with consequential improvements in the reliability of such data and the safety of patients and reducing the risk of other deaths occurring in similar circumstances in the future.
” 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 Cross-domain validation of automatically calculated BMI is not currently implementable, and implementation would present substantial challenges and further clinical risks requiring balanced assessment.
Verbatim wording from the response “Where there is an automated calculation using other data items (such as is the case for BMI), there is no currently implementable means to apply validation – or define normal – across domains. It should also be noted that the ranges of values that may be possible (or probable) for height, weight and BMI vary by age, gender, and may vary by ethnicity.” 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 GP IT systems are centrally assured against the GP IT Futures Framework and statutory clinical safety standards require consideration of data-entry and transmission hazards.
Verbatim wording from the response “Core GP IT records systems are developed - and centrally assured - against standards set out in the GP IT Futures Framework. More information about this can be found here.” Source location Response from NHS England
Open published response
17 Apr 2024 Thomas Geoffrey WAKEFIELD · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1 Failure of diagnostic guidance to require consideration and exclusion of abdominal aortic aneurysm when diagnosing acute pancreatitis View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Thomas Geoffrey WAKEFIELD · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Thomas Wakefield, aged 79, was admitted to hospital on 22 September 2023 after severe stomach pain and sudden collapse at home, and was found deceased in bed the following day. The report identifies concern that abdominal aortic aneurysm and acute pancreatitis can present similarly and may be misidentified, and that guidance did not specifically require exclusion of abdominal aortic aneurysm when pancreatitis was suspected.
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 diagnostic guidance to require consideration and exclusion of abdominal aortic aneurysm when diagnosing acute pancreatitis
Wider context from the report “During a review of the NICE guidelines entitled “Abdominal Aortic Aneurysm: diagnosis and management”, and the international guidance, it became apparent that there is a lack of caution within the guidance about the recognised risk that abdominal aortic aneurysm and acute pancreatitis are known to be diagnosed misidentified by clinicians . These conditions can have similar presenting features.
Whilst the guidance states that if there is uncertainty about a diagnosis of pancreatitis as not all criteria are met, imaging tests should be undertaken, this does not specifically require the exclusion of abdominal aortic aneurysm which is fatal if untreated . The clinical presentation alongside amylase results in this case met the criteria for a diagnosis of pancreatitis.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the coroner’s concerns about clinical guidance for abdominal aortic aneurysm and acute pancreatitis.
Verbatim wording from the response “Your Report raises the concern that existing clinical guidance does not provide the adequate caution about the recognised risk or diagnoses for abdominal aortic aneurysm (AAA) and acute pancreatitis.” 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 Concerns about relevant clinical guidelines should be referred to the organisations responsible for producing them.
Verbatim wording from the response “The responsibility for the relevant clinical guidelines does not fall within the remit of NHS England, who are independent of the National Institute for Health and Care Excellence (NICE) and the Royal Colleges. NHS England would therefore suggest that the coroner refer their concerns to the responsible organisations.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for relevant clinical guidelines falls outside NHS England’s remit and authority.
Verbatim wording from the response “The responsibility for the relevant clinical guidelines does not fall within the remit of NHS England, who are independent of the National Institute for Health and Care Excellence (NICE) and the Royal Colleges. NHS England would therefore suggest that the coroner refer their concerns to the responsible organisations.” Source location Response from NHS England
Open published response
17 Apr 2024 Margaret Avril Burman · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 2 Lack of appropriate community care causing medically fit patients to remain on hospital wards View source Insufficient staffing and resources for falls mitigation on hospital wards View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Margaret Avril Burman · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Margaret Avril Burman, who preferred to be known as Avril, died on 13 July 2021 after an unwitnessed fall at Salisbury District Hospital caused a head injury and intracranial bleed. The report raises concerns that falls risk assessments and enhanced care arrangements were inadequate, and that staffing shortages meant no Healthcare Assistant was available to monitor the ward bay. It also identifies a broader concern that elderly hospital patients remain at significant risk of traumatic and fatal falls because appropriate falls mitigation measures are unavailable.
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 appropriate community care causing medically fit patients to remain on hospital wards
Wider context from the report “As I have previously indicated in a Regulation 28 Report submitted to you (Raymond Eggleton dated 17th November 2023 which remains unanswered by you) (Department of Health) falls in the hospital environment do not happen, however, as of the view in Avril’s case that had there been an appropriate Healthcare Assistant present then Avril’s fall and death more likely than not would have been avoided.
During the course of the Inquest, I heard evidence from the Hospital’s Falls Specialist, ████████ who indicated that whilst staffing issues have improved there remains a difficulty ensuring appropriate staffing especially when responding to the ever-changing needs on wards where they are occupied by people at risk of falls. She explained to me that in relation to 2 wards in particular, one of which included Spire Ward which is a general geriatric surgical ward and the other which is a trauma and orthopaedic ward, both of which can take approximately 30 patients, that having conducted her own analysis it is transpired that of those admitted onto both those wards that approximately 80% either had a history of falls or the reason for their admission related to a fall. Of those at risk of a fall where the enhanced care toolkit had been deployed, she told me that 70% of those at falls risk required and warranted 1 to 1 support. Generally, these wards have a nursing ratio of between 1 to 8 patients or sometimes 1 to 6 patients with appropriate Healthcare Assistant support. As you can see in relation to a ward of 30 patients, a situation starts to present itself where the majority of personnel on the ward are not providing nursing support but are providing 1 to 1 falls mitigation support, and there simply are not the resources available to provide such cover. As a consequence, where there is an identifiable falls risk, the situation arises and continues at the moment where those patients are not being appropriately safeguarded against the risk of falls on wards. Especially where patients have conditions such as Dementia and Alzheimer’s it can sometimes be the case that it only takes a relatively minor collapse to cause a significant head trauma that leads to death.
The position is further compounded by the fact that I was told the hospital is confronted with the additional problem that it can have up to 70% of those patients on these 2 wards being in a condition where they are medically stabilised and fit to be discharged but due to lack of appropriate care in the community they are remaining on the wards . The longer they remain on the wards the greater the risk of falls especially if they are medically stabilised when in such circumstances, they are more likely to be mobile.
I asked ████████ as to how she thought that improvements could be made and she indicated to me in her evidence that she was of the view that there should be national leadership and a standardised toolkit when assessing falls risks on hospital wards and that there should also be a greater degree of sharing of learning where methods of good practice have been adopted by other Trusts that could easily be adopted by Trusts where this is a challenge.
As I indicated in Mr Eggleton’s Regulation 28 Report, the problem here is multifactorial but as it remains at the moment, I am concerned that the elderly on hospital wards are at significant risk of sustaining a traumatic and fatal injury by having a fall on a ward due to the unavailability of appropriate and necessary falls mitigation measures.
The resolution of this problem is not about the amount of money or the increase in money that is injected into the National Health Service and my concern is that a more strategic approach is required. More money may well indeed be injected into the National Health Service but with inflation as it has been and with wage rises that have taken place in real terms the increase maybe small and the reality is that in real terms it may amount to a reduction in what can be purchased with that money.
The commitment to provide 5000 extra “core” beds to deal with increasing demand is only going to add to the concern unless this issue is addressed.
As I have stated in my last Regulation 28 Report dealing with this issue, the problem is multifactorial, but it is a solution in respect of which the government undoubtedly has a crucial and essential role to play.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 and resources for falls mitigation on hospital wards
Wider context from the report “As I have previously indicated in a Regulation 28 Report submitted to you (Raymond Eggleton dated 17th November 2023 which remains unanswered by you) (Department of Health) falls in the hospital environment do not happen, however, as of the view in Avril’s case that had there been an appropriate Healthcare Assistant present then Avril’s fall and death more likely than not would have been avoided.
During the course of the Inquest, I heard evidence from the Hospital’s Falls Specialist, ████████ who indicated that whilst staffing issues have improved there remains a difficulty ensuring appropriate staffing especially when responding to the ever-changing needs on wards where they are occupied by people at risk of falls . She explained to me that in relation to 2 wards in particular, one of which included Spire Ward which is a general geriatric surgical ward and the other which is a trauma and orthopaedic ward, both of which can take approximately 30 patients, that having conducted her own analysis it is transpired that of those admitted onto both those wards that approximately 80% either had a history of falls or the reason for their admission related to a fall. Of those at risk of a fall where the enhanced care toolkit had been deployed, she told me that 70% of those at falls risk required and warranted 1 to 1 support. Generally, these wards have a nursing ratio of between 1 to 8 patients or sometimes 1 to 6 patients with appropriate Healthcare Assistant support. As you can see in relation to a ward of 30 patients, a situation starts to present itself where the majority of personnel on the ward are not providing nursing support but are providing 1 to 1 falls mitigation support, and there simply are not the resources available to provide such cover . As a consequence, where there is an identifiable falls risk, the situation arises and continues at the moment where those patients are not being appropriately safeguarded against the risk of falls on wards . Especially where patients have conditions such as Dementia and Alzheimer’s it can sometimes be the case that it only takes a relatively minor collapse to cause a significant head trauma that leads to death.
The position is further compounded by the fact that I was told the hospital is confronted with the additional problem that it can have up to 70% of those patients on these 2 wards being in a condition where they are medically stabilised and fit to be discharged but due to lack of appropriate care in the community they are remaining on the wards. The longer they remain on the wards the greater the risk of falls especially if they are medically stabilised when in such circumstances, they are more likely to be mobile.
I asked ████████ as to how she thought that improvements could be made and she indicated to me in her evidence that she was of the view that there should be national leadership and a standardised toolkit when assessing falls risks on hospital wards and that there should also be a greater degree of sharing of learning where methods of good practice have been adopted by other Trusts that could easily be adopted by Trusts where this is a challenge.
As I indicated in Mr Eggleton’s Regulation 28 Report, the problem here is multifactorial but as it remains at the moment, I am concerned that the elderly on hospital wards are at significant risk of sustaining a traumatic and fatal injury by having a fall on a ward due to the unavailability of appropriate and necessary falls mitigation measures .
The resolution of this problem is not about the amount of money or the increase in money that is injected into the National Health Service and my concern is that a more strategic approach is required. More money may well indeed be injected into the National Health Service but with inflation as it has been and with wage rises that have taken place in real terms the increase maybe small and the reality is that in real terms it may amount to a reduction in what can be purchased with that money.
The commitment to provide 5000 extra “core” beds to deal with increasing demand is only going to add to the concern unless this issue is addressed.
As I have stated in my last Regulation 28 Report dealing with this issue, the problem is multifactorial, but it is a solution in respect of which the government undoubtedly has a crucial and essential role to play.
” 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 the NHS Long Term Workforce Plan to increase, train, retain and reform the NHS workforce.
Verbatim wording from the response “Regarding staffing levels, the headcount for registered nurses and support staff has increased over the last decade,² however difficulties do remain in ensuring appropriate levels of staffing, especially to cover wards where patients are at risk of falls. Local nurse leaders are responsible for calculating safe levels of staffing using the Safer Nursing Care Tool - Sheffield Group and Boards for NHS Trusts have been required to report on their staffing levels to NHS England on a six-monthly basis since 2014.” 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 Improve discharge processes and capacity modelling to support appropriate commissioned community care capacity.
Verbatim wording from the response “Your Report also raises a concern around patients medically fit for discharge are remaining in hospital due to a lack of appropriate community care being available. This remains a challenge for the NHS and social care services across England. As a key part of NHS England’s Urgent & Emergency Care recovery, NHS England together with colleagues across the DHSC and the Department for Levelling up, Housing and Communities (DLUHC) are focussed on improving discharge processes and capacity modelling to ensure the right number of commissioned beds/non-bedded care.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake programmes improving admissions avoidance and discharge flow to reduce patients remaining in acute medical beds without criteria to reside.
Verbatim wording from the response “A range of programmes aimed at improving both admissions avoidance and discharge flow is being undertaken to support the reduction in the number of patients in acute medical beds with no criteria to reside. This work is a key priority for the NHS and is being driven through the published NHS Operational Planning Guidance and the Better Care Fund planning process and has associated improvement support available to regions and 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 Develop and provide national falls-risk guidance and implementation toolkits for hospital patients at risk of falls.
Verbatim wording from the response “Your Report raises concerns over appropriate staffing falls mitigation measures on wards occupied by people at risk of falls, in particular patients with dementia or Alzheimer’s Disease, and that there should be ‘national leadership and a standardised toolkit when assessing falls risk on hospital wards’ and that there should also be a greater degree of sharing of learning.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing national falls guidance and implementation toolkits are considered sufficient to support appropriate falls-risk assessment and interventions.
Verbatim wording from the response “National leadership has already developed national guidance based on evidence-based practice which include falls risk assessment and toolkits to support implementation of appropriate interventions. At the time of Margaret’s admission to hospital in 2021, there was existing guidance available to support best practice around patients at risk of falls.” 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 nurse leaders are responsible for calculating safe staffing levels, with NHS Trust boards reporting staffing levels to NHS England.
Verbatim wording from the response “Regarding staffing levels, the headcount for registered nurses and support staff has increased over the last decade,² however difficulties do remain in ensuring appropriate levels of staffing, especially to cover wards where patients are at risk of falls. Local nurse leaders are responsible for calculating safe levels of staffing using the Safer Nursing Care Tool - Sheffield Group and Boards for NHS Trusts have been required to report on their staffing levels to NHS England on a six-monthly basis since 2014.” Source location Response from NHS England
Open published response
Concerns raised 5 Failure to ensure a care plan is in place before discharge View source Rushed and uninformed decision making View source Failure to provide requisite information before relying on decision-making capacity View source Failure to ensure an adequately assessed discharge planning policy View source Failure to protect properly considered discharge planning from bed-space pressure View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mr Timothy Charles Clayton · 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 Timothy Charles Clayton had alcohol-related brain damage, malnutrition, reduced mobility and fluctuating confusion, and was discharged to live alone despite concerns about his ability to care for himself. His flat was inadequately heated, and he was found profoundly hypothermic after self-neglecting; he died at Epsom General Hospital on 12 December 2022. The principal concerns were inadequate discharge planning, insufficient information sharing and investigation, failure to involve or heed his family, an erroneous reliance on his capacity, and pressure to vacate hospital beds.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure a care plan is in place before discharge
Wider context from the report “2. There was a misunderstanding by a clinician in relation to whether capacity to make a decision can be relied on to justify actions taken when the requisite information which needed to be considered by Mr Clayton in relation to that decision and its consequences had not been provided to him. Mr Clayton’s expressed wish to go home alone, without any care plan in place, was relied on, erroneously, to justify an unsafe discharge on the basis that he had capacity.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Rushed and uninformed decision making
Wider context from the report “3. The pressure to vacate bed spaces impacted on clinicians’ ability to prepare a properly considered discharge plan and led to rushed uninformed decision making .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 requisite information before relying on decision-making capacity
Wider context from the report “2. There was a misunderstanding by a clinician in relation to whether capacity to make a decision can be relied on to justify actions taken when the requisite information which needed to be considered by Mr Clayton in relation to that decision and its consequences had not been provided to him . Mr Clayton’s expressed wish to go home alone, without any care plan in place, was relied on, erroneously, to justify an unsafe discharge on the basis that he had capacity.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure an adequately assessed discharge planning policy
Wider context from the report “1. The policy in relation to discharge planning remains under review , including how families are to be involved, so it has not been possible to assess the adequacy of the new policy .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to protect properly considered discharge planning from bed-space pressure
Wider context from the report “3. The pressure to vacate bed spaces impacted on clinicians’ ability to prepare a properly considered discharge plan and led to rushed uninformed decision making.
” 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 improving in-hospital discharge through early planning and early involvement of patients, carers, families and care transfer hubs.
Verbatim wording from the response “The Urgent and emergency care recovery plan year 2: Building on learning from 2023/24, published in May 2024, sets out commitment to continue to improve in-hospital discharge processes by ensuring early discharge planning, including the effective involvement of patients, carers and families, in line with statutory guidance. Acute providers are asked to continue to improve in-hospital processes to improve timeliness of discharge, including early discharge planning from the point of admission and early involvement of care transfer hubs where patients are likely to have more complex discharge needs.” 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 additional acute bed capacity, supported by capital investment, to improve hospital flow and reduce discharge pressure.
Verbatim wording from the response “The delivery plan for recovering urgent and emergency care services committed to providing the NHS with additional bed capacity to improve hospital flow and performance. The target of 5,000 additional core general and acute beds, against previously planned levels, was met and consistently exceeded in January 2024, supported by £250 million for 30 capital schemes across the country. 2024/25 operational planning guidance sets out an ask for systems to maintain their levels of acute core general and acute beds in 2024/25, and to expand their bedded and non-bedded intermediate care capacity, through the additional £400 million distributed via the Better Care Fund (BCF), to support improvements in hospital discharge and enable step-up care in the community.” 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 Establish care transfer hubs across hospitals to coordinate discharges for patients with complex needs.
Verbatim wording from the response “plan was the requirement that all Trusts work together with local authorities and system partners to establish a Care Transfer Hub to manage discharges for patients with more complex needs.” Source location Response from NHS England
Open published response
17 Apr 2024 Jade Marie GRIFFITHS-JONES · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure to meet target ambulance response times View source Delays in hospital handover compromising ambulance crew availability 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
Jade Marie GRIFFITHS-JONES · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jade Marie Griffiths-Jones died in hospital on 4 June 2023 after suffering a cardiac arrest caused by coronary artery disease and sustaining severe hypoxic brain injury. An ambulance was not available to attend her earlier chest-pain call within target times, with concerns about ambulance response delays linked to increased demand and hospital handover delays.
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 meet target ambulance response times
Wider context from the report “1. During the inquest evidence was given on behalf of West Midlands Ambulance Service from ████████, Learning Response Lead, that at the time of Jade's initial call reporting centralised chest pain at 13:33 on the 31st May 2023 the Trust was experiencing increased volume of calls and significant hospital delays and therefore could not resource the category 2 disposition within national target times (mean average of 18 minutes, 90th centile of 40 minutes). The call was still unresourced when she was reported to be in cardiac arrest during a further call at 15:01 (the 4th call). The Trust's Gold Dashboard that was captured closest to the clock start time for the first call (captured at 13:00:32) identified that there were delays in the mean and 90th percentile response times for Category 1, 2, 3 calls . There was 3 available ambulance resource within the sector at that point in time with 54 Category 2 and 43 Category 3 cases awaiting resource allocation, and 16 cases yet to be prioritised. There were regional hospital delays of up to 218 minutes.
2. For the 2 hours before Jade's call the Birmingham sector had been experiencing a 2 hour spike in demand. However, the real problem affecting resourcing was pandemic crews being stuck at hospitals awaiting handover. In 2023 to 2024 West Midlands Ambulance Service lost approximately 250,000 response hours due to delays at hospitals.
3. West Midlands Ambulance Service have taken a broad range of measures in recent years to tackle increasing response times including measures to reduce call demand through public education, to avert calls away from ambulance services and hospitals via clinical validation, to improve patient flow through intelligent conveying and to increase the number of resources in operation. Aside from seeking funding to recruit further paramedics and increase ambulance numbers alongside continued monitoring and learning there is nothing West Midlands Ambulance Service can identify that they can do to improve the situation further.
4. West Midlands Ambulance Service continue to fail to meet target response times and have been made the subject of a regulation 12 notice on this topic by the CQC.
5. The evidence of West Midlands Ambulance Service is that if hospital handover delays didn’t exist they would be likely to be meeting their response targets as they did before hospital delays became chronic.
In the circumstances it is my conclusion that the availability of ambulance crews is continuing to be compromised by delays at hospitals resulting in delays in response times which creates a risk to the life.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Delays in hospital handover compromising ambulance crew availability
Wider context from the report “1. During the inquest evidence was given on behalf of West Midlands Ambulance Service from ████████, Learning Response Lead, that at the time of Jade's initial call reporting centralised chest pain at 13:33 on the 31st May 2023 the Trust was experiencing increased volume of calls and significant hospital delays and therefore could not resource the category 2 disposition within national target times (mean average of 18 minutes, 90th centile of 40 minutes). The call was still unresourced when she was reported to be in cardiac arrest during a further call at 15:01 (the 4th call). The Trust's Gold Dashboard that was captured closest to the clock start time for the first call (captured at 13:00:32) identified that there were delays in the mean and 90th percentile response times for Category 1, 2, 3 calls. There was 3 available ambulance resource within the sector at that point in time with 54 Category 2 and 43 Category 3 cases awaiting resource allocation, and 16 cases yet to be prioritised. There were regional hospital delays of up to 218 minutes.
2. For the 2 hours before Jade's call the Birmingham sector had been experiencing a 2 hour spike in demand. However, the real problem affecting resourcing was pandemic crews being stuck at hospitals awaiting handover . In 2023 to 2024 West Midlands Ambulance Service lost approximately 250,000 response hours due to delays at hospitals .
3. West Midlands Ambulance Service have taken a broad range of measures in recent years to tackle increasing response times including measures to reduce call demand through public education, to avert calls away from ambulance services and hospitals via clinical validation, to improve patient flow through intelligent conveying and to increase the number of resources in operation. Aside from seeking funding to recruit further paramedics and increase ambulance numbers alongside continued monitoring and learning there is nothing West Midlands Ambulance Service can identify that they can do to improve the situation further.
4. West Midlands Ambulance Service continue to fail to meet target response times and have been made the subject of a regulation 12 notice on this topic by the CQC.
5. The evidence of West Midlands Ambulance Service is that if hospital handover delays didn’t exist they would be likely to be meeting their response targets as they did before hospital delays became chronic.
In the circumstances it is my conclusion that the availability of ambulance crews is continuing to be compromised by delays at hospitals resulting in delays in response times which creates a risk to the life.
” 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 Drive further efficiencies in acute patient flow, same-day care, care closer to home, and avoidance of frail and elderly patients’ avoidable attendances.
Verbatim wording from the response “Improving ambulance handover delays is the responsibility of all providers, commissioning bodies (Integrated Care Boards (ICBs)) and regulators. This year (2024/25) NHS England, through regular assurance and planning rounds, are engaging with ICBs on a weekly basis until assurance has been given that everyone is working to reduce emergency department crowding, improve acute front door services and release the ambulance service/s within their commissioned frameworks for 2024/25. In addition, throughout 2024/25 further work will be done to enhance and drive further efficiencies in acute patient flow, avoidable attendance for the frail and elderly emphasising same day care and care closer to home as a priority and this will aim to further improve the quality and standard of care across the emergency unscheduled care pathway.” 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 Engage weekly with Integrated Care Boards through assurance and planning rounds to reduce emergency department crowding, improve acute front-door services, and release ambulance capacity.
Verbatim wording from the response “Improving ambulance handover delays is the responsibility of all providers, commissioning bodies (Integrated Care Boards (ICBs)) and regulators. This year (2024/25) NHS England, through regular assurance and planning rounds, are engaging with ICBs on a weekly basis until assurance has been given that everyone is working to reduce emergency department crowding, improve acute front door services and release the ambulance service/s within their commissioned frameworks for 2024/25. In addition, throughout 2024/25 further work will be done to enhance and drive further efficiencies in acute patient flow, avoidable attendance for the frail and elderly emphasising same day care and care closer to home as a priority and this will aim to further improve the quality and standard of care across the emergency unscheduled care pathway.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for improving ambulance handover delays rests with providers, commissioning bodies and regulators.
Verbatim wording from the response “Improving ambulance handover delays is the responsibility of all providers, commissioning bodies (Integrated Care Boards (ICBs)) and regulators. This year (2024/25) NHS England, through regular assurance and planning rounds, are engaging with ICBs on a weekly basis until assurance has been given that everyone is working to reduce emergency department crowding, improve acute front door services and release the ambulance service/s within their commissioned frameworks for 2024/25. In addition, throughout 2024/25 further work will be done to enhance and drive further efficiencies in acute patient flow, avoidable attendance for the frail and elderly emphasising same day care and care closer to home as a priority and this will aim to further improve the quality and standard of care across the emergency unscheduled care pathway.” Source location Response from NHS England
Open published response
Concerns raised 2 Lack of awareness among general practice doctors of the fatal overdose risks of Propranolol View source Failure to limit quantities of Propranolol prescribed to people at risk of overdose 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
Joshua Arthur Stafford Delaney · 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 Arthur Stafford Delaney, aged 19, had a history of mental illness, suicidal ideation and previous suicide attempts. On 19 January 2020, he took a large overdose of Propranolol, was found collapsed, and died despite resuscitation attempts. The principal concern was that GPs may not be aware of the risk of fatal Propranolol overdose and may prescribe quantities to people at risk, potentially causing future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness among general practice doctors of the fatal overdose risks of Propranolol
Wider context from the report “The evidence of the General Practitioner in this case was to the effect that prior to this death, neither he nor his colleagues were aware that Propranolol carried any significant risk of death through deliberate overdose . The evidence of the doctor in question was that because of this specific incident, there has been a change in their approach to prescribing of Propranolol at his GP surgery, with smaller quantities prescribed (1 to 10 patients who might be at risk of taking an overdose. Shortly after this incident (11 February 2020) there was, coincidentally, an article in the British Medical Journal in respect of Propranolol, ("Doctors and paramedics must be better prepared to deal with propranolol overdoses"). However, the doctor’s evidence in the inquest was that he did not believe that GPs generally were currently aware of the risk of Propranolol overdoses .
The evidence from the Consultant Psychiatrist from the Community Mental Health Team was that they would not usually prescribe Propranolol, and he also considered that GPs may not be aware of the overdose risk posed by the drug .
The inquest also heard from the toxicologist, who gave evidence that her anecdotal experience was that there had in recent years been a significant number of deaths caused by Propranolol overdoses.
In the circumstances, I am concerned that doctors in General Practice may not be aware of the risks of fatal overdose from Propranolol , and that in the absence of greater awareness by GPs, the prescription of quantities of Propranolol to those at risk may cause 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 limit quantities of Propranolol prescribed to people at risk of overdose
Wider context from the report “The evidence of the General Practitioner in this case was to the effect that prior to this death, neither he nor his colleagues were aware that Propranolol carried any significant risk of death through deliberate overdose. The evidence of the doctor in question was that because of this specific incident, there has been a change in their approach to prescribing of Propranolol at his GP surgery, with smaller quantities prescribed (1 to 10 patients who might be at risk of taking an overdose. Shortly after this incident (11 February 2020) there was, coincidentally, an article in the British Medical Journal in respect of Propranolol, ("Doctors and paramedics must be better prepared to deal with propranolol overdoses"). However, the doctor’s evidence in the inquest was that he did not believe that GPs generally were currently aware of the risk of Propranolol overdoses.
The evidence from the Consultant Psychiatrist from the Community Mental Health Team was that they would not usually prescribe Propranolol, and he also considered that GPs may not be aware of the overdose risk posed by the drug.
The inquest also heard from the toxicologist, who gave evidence that her anecdotal experience was that there had in recent years been a significant number of deaths caused by Propranolol overdoses.
In the circumstances, I am concerned that doctors in General Practice may not be aware of the risks of fatal overdose from Propranolol, and that in the absence of greater awareness by GPs, the prescription of quantities of Propranolol to those at risk may cause future deaths .
” 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 NICE to strengthen cautions about the risks of propranolol use.
Verbatim wording from the response “My colleagues from NHS England’s National Patient Safety Team have been engaging with NICE to flag the circumstances of Joshua’s death and inviting them to strengthen their cautions around the use of Propranolol.” 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 Engage MHRA regarding communications about propranolol risks.
Verbatim wording from the response “Following our review of this case, it has also been agreed that NHS England will issue communications to GPs to reiterate that NICE do not recommend Propranolol as a treatment option for anxiety, and emphasising the risks involved in its administration, and we will do so as soon as practicable. NHS England are also engaging with the Medicines & Healthcare Products Regulatory Agency (MHRA), who we understand are also considering some communications on this issue. NHS England are happy to update the Coroner in due course and once communications have been issued.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue communications to GPs reiterating that NICE does not recommend propranolol for anxiety and emphasising overdose risks.
Verbatim wording from the response “Following our review of this case, it has also been agreed that NHS England will issue communications to GPs to reiterate that NICE do not recommend Propranolol as a treatment option for anxiety, and emphasising the risks involved in its administration, and we will do so as soon as practicable. NHS England are also engaging with the Medicines & Healthcare Products Regulatory Agency (MHRA), who we understand are also considering some communications on this issue. NHS England are happy to update the Coroner in due course and once communications have been issued.” Source location Response from NHS England
Open published response
2 Apr 2024 Alan Andrew SOANE · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Failure to take national action to address the Consultant Histopathologist shortage View source Failure to provide a Consultant Histopathologist at Hepato-pancreato-biliary MDT meetings View source National shortage of Consultant Histopathologists 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
Alan Andrew SOANE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alan Andrew Soane underwent a Whipple’s procedure after an incorrect diagnosis of duodenal cancer and died on 26 June 2023 from known complications of the procedure. The report raises concerns about the absence of a Consultant Histopathologist at Hepato-pancreato-biliary MDT meetings and the wider national shortage of Consultant Histopathologists, which was acknowledged as contributing to the incorrect diagnosis.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to take national action to address the Consultant Histopathologist shortage
Wider context from the report “The NHS Trust in this case was, and remains, unable to provide for the presence of a Consultant Histopathologist at Hepato-pancreato-biliary MDT meetings. It was acknowledged that this was a factor that led to Mr Soane being given a cancer diagnosis that was incorrect. This inability to provide a Consultant Histopathologist is something that has been on the Trust’s risk register for over five years and recruitment exercises have taken place, to no avail. I was told in evidence that this is attributed to the fact that nationally, 25% of Consultant Histopathologist roles remain vacant; in short, there is a national shortage of Consultant Histopathologists.
The concern here is that a national shortage of Consultant Histopathologists puts a widespread proportion of the patient population at a significant risk.
I was reassured that the individual NHS Trust had made continued efforts to reduce the risks they identified, by attempting to recruit to the vacant post. However, I was not reassured that action has been taken at a national level to address the shortage generally .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 Consultant Histopathologist at Hepato-pancreato-biliary MDT meetings
Wider context from the report “The NHS Trust in this case was, and remains, unable to provide for the presence of a Consultant Histopathologist at Hepato-pancreato-biliary MDT meetings . It was acknowledged that this was a factor that led to Mr Soane being given a cancer diagnosis that was incorrect. This inability to provide a Consultant Histopathologist is something that has been on the Trust’s risk register for over five years and recruitment exercises have taken place, to no avail. I was told in evidence that this is attributed to the fact that nationally, 25% of Consultant Histopathologist roles remain vacant; in short, there is a national shortage of Consultant Histopathologists.
The concern here is that a national shortage of Consultant Histopathologists puts a widespread proportion of the patient population at a significant risk.
I was reassured that the individual NHS Trust had made continued efforts to reduce the risks they identified, by attempting to recruit to the vacant post. However, I was not reassured that action has been taken at a national level to address the shortage generally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 shortage of Consultant Histopathologists
Wider context from the report “The NHS Trust in this case was, and remains, unable to provide for the presence of a Consultant Histopathologist at Hepato-pancreato-biliary MDT meetings. It was acknowledged that this was a factor that led to Mr Soane being given a cancer diagnosis that was incorrect. This inability to provide a Consultant Histopathologist is something that has been on the Trust’s risk register for over five years and recruitment exercises have taken place, to no avail. I was told in evidence that this is attributed to the fact that nationally, 25% of Consultant Histopathologist roles remain vacant; in short, there is a national shortage of Consultant Histopathologists .
The concern here is that a national shortage of Consultant Histopathologists puts a widespread proportion of the patient population at a significant risk .
I was reassured that the individual NHS Trust had made continued efforts to reduce the risks they identified, by attempting to recruit to the vacant post. However, I was not reassured that action has been taken at a national level to address the shortage generally.
” 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 Expand domestic education, training and recruitment to address anticipated NHS staffing shortfalls.
Verbatim wording from the response “NHS England is working at a national level to deliver the Long-Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training, and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years.” 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 Improve workforce culture, leadership and wellbeing to support staff retention in NHS employment.
Verbatim wording from the response “NHS England is working at a national level to deliver the Long-Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training, and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years.” 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 Trusts, rather than NHS England, are responsible for ensuring safe staffing levels in hospitals’ current day-to-day operations.
Verbatim wording from the response “NHS England is working at a national level to deliver the Long-Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training, and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years.” Source location Response from NHS England
Open published response
Concerns raised 7 Failure to require practitioners to pass essential epilepsy information to patients on discharge View source Lack of guidance on contacting the secondary care team after recurrent seizures View source Lack of discharge guidance on maintaining medication compliance despite prolonged seizure freedom View source Lack of required annual epilepsy reviews in general practice View source Lack of a care pathway for urgent neurology reviews in response to patient concerns View source Lack of discharge guidance on notifying clinicians about recurrent seizures View source Lack of clear guidance on longer-term epilepsy monitoring and safe discharge timing View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Andrew Ewin-Ripp · 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
Andrew Ewin-Ripp, who had epilepsy, suffered a fit at home on 1 November 2022, was found in cardiac arrest, and died in hospital on 4 November 2022. The reported cause of death was sudden unexpected death in epilepsy (SUDEP). Concerns included lengthy waits for neurology care, the absence of clear guidance and systems for monitoring, discharge information, and urgent review after seizure recurrence.
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 require practitioners to pass essential epilepsy information to patients on discharge
Wider context from the report “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern:
(1) GP practices are not required to carry out annual reviews of epilepsy patients, as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures.
(2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy. How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this.
(3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures. There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge .
(4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns, such as a return of seizures or not tolerating medication.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on contacting the secondary care team after recurrent seizures
Wider context from the report “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern:
(1) GP practices are not required to carry out annual reviews of epilepsy patients, as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures.
(2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy. How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this.
(3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures . There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge.
(4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns, such as a return of seizures or not tolerating medication.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of discharge guidance on maintaining medication compliance despite prolonged seizure freedom
Wider context from the report “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern:
(1) GP practices are not required to carry out annual reviews of epilepsy patients, as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures.
(2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy. How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this.
(3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period ; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures. There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge.
(4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns, such as a return of seizures or not tolerating medication.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of required annual epilepsy reviews in general practice
Wider context from the report “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern:
(1) GP practices are not required to carry out annual reviews of epilepsy patients , as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures.
(2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy. How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this.
(3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures. There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge.
(4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns, such as a return of seizures or not tolerating medication.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of a care pathway for urgent neurology reviews in response to patient concerns
Wider context from the report “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern:
(1) GP practices are not required to carry out annual reviews of epilepsy patients, as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures.
(2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy. How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this.
(3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures. There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge.
(4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns , such as a return of seizures or not tolerating medication.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of discharge guidance on notifying clinicians about recurrent seizures
Wider context from the report “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern:
(1) GP practices are not required to carry out annual reviews of epilepsy patients, as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures.
(2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy. How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this.
(3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures. There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge.
(4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns, such as a return of seizures or not tolerating medication.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance on longer-term epilepsy monitoring and safe discharge timing
Wider context from the report “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern:
(1) GP practices are not required to carry out annual reviews of epilepsy patients, as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures.
(2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy . How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this .
(3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures. There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge.
(4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns, such as a return of seizures or not tolerating medication.
” 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 GP practices are required to follow clinical guidelines that include annual epilepsy reviews.
Verbatim wording from the response “Your Report raised the concern that GP Practices are not required to carry out annual reviews of epilepsy patients. GP Practices required to follow and pay due regard to clinical guidelines. The National Institute for Health and Care Excellence (NICE) has issued clinical guidelines to general practice on annual reviews, including for Epilepsy.” 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 NICE is responsible for guidelines on long-term epilepsy monitoring and urgent neurology review pathways.
Verbatim wording from the response “Your Report also raises the concerns that there is no clear guidance for the long-term monitoring of patients with epilepsy and that there was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns. The National Institute for Health and Care Excellence (NICE) are responsible for the relevant guidelines: Epilepsies in children, young people and adults (nice.org.uk). Most patients with epilepsy will be discharged from follow-up once they are free of seizures for 12 months. At this point, their medication would only be changed if they had further seizures or other issues arise (such as possible adverse effects or consideration of pregnancy). Some patients with additional issues would be monitored for longer (see section 4.5.1 of the guidance).” Source location Response from NHS England
Open published response
Concerns raised 13 Inadequate risk assessment in response to urgent referrals View source Unavailability of a handover document between shifts for urgent referral downgrading View source Inadequate decision making when downgrading urgent referrals View source Failure to introduce a screening tool for determining PSIRF implementation View source Incomplete and ineffective rollout of STORM training to staff View source Inadequate PSIRF processes for addressing serious patient incidents View source Failure to define which statements are to be taken for serious patient incident investigations View source Failure to retain recordings of calls for serious patient incident investigations View source Failure to implement the SOP for downgrading urgent referrals View source Failure by NSFT to implement the Patient Safety Incident Response Framework View source Failure to make adequate discharge decisions after failed engagement with mental health services View source Failure to preserve recordings of calls between patients and the crisis call handler View source Inadequate safety planning in response to urgent referrals View source See 10 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
Ellen Ocean WOOLNOUGH · 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
Ellen Ocean WOOLNOUGH was found suspended by a ligature at her home on 20 July 2022 after concerns had arisen about her physical and mental health. Resuscitation restored circulation, but she suffered an irreversible hypoxic brain injury and died in hospital on 28 July 2022. The principal concerns relate to mental health service discharge decisions after failed engagement, the response to urgent referrals including risk assessment and safety planning, the implementation of the Patient Safety Incident Response Framework, and the preservation of call recordings and other evidence.
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 risk assessment in response to urgent referrals
Wider context from the report “2. The adequacy of NSFT’s Crisis Rehabilitation Home Treatment Team (CRHTT) response to an urgent referral, in particular; risk assessment , safety planning and decision making concerning the downgrading of referrals.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 a handover document between shifts for urgent referral downgrading
Wider context from the report “ii. Whilst the downgrade policy concerning urgent referrals has been tightened up, key parts of the process, such as the handover document between shifts, is still to be introduced .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 decision making when downgrading urgent referrals
Wider context from the report “2. The adequacy of NSFT’s Crisis Rehabilitation Home Treatment Team (CRHTT) response to an urgent referral, in particular; risk assessment, safety planning and decision making concerning the downgrading of referrals .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 introduce a screening tool for determining PSIRF implementation
Wider context from the report “iv. Changes to the way the Trust investigates incidents such as Ellie’s, including the use of a screening tool to determine how the PSIRF process is implemented , the requirement to retain recordings of calls and which statements are to be taken to inform serious patient incident investigations, are still to be introduced 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 Incomplete and ineffective rollout of STORM training to staff
Wider context from the report “i. STORM training continues to be rolled out , although the evidence from a number of witnesses questioned the effectiveness of the rollout in reaching all staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Inadequate PSIRF processes for addressing serious patient incidents
Wider context from the report “3. Adequacy of the NHS England Patient Safety Incident Response Framework (PSIRF) to address serious incidents concerning patients and the implementation of this framework by NSFT.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 define which statements are to be taken for serious patient incident investigations
Wider context from the report “iv. Changes to the way the Trust investigates incidents such as Ellie’s, including the use of a screening tool to determine how the PSIRF process is implemented, the requirement to retain recordings of calls and which statements are to be taken to inform serious patient incident investigations , are still to be introduced 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 retain recordings of calls for serious patient incident investigations
Wider context from the report “iv. Changes to the way the Trust investigates incidents such as Ellie’s, including the use of a screening tool to determine how the PSIRF process is implemented, the requirement to retain recordings of calls and which statements are to be taken to inform serious patient incident investigations, are still to be introduced 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 implement the SOP for downgrading urgent referrals
Wider context from the report “iii. The Trust SOP addressing the downgrading of urgent referrals , which I was told was revised in 2023, has not been provided to the Court and has not been implemented 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 by NSFT to implement the Patient Safety Incident Response Framework
Wider context from the report “3. Adequacy of the NHS England Patient Safety Incident Response Framework (PSIRF) to address serious incidents concerning patients and the implementation of this framework by NSFT .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Failure to make adequate discharge decisions after failed engagement with mental health services
Wider context from the report “1. The adequacy of Norfolk and Suffolk NHS Foundation Trust’s (NSFT) Integrated Delivery Team (IDT) decision making concerning the discharge of a patient from mental health services in circumstances where a failed engagement has occurred .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 preserve recordings of calls between patients and the crisis call handler
Wider context from the report “v. The failure by NSFT to preserve important evidence , in the form of recordings of calls between Ellie and the NSFT crisis call handler , at a time when it was not on notice that this evidence would be important and relevant for the conduct of the Inquest, remains a concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 safety planning in response to urgent referrals
Wider context from the report “2. The adequacy of NSFT’s Crisis Rehabilitation Home Treatment Team (CRHTT) response to an urgent referral, in particular; risk assessment, safety planning and decision making concerning the downgrading of referrals.
” 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 Norfolk and Suffolk NHS Foundation Trust is responsible for addressing the care concerns and providing details of PSIRF implementation.
Verbatim wording from the response “I note that your Report has also been addressed to Norfolk and Suffolk NHS Foundation Trust who are the appropriate organisation to answer the majority of the concerns raised in your Report. NHS England has engaged with the Trust on the issues raised in your Report about Ellen’s care and have been sighted on the action plan and statement submitted to you at inquest. We note from the Trust that their actions include:” Source location 2024-0184 - Response from NHS England
Open published response
20 Mar 2024 Jonathan Harris · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Shortage of available inpatient psychiatric beds in Surrey View source Failure to fill a Consultant Psychiatrist post in a community mental health team 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
Jonathan Harris · 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
Jonathan Harris died in the early hours of 27 June 2022 after deliberately suspending himself while suffering a relapse of paranoid schizophrenia. The inquest concluded that his relapse followed reductions in antipsychotic medication and that an inpatient psychiatric bed was unavailable when an assessment was required. The court was concerned about the vacant consultant psychiatrist post and the shortage of inpatient psychiatric beds, which it considered presented a risk of future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS England; that does not assign responsibility.
PFD Monitor interpretation Shortage of available inpatient psychiatric beds in Surrey
Wider context from the report “The court heard that a Consultant Psychiatrist post in the community mental health team that treated Mr Harris has been vacant with no suitable applicants since 1 May 2022. The court heard that this is in the context of a national shortage of suitably qualified psychiatrists.
The court also heard that there is an ongoing shortage of available inpatient psychiatric beds in Surrey and that this is in the context of a national shortage of inpatient psychiatric beds .
The court is concerned that both of these matters present a 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 fill a Consultant Psychiatrist post in a community mental health team
Wider context from the report “The court heard that a Consultant Psychiatrist post in the community mental health team that treated Mr Harris has been vacant with no suitable applicants since 1 May 2022 . The court heard that this is in the context of a national shortage of suitably qualified psychiatrists .
The court also heard that there is an ongoing shortage of available inpatient psychiatric beds in Surrey and that this is in the context of a national shortage of inpatient psychiatric beds.
The court is concerned that both of these matters present a risk of future deaths.
” 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 Implement the Long Term Workforce Plan to expand and sustain the mental health workforce.
Verbatim wording from the response “NHS England is working at a national level to deliver the Long Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years.” 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 Improve patient flow and reduce out-of-area placements through community service improvements, shorter inpatient stays and reduced discharge delays.
Verbatim wording from the response “In 2024/25 NHS England and systems will have a renewed focus on improving patient flow and reducing the use of out of area placements. This will be delivered through ongoing improvements to community mental health services, as well as focussed work to reduce inpatient lengths of stay and delays around discharge linked to onward care, support and housing, all of which will improve access to mental health beds closer to home for patients.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest additional funding in mental health, community, crisis, acute and inpatient services to improve access and reduce pressure on beds.
Verbatim wording from the response “In some local areas where there is a need for more beds, this is being addressed in part through investment in new units, however, this should be considered as part of whole system transformation approach. This is supported by the NHS Long Term Plan (LTP), which is seeing an additional £2.3bn funding invested in mental health services from 2019/20 – 2023/24, around £1.3bn of which is for adult community, crisis and acute mental health services to help people get quicker access to the care they need and prevent avoidable deterioration and hospital admission. A further £1.6bn has been made available via the better care fund from 2023-25 which can be used to support mental health inpatient services as well as the wider system which should help to reduce pressures on local inpatient services so that those who need to access beds can do so quickly and locally.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Trusts are responsible for ensuring safe staffing levels in day-to-day hospital operations.
Verbatim wording from the response “These actions will aim to close anticipated staffing shortfalls in the NHS in the long term, however Trusts have a responsibility to ensure safe staffing levels in the current day to day operation of their hospitals. This is in line with Care Quality Commission (CQC) Regulation 18 which states that providers must deploy enough suitably” Source location Response from NHS England
Open published response
Concerns raised 1 Failure of anticoagulation guidance to address patients with coronary stents undergoing therapeutic endoscopy while taking a single anticoagulant 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
Terence William SULLIVAN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Terence Sullivan underwent surgery to remove a sigmoid colon polyp on 8 August 2023, after temporarily stopping rivaroxaban. He suffered an acute myocardial infarction caused by blockage in a coronary artery stent and died in hospital on 10 August 2023. The principal concern was that NICE and BSG guidance may not reflect best practice for patients with coronary stents taking a single anticoagulant who require therapeutic endoscopy, including whether pre-operative consultation with an interventional cardiologist is needed.
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 anticoagulation guidance to address patients with coronary stents undergoing therapeutic endoscopy while taking a single anticoagulant
Wider context from the report “Since June 2023, Mr. Sullivan had been on a single anticoagulant medication ( Rivaroxaban ) to prevent previously inserted coronary stents from blocking. The clinicians who carried out the endoscopic procedure on 8.8.23, however, ensured that he had not taken any Rivaroxaban for the previous 48 hours. This was in accordance with Worcestershire Acute Hospital NHS Trust ( WAHT )’s own guidance, itself based on NICE guidance “NICE Clinical Scenario: Rivaroxaban for a therapeutic endoscopy”. I also heard evidence that the equivalent guidance from the British Society of Gastroenterology ( BSG ) provided similar advice.
At inquest, I heard evidence from WAHT’s Clinical Director for Critical Care that none of the aforementioned guidance considered the specific, and increasingly more common, scenario of a patient with coronary stents who is on a single ( as opposed to more than one ) anticoagulant medication, and who requires a therapeutic endoscopic procedure. The Clinical Director felt that in those specific circumstances, best practice requires pre-operative consultation with an interventional cardiologist, to decide on the best anticoagulation strategy during the procedure.
I am concerned to hear that current guidance on this specific issue from both NICE and BSG may not now reflect current best practice.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for the relevant clinical guidance rests with NICE and the British Society of Gastroenterology.
Verbatim wording from the response “As your Report references, NICE and the BSG publish the relevant clinical guidance on the issues raised. This does not come under NHS England’s remit. We note that you have also addressed your Report to both organisations and refer you to their” 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 Publishing the relevant clinical guidance falls outside the respondent’s remit.
Verbatim wording from the response “As your Report references, NICE and the BSG publish the relevant clinical guidance on the issues raised. This does not come under NHS England’s remit. We note that you have also addressed your Report to both organisations and refer you to their” 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