8 Dec 2023 Claire Nicole Briggs · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Lack of consistent and reliable understanding of respective emergency service roles for suspected drug overdoses View source Lack of a consistent and reliable method for police escalation of suspected drug overdose concerns to the ambulance service View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Claire Nicole Briggs · 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
Claire Nicole Briggs died at Stepping Hill Hospital on 28 November 2022 after a propranolol overdose. The report identified delays in ambulance response and failures to conduct timely clinical reviews, alongside the absence of a consistent and reliable process for police officers to escalate concerns about suspected drug overdoses to the ambulance service.
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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent and reliable understanding of respective emergency service roles for suspected drug overdoses
Wider context from the report “The evidence I heard was that a Joint Operating Protocol between the North West Ambulance Service and the five regional police forces designed to address the issues of which emergency service should take responsibility for incidents involving drug overdoses and the method by which the police officers attending such incidents prior to the arrival of the ambulance service can escalate their concerns over a person suspected to have taken a drug overdose, was in an advanced stage of completion, but was stalled in July 2022.
Whilst I heard that discussions have recently recommenced, they now encompass the Right Care, Right Person model, the findings of the Manchester Arena Bombing Enquiry and that additionally, the Fire and Rescue Service and the British Transport Police have now become involved.
Pending agreement of a Joint Operating Protocol, there does not appear to be any consistent and reliable understanding in place across the police forces and the North West Ambulance Service to provide clarity as to the roles of the respective services and the method by which concerns about individual patients can be escalated to the ambulance service by police officers dealing with those who are suspected to have taken drug overdoses.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a consistent and reliable method for police escalation of suspected drug overdose concerns to the ambulance service
Wider context from the report “The evidence I heard was that a Joint Operating Protocol between the North West Ambulance Service and the five regional police forces designed to address the issues of which emergency service should take responsibility for incidents involving drug overdoses and the method by which the police officers attending such incidents prior to the arrival of the ambulance service can escalate their concerns over a person suspected to have taken a drug overdose, was in an advanced stage of completion, but was stalled in July 2022.
Whilst I heard that discussions have recently recommenced, they now encompass the Right Care, Right Person model, the findings of the Manchester Arena Bombing Enquiry and that additionally, the Fire and Rescue Service and the British Transport Police have now become involved.
Pending agreement of a Joint Operating Protocol, there does not appear to be any consistent and reliable understanding in place across the police forces and the North West Ambulance Service to provide clarity as to the roles of the respective services and the method by which concerns about individual patients can be escalated to the ambulance service by police officers dealing with those who are suspected to have taken drug overdoses .
” 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 concerns with two other Northwest integrated care boards and coordinate steps to progress them.
Verbatim wording from the response “Following the inquest, you raised concerns in your Regulation 28 Report that there is a risk a future death will occur unless action is taken. We have worked with the 2 other ICBs in the Northwest who also use North West Ambulance Service particularly Lancashire ICB who act as a lead commissioner for the provider to review the concerns and ensure steps are taken to progress the concerns raised.” Source location Response from Greater Manchester ICB
Open published response
Concerns raised 4 Failure to enforce pharmacy questioning and pharmacist presence for over-the-counter cyclizine purchases View source Lack of professional understanding of using the Controlled Drugs local intelligence network for non-controlled drugs View source Absence of a commissioned pathway for GPs to refer compromised community patients requiring blood tests View source Failure to consider cyclizine addiction in eating disorder services View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Charlene Roberts · 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
Charlene Roberts died at Fairfield General Hospital on 12 January 2023 after suffering cardiac arrest during an inpatient admission; her cause of death was confirmed as cyclizine toxicity, with aspiration pneumonia, anorexia and factitious disorder also recorded. The principal concerns included the availability and prescribing of cyclizine, limited professional understanding of cyclizine dependence and the use of local intelligence systems for non-controlled drugs, and the lack of a commissioned community pathway for obtaining blood samples from compromised patients.
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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to enforce pharmacy questioning and pharmacist presence for over-the-counter cyclizine purchases
Wider context from the report “The court heard evidence that intravenous cyclizine is by prescription only but oral cyclizine can be purchased over the counter at a pharmacy. In order to purchase oral cyclizine in a pharmacy a pharmacist should seek information as to why it is required and should be present . Charlene’s family gave evidence that following Charlene’s death they had been able to obtain cyclizine in a pharmacy directly from a pharmacy assistant with no questions being asked of them .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of professional understanding of using the Controlled Drugs local intelligence network for non-controlled drugs
Wider context from the report “Cyclizine is not a controlled drug. At one stage consideration was given to using the Controlled Drugs local intelligence network as convened by NHS England (Controlled Drugs (Supervision and Management of Use) Regulations 2013) to put an alert out to local pharmacies to warn them about Charlene’s purchasing of cyclizine.
From the evidence there was a lack of clarity and understanding from professionals as to whether this local network could be used for drugs which are not controlled drugs . The fact that the legislation refers to controlled drugs may mean there is a lack of understanding about using this for system for non controlled drugs such as cyclizine.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Absence of a commissioned pathway for GPs to refer compromised community patients requiring blood tests
Wider context from the report “During the course of the evidence the court heard evidence from the GP who was responsible for obtaining weekly bloods to monitor her eating disorder. There is no commissioned pathway in Rochdale for GPs to refer patients who require bloods but who are compromised and therefore hard to obtain blood from . As a result patients are attending A&E departments for these to be taken .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to consider cyclizine addiction in eating disorder services
Wider context from the report “The court was made aware of the research conducted in 2009 as published in the journal PNS, “Proceedings of the Nutrition Society”, “Cyclizine dependence in patients with complex nutritional requirements” Thursby-Pelham, De Silva, Stroud and Fine, 23 July 2009. This identified cyclizine dependence in four female patients who all had complex nutritional problems.
Whilst it is acknowledged that this is one study and as stated cyclizine addiction is rare, it was not something which had been considered before Charlene’s addiction by the Eating Disorder Service . For the Manchester Eating Disorder Service there is now a greater awareness of cyclizine. This may be important nationally given its use as an anti-emetic.
” 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 Complete a Greater Manchester review of phlebotomy provision to identify variation and support more consistent patient access.
Verbatim wording from the response “In addition to the locality-specific actions as set out above, a GM level review of phlebotomy provision has been undertaken recently which has identified the variation in provision and sets out the intention to improve the consistency of offer to patients across Greater Manchester. This is also a priority deliverable of the Greater Manchester Primary Care Blueprint.” Source location Response from Greater Manchester NHS
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 Reiterate the process for arranging supported blood testing to all GP practices through GP communications.
Verbatim wording from the response “There are a very small group of people who may be more difficult to take blood than others due to clinical presentation. Rochdale GPs do have the ability to arrange, on a case-by-case basis, where a compromised patient needs to have bloods taken with support from ultrasound.” Source location Response from Greater Manchester NHS
Open published response
17 Oct 2023 Terence Davenport · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Lack of suitable care and nursing bed capacity causing unsuitable acute hospital placements View source Failure of safeguarding information sharing between local authorities, care homes and police View source Failure to ensure resident suitability for care home placement View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Terence Davenport · 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 Davenport, who had severe dementia, was pushed by another resident at Kings Park Nursing Home on 23 May 2022, suffered a fractured neck of femur, and died at Tameside General Hospital on 24 September 2022 after declining following surgery. Concerns included his prolonged stay in an acute hospital because a suitable care placement was unavailable, and inadequate information sharing about the other resident’s aggressive behaviour, which meant risks to staff and residents were not understood.
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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of suitable care and nursing bed capacity causing unsuitable acute hospital placements
Wider context from the report “1. The inquest heard evidence that the acute hospital setting was difficult for Mr Davenport due to his dementia and created risks to his health once he was medically optimised. He had to remain there due to a lack of suitable care/nursing beds. This meant that he was in an unsuitable care setting and that a bed that could have been utilised for an acute patient was not available;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of safeguarding information sharing between local authorities, care homes and police
Wider context from the report “2. The inquest was told that resident who pushed Mr Davenport was not suitable for placement at the care home where the incident happened. The care home where previous incidents had occurred was out of area. The inquest was told that lack of information sharing between two GM local authorities, the care homes involved and GMP meant that the safeguarding issue was not recognised. It was unclear if this was due to an effective information sharing protocol not existing between local authorities/care homes/GMP in Greater Manchester or it not being adhered to. However, the impact was that the risk of harm was not understood , and staff and residents were put 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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure resident suitability for care home placement
Wider context from the report “2. The inquest was told that resident who pushed Mr Davenport was not suitable for placement at the care home where the incident happened . The care home where previous incidents had occurred was out of area. The inquest was told that lack of information sharing between two GM local authorities, the care homes involved and GMP meant that the safeguarding issue was not recognised. It was unclear if this was due to an effective information sharing protocol not existing between local authorities/care homes/GMP in Greater Manchester or it not being adhered to. However, the impact was that the risk of harm was not understood, and staff and residents were put at risk.
” 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 Present the case learning to Tameside care home managers and deliver a further session on discharge and transfers between community and acute settings.
Verbatim wording from the response “Additionally learning from this report will be presented to Tameside Care Home Managers in December 2023; the learning will focus on sharing risk information across settings as well as completing robust pre-admission risk assessments. An additional face to face session will take place in February; this will be attended by ICFT Trust Colleagues with a focus on issues around discharge and transfer between community and acute settings.” Source location Response from Greater Manchester Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a system-wide workforce and market development mitigation plan to support nursing-care providers’ resilience during winter and the medium term.
Verbatim wording from the response “System-wide market risks across GM have been escalating over the past 9-12 months, with the highest in the nursing care market. Impact on residents and the workforce continues to be minimised by system leaders and providers when nursing homes exit the market either by de-registering/ownership or closure. We anticipate that there will be more closures over the coming months, and that these will continue to be managed locally with as least impact as possible. A system-wide mitigation plan focussing on workforce and market development has been developed to support providers to remain resilient over Winter and into the medium-term.” Source location Response from Greater Manchester Integrated Care Board
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 Share learning through the Greater Manchester System Quality Group on robust information sharing when patients move across settings and localities.
Verbatim wording from the response “3) Wider Learning via NHS Greater Manchester – learning will be shared via the GM System Quality Group around ensuring robust information being shared when patients are moving across settings and localities, this is particularly important currently due to current pressures on discharge.” Source location Response from Greater Manchester Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide direct digital support to residential and nursing homes to help residents remain in or return to care settings after discharge.
Verbatim wording from the response “3. Tameside Digital Health Team (based at Tameside ICFT) provide a face to face digital service directly with Residential and Nursing Homes to support residents to remain in the Care Sector with support wherever possible. They will also support in working with Residential and Nursing Homes to support residents in the Home once they have been discharged.” Source location Response from Greater Manchester Integrated Care Board
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 Home Finders Team to facilitate timely, appropriate discharge placements and release acute capacity.
Verbatim wording from the response “Ensuring acute capacity is available in our hospitals is an ongoing and significant challenge across Greater Manchester. In Tameside, there is a Home Finder Team based in the Integrated Urgent Care Team (IUCT) at Tameside Integrated Care Foundation Trust who work with patients and families to facilitate a timely and appropriate discharge for medically optimised patients so acute beds can be made available.” Source location Response from Greater Manchester Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold weekly Executive Length of Stay meetings and continuously monitor patients with No Criteria to Reside to identify and remove discharge barriers.
Verbatim wording from the response “2. Tameside locality partners meet weekly in an Executive Length Of Stay meeting to consider any barriers to discharging patients with “No Criteria to Reside” (NCTR) and work together to identify and remove any barriers to appropriate discharge. The number of patients with NCTR are monitored continuously both locally and at GM level to inform understanding of the capacity of the system to meet ongoing needs of the population.” Source location Response from Greater Manchester Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Send providers learning from the case on robust pre-admission risk assessments and personalised care planning that considers impacts on other residents, families and staff.
Verbatim wording from the response “1) In Tameside part of our contractual and quality management oversight is around ensuring that there are robust pre-admission assessments undertaken and subsequent care planning is undertaken in line with assessment or risk. A separate communication will be sent to providers to include learning from Mr Davenport’s case, highlighting to Homes the importance of robust pre-admission risk assessments and subsequent personalised care planning around a resident’s needs whilst factoring wider impact i.e., environmental and impact on other residents, families, and staff.” Source location Response from Greater Manchester Integrated Care Board
Open published response
Concerns raised 1 Lack of a specialist blood-testing referral service for patients with difficult venous access View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stephen Ratcliffe · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen Ratcliffe, who had a history of illicit drug and alcohol use and mental health conditions, was found deceased at home on 6 February 2023 after last being contacted when he collected methadone on 10 January 2023. The medical cause of death was recorded as respiratory depression due to combined drug toxicity, with developing liver cirrhosis and anxiety and depression also recorded; the principal concern was that no diabetes test was obtained because of difficult venous access and the absence of a specialist blood-taking service for GPs to refer to.
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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a specialist blood-testing referral service for patients with difficult venous access
Wider context from the report “1. The court heard that due to the deceased having compromised venous access as a result of his drug use, the GP practice were unable to take his bloods. The evidence before the court was that there is no specialist service for GPs to refer a patient to for bloods when venous access is difficult. Evidence was heard that this had been raised previously to the CCG. As a result, in this case no test for diabetes was obtained.
” 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 Present and share learning from the locality check-and-challenge exercise with the Greater Manchester System Quality Group.
Verbatim wording from the response “1. Learning from the check and challenge exercise to be presented/shared with the Greater Manchester System Quality Group on the 18th of January 2024. This meeting is attended by commissioners, including commissioners of specialist services, localities, regulators, Healthwatch and NICE. Through sharing in this forum, we expect members to review and ensure learning is incorporated into their commissioned services. There will be a follow up review of implementation in July 2024.” Source location Response from Greater Manchester Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Promote the Bury difficult-venous-access referral pathway through targeted communications.
Verbatim wording from the response “practices in relation to patients where venous access is difficult. Where venous access is difficult general practitioners (GPs) will be able to refer into the Same Day Emergency Care (SDEC) service. This new pathway will be promoted through targeted communications across Bury.” Source location Response from Greater Manchester Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a briefing to check and challenge difficult-venous-access arrangements across Greater Manchester localities.
Verbatim wording from the response “To better understand the pathways across the other localities we will be developing a briefing, highlighting this event and using this to check and challenge what arrangements each locality has in place for access for patients where it is difficult to obtain blood.” Source location Response from Greater Manchester Integrated Care Board
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 Complete a Greater Manchester review of phlebotomy provision and identified variation in services.
Verbatim wording from the response “In addition to the locality-specific actions as set out above, a GM level review of phlebotomy provision has been undertaken recently which has identified the variation in provision and sets out the intention to improve the consistency of offer to patients across Greater Manchester. This is also a priority deliverable of the Greater Manchester Primary Care Blueprint.” Source location Response from Greater Manchester Integrated Care Board
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 Establish a Bury pathway enabling GPs to refer patients with difficult venous access to Same Day Emergency Care.
Verbatim wording from the response “Bury Clinical Senate has reviewed this incident and a new pathway has been confirmed for Bury general” Source location Response from Greater Manchester Integrated Care Board
Open published response
21 Jul 2023 Thomas Barton · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Risk of deconditioning and infection for frail elderly patients during unnecessary hospital stays View source Insufficient availability of suitable social care causing delayed hospital discharges View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Thomas Barton · 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 Barton was admitted to hospital for a urinary tract infection and remained there while arrangements for additional care at home were organised. He contracted COVID-19 during the delayed discharge, deteriorated with dysphagia and aspiration pneumonia, and was discharged to a nursing home on end-of-life care, where he died. The principal concern was that delays in discharge caused by limited social care availability placed frail elderly patients at increased risk of deconditioning, infection and preventable 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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Risk of deconditioning and infection for frail elderly patients during unnecessary hospital stays
Wider context from the report “The inquest heard that the delayed discharge of Mr Barton from hospital was due to the challenges of putting an appropriate social care package in place. The evidence before the inquest was that delayed discharges such as Mr Barton’s put the lives of frail elderly patients at risk as it is far more likely that they will become deconditioned and develop an infection if they spend unnecessary time in hospital . The evidence was that delayed discharges such as Mr Barton’s were not uncommon due to the demand on social care and the availability of suitable care. The evidence was that speedier discharges would occur if there was improved availability of social care and that this would improve outcomes for elderly patients and reduce the risk of preventable deaths occurring.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of suitable social care causing delayed hospital discharges
Wider context from the report “The inquest heard that the delayed discharge of Mr Barton from hospital was due to the challenges of putting an appropriate social care package in place . The evidence before the inquest was that delayed discharges such as Mr Barton’s put the lives of frail elderly patients at risk as it is far more likely that they will become deconditioned and develop an infection if they spend unnecessary time in hospital. The evidence was that delayed discharges such as Mr Barton’s were not uncommon due to the demand on social care and the availability of suitable care . The evidence was that speedier discharges would occur if there was improved availability of social care and that this would improve outcomes for elderly patients and reduce the risk of preventable deaths occurring.
” 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 Fund home-from-hospital support from voluntary and community organisations alongside independent care providers.
Verbatim wording from the response “Response from NHS GM:
Whilst we appreciate that during the period of time that Mr Barton was in hospital there was increased demand on care at home, we are confident that there is sufficient capacity to support timely discharges from hospital for people to return to their homes. Supported by NHS GM funding, localities have commissioned home from hospital support from voluntary/community organisations in addition to the independent care providers that provide substantive services.” Source location Response from Greater Manchester Integrated Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake capacity and demand modelling of homecare and care-home markets to inform local market development.
Verbatim wording from the response “NHS GM have recently undertaken capacity and demand modelling of home care and care home markets. Localities are using the detailed modelling and analysis to inform development and shaping of their market, to ensure that it continues to meet the needs of current and future Greater Manchester residents.” Source location Response from Greater Manchester Integrated Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS GM considers commissioned home-from-hospital support and existing care capacity sufficient to support timely hospital discharges.
Verbatim wording from the response “Response from NHS GM:
Whilst we appreciate that during the period of time that Mr Barton was in hospital there was increased demand on care at home, we are confident that there is sufficient capacity to support timely discharges from hospital for people to return to their homes. Supported by NHS GM funding, localities have commissioned home from hospital support from voluntary/community organisations in addition to the independent care providers that provide substantive services.” Source location Response from Greater Manchester Integrated Care
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 Trafford Council considers existing homecare, residential care and supported-living provision sufficient in those areas, despite identified specialist capacity gaps.
Verbatim wording from the response “As indicated above, there is a reasonable supply of homecare currently.” Source location Response from Greater Manchester Integrated Care
Open published response
20 Jul 2023 Elliott James Harratt · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to clearly communicate sensitising events and the required Anti-D action View source Lack of clear, accessible signposting of events requiring a call to maternity triage View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Elliott James Harratt · 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
Elliott James Harratt was born at the family home following his mother's early labour, transferred to Tameside General Hospital, and died there on 29 January 2023 from extreme prematurity. The inquest identified concerns that expectant mothers were not given clear, readily accessible information about sensitising events requiring Anti-D treatment or when to contact maternity triage; this matter did not contribute to Elliott's 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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly communicate sensitising events and the required Anti-D action
Wider context from the report “The inquest heard evidence that the rhesus status of Elliott’s mum meant that after a sensitising event Anti D needed to be given to prevent Rhesus disease in a newborn baby. The evidence before the inquest was that the type of events that would constitute a sensitising event and what action was then required were not made clear to Elliott’s mum . In addition, the type of events where a call to maternity triage for advice were not made clear to his mum.
This was, the evidence suggested, because there was no readily accessible or consistent list given to expectant mothers at booking in appointments or at follow up signposting them. Such a document in the form of a handout laminate or as a list in the handheld notes would increase awareness of events where a call to maternity triage would be advisable for health of both the mother and baby enabling health professionals to intervene at the earliest possible stage.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of clear, accessible signposting of events requiring a call to maternity triage
Wider context from the report “The inquest heard evidence that the rhesus status of Elliott’s mum meant that after a sensitising event Anti D needed to be given to prevent Rhesus disease in a newborn baby. The evidence before the inquest was that the type of events that would constitute a sensitising event and what action was then required were not made clear to Elliott’s mum. In addition, the type of events where a call to maternity triage for advice were not made clear to his mum .
This was, the evidence suggested, because there was no readily accessible or consistent list given to expectant mothers at booking in appointments or at follow up signposting them . Such a document in the form of a handout laminate or as a list in the handheld notes would increase awareness of events where a call to maternity triage would be advisable for health of both the mother and baby enabling health professionals to intervene at the earliest possible stage.
” 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 Highlight the importance of giving RhD-positive mothers appropriate guidance, written information and advice on when to contact services.
Verbatim wording from the response “We will use this event as an opportunity to highlight the importance of ensuring that mothers who do have a D blood type, have the appropriate guidance, written information and understand when to contact services.” Source location Response from Greater Manchester Integrated Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing written, verbal and online advice consistently tells mothers when to contact maternity services, despite differing Trust arrangements.
Verbatim wording from the response “Each of our Trusts in Greater Manchester that provide maternity services are set up slightly differently in relation to how they deliver services, however the advice they provide to mothers on when to contact services is consistent across the system and comes in many forms, written, verbal and online.” Source location Response from Greater Manchester Integrated Care
Open published response
19 Jul 2023 Bernhard John Marek · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Delays in ambulance offloading at Emergency Departments View source Delays in ambulance attendance for frail elderly patients with hip fractures View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Bernhard John Marek · 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
Bernhard John Marek sustained an accidental fall, suffered a fractured neck of femur, and died in hospital on 6 January 2023 after developing pneumonia. Concerns included prolonged ambulance waits for frail elderly patients with hip fractures and delays in ambulances offloading patients at 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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance offloading at Emergency Departments
Wider context from the report “The resource issues faced by the ambulance service were exacerbated by long delays faced by ambulances to offload patients at Emergency Departments .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance attendance for frail elderly patients with hip fractures
Wider context from the report “The inquest was told that the wait time that was given at the time of the initial call was due to demand on the ambulance service and that such delays were not unusual throughout December due to demand and resources . As a consequence frail elderly patients such as Mr Marek with hip fractures were regularly waiting significant periods of time for the ambulance service .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review ambulance performance regularly through the regional Strategic Partnership and Transformation Board and work towards achieving Ambulance Response Programme standards.
Verbatim wording from the response “████████est, ambulance performance is reviewed regularly via the Strategic Partnership and Transformation Board, a joint committee between NWAS and the Integrated Care Boards in the region. We acknowledge that there remains work to be done to improve NWAS performance but are committed to achieving the ARP standards in the region.” Source location Response from Greater Manchester Integrated Care
Open published response
19 Jul 2023 Michael Kevin Amesbury · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure of inter-trust referral systems to provide timely electronic transfer of clinical information, images and notes View source Delays in cardiology clinic assessment due to insufficient clinician or appointment-slot availability View source Insufficient trans-oesophageal echocardiogram resources View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Kevin Amesbury · 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 Kevin Amesbury had extensive cardiac disease and became increasingly unwell while awaiting assessment for severe mitral regurgitation. He died in hospital after becoming unresponsive and undergoing cardiopulmonary resuscitation; post-mortem examination identified bilateral bronchopneumonia and aspiration of gastric contents, with heart failure contributing to reduced physiological reserves. The concerns included delays and problems in referrals between secondary and tertiary services, information-sharing and transfer of clinical records and images, and delays in cardiology assessment and trans-oesophageal echocardiography due to resource and appointment constraints.
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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of inter-trust referral systems to provide timely electronic transfer of clinical information, images and notes
Wider context from the report “1. The inquest heard evidence that Mr Amesbury needed to be referred from secondary to tertiary services within Greater Manchester. The inquest heard evidence that the speed and quality of that referral was impacted by the way in which information was shared between clinicians in different trusts within Greater Manchester . The use of different systems and reliance on postal services and lack of a clear, effective electronic system of referrals including transfer of images /notes meant there were delays in assessing patients which led to a delay in formulating a treatment plan in tertiary services;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in cardiology clinic assessment due to insufficient clinician or appointment-slot availability
Wider context from the report “2. The evidence also indicated that there were delays in patients who had been identified as requiring cardiology input being seen in cardiology clinics due to availability of clinicians/appointment slots inquest . This was exacerbated where there was a need for trans-oesophageal echocardiogram due to resource issues. The inquest heard that this type of echocardiogram could be key in understanding the cardiac issues of a 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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient trans-oesophageal echocardiogram resources
Wider context from the report “2. The evidence also indicated that there were delays in patients who had been identified as requiring cardiology input being seen in cardiology clinics due to availability of clinicians/appointment slots inquest. This was exacerbated where there was a need for trans-oesophageal echocardiogram due to resource issues . The inquest heard that this type of echocardiogram could be key in understanding the cardiac issues of a patient.
” 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 Discuss with information officers and the Digital Delivery Executive how to develop the referral-platform proposal into a funded project.
Verbatim wording from the response “Work to resolve this aligns closely with the GM digital strategy, the opportunities that the ICB brings for visibility, spread and scale. GM ICB commits to exploring and as appropriate, implementing this across other GM services. We will be progressing this with chief information officers across the integrated care system for an outline discussion to consider how this could be worked up into a funded project within the strategy delivery plan.” Source location Response from Greater Manchester Integrated Care
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 Explore extending referral-platform benefits to other Greater Manchester services.
Verbatim wording from the response “exploring. Attached as appendix 1 is a briefing note which outlines how a secondary to tertiary referral platform (Patient Pass) has been used to excellent effect in Renal, Neurosurge████████ Northern Care Alliance (NCA). There are significant benefits for outcomes re safety and productivity. We are looking at how we can bring the benefits of this type of technology to other services.” Source location Response from Greater Manchester Integrated Care
Open published response
10 Feb 2023 Sandra Adina Lomax · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to ensure regular participation of all Trusts in the GM Upper GI MDT View source Absence of a commissioned pan-Greater Manchester specialist service for complex oesophageal stricture cases View source Lack of detailed national guidance on management of oesophageal strictures and when and how to approach stenting View source Failure of the MDT to effectively communicate agreed actions and recommendations for individual patients View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sandra Adina Lomax · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sandra Adina Lomax died at Stepping Hill Hospital on 25 June 2022 after complications developed from an oesophageal stent that was not removed within the required six-week period. The concerns included inadequate communication and case ownership, delayed escalation, lack of detailed national guidance, absence of a commissioned specialist service, staffing gaps in the regional MDT, and ineffective communication of MDT recommendations.
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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure regular participation of all Trusts in the GM Upper GI MDT
Wider context from the report “3. The inquest also heard evidence that to support management of cases such as Mrs Lomax there was a regular GM Upper GI MDT led by Salford Royal Hospital. However staffing issues meant that there was not a regular presence for all Trusts at the meeting . This impacted effective communication and impacted 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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Absence of a commissioned pan-Greater Manchester specialist service for complex oesophageal stricture cases
Wider context from the report “2. Within Greater Manchester the inquest was told that the Christie were seeking to develop a specialist service for these complex cases but funding of a commissioned pan GM service was fundamental to a successful roll out that would benefit such patients as Mrs Lomax. The absence of such a service meant that cases such as Mrs Lomax’s could arise going forward given that in most hospitals even experienced radiologists/gastroenterologists would have limited experience on how to manage such cases;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of detailed national guidance on management of oesophageal strictures and when and how to approach stenting
Wider context from the report “1. The inquest heard evidence that the development of oesophageal strictures such as Mrs Lomax’s was a relatively new development as a consequence of advances in chemo/radiotherapy that meant that surgery was not the only option for oesophageal cancer. However the management of these strictures was complicated and there was no detailed national guidance on management of them and in particular when and how stenting should be approached . The development and implementation of detailed National Guidance was the inquest was told key to improving outcomes for patients such as Mrs Lomax across England;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of the MDT to effectively communicate agreed actions and recommendations for individual patients
Wider context from the report “4. This was compounded by the fact that the inquest heard evidence that the MDT did not have a system of effective communication of agreed actions and recommendations for individual patients discussed at the MDT . As a consequence local clinicians were unsighted as to the recommended way forward . The inquest was told that an effective and consistent pan GM approach to sharing the outcomes of MDTs would improve patient outcomes.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue implementing Cancer MDT Standards and auditing MDT communication and effectiveness across Greater Manchester.
Verbatim wording from the response “Recognising the challenges in relation to MDT working, the Greater Manchester Cancer Alliance have an improvement programme in place in relation to MDT reform:” Source location Response from Greater Manchester Integrated Care
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 Present the learning to the Greater Manchester System Quality Group for review and incorporation into commissioned services.
Verbatim wording from the response “Actions taken or being taken to share learning across Greater Manchester ████████” Source location Response from Greater Manchester Integrated Care
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 NICE is responsible for developing detailed national guidance on managing oesophageal strictures and stenting.
Verbatim wording from the response “The inquest heard evidence that the development of oesophageal strictures such as Mrs Lomax’s was a relatively new development as a consequence of advances in chemo/radiotherapy that meant that surgery was not the only option for oesophageal cancers. However the management of these strictures was complicated and there was no detailed national guidance on the management of them and in particular when and how stenting should be approached. The development and implementation of detailed National Guidance was the inquest was told key to improving outcomes for patients such as Mrs Lomax across England;” Source location Response from Greater Manchester Integrated Care
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 Cancer services provided by The Christie are commissioned by NHS England, not Greater Manchester Integrated Care.
Verbatim wording from the response “Mrs Lomax was treated by The Christie NHS Foundation Trust. The service provided by the Trust is commissioned by NHS England, and not Greater Manchester Integrated Care, because cancer is included within the list of prescribed specialised services. Prescribed specialised services are services which support people with a range of rare and complex conditions, and unlike the majority of NHS care, which is arranged locally, these services are planned nationally and regionally. This is because the services are delivered by specialist teams of doctors, nurses and other health professionals who have the necessary skills and experience, and as a result they are not available in every local hospital.” Source location Response from Greater Manchester Integrated Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England’s regional specialised commissioning team is responsible for reviewing and considering proposals for specialised services for these complex cases.
Verbatim wording from the response “NHS England have confirmed that they are going to take this Regulation 28 Report into consideration and review management of stents through the relevant Clinical Reference Group that covers oesophageal cancer.” Source location Response from Greater Manchester Integrated Care
Open published response
Concerns raised 2 Insufficient availability of community psychotherapy services for older adults with needs exceeding the Thinking Ahead service View source Insufficient availability of beds for informal admissions to older adults mental health wards View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James Alan Tice · 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 Alan Tice, who had recurrent depressive disorder with anxiety features, took his own life at home on 28 April 2022 while awaiting an informal admission to an older adult mental health ward. The report identifies concerns about the availability of beds for such admissions and psychotherapy services for older adults whose needs exceed community provision.
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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of community psychotherapy services for older adults with needs exceeding the Thinking Ahead service
Wider context from the report “(2) Availability of psychotherapy services for older adults in the community whose needs exceed the service available through Thinking Ahead.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of beds for informal admissions to older adults mental health wards
Wider context from the report “(1) Availability of beds for patients requiring an informal admission to an older adults mental health ward in the area covered by Pennine Care NHS Foundation Trust
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the Regulation 28 report and response with Greater Manchester mental health commissioners.
Verbatim wording from the response “3. Regulation 28 Report and response to be shared with mental health commissioners in Greater Manchester to ensure that a review of older adult inpatient provision is undertaken.” Source location Response from Greater Manchester Integrated Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake a review of older adult inpatient provision.
Verbatim wording from the response “3. Regulation 28 Report and response to be shared with mental health commissioners in Greater Manchester to ensure that a review of older adult inpatient provision is undertaken.” Source location Response from Greater Manchester Integrated Care
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 Mental health commissioners are assigned responsibility for reviewing older adult inpatient provision.
Verbatim wording from the response “3. Regulation 28 Report and response to be shared with mental health commissioners in Greater Manchester to ensure that a review of older adult inpatient provision is undertaken.” Source location Response from Greater Manchester Integrated Care
Open published response
Concerns raised 1 Gap in commissioning arrangements for dermatology services for out-of-area in-patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Violet Elizabeth Howard · 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
Violet Elizabeth Howard was admitted to hospital with sepsis caused by a hepatic abscess and later developed extensive eczematised psoriasis. The psoriasis affected her fluid balance, renal function and general reserves and was a contributory factor in her death; earlier dermatology input was considered likely to have reduced her distress, discomfort and pain, although the evidence did not establish that it would have prevented her death. The principal concern was a gap in dermatology commissioning arrangements for in-patients at Royal Oldham Hospital who lived outside the Oldham area.
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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Gap in commissioning arrangements for dermatology services for out-of-area in-patients
Wider context from the report “(1) There is a gap in the commissioning arrangements for dermatology services covering in-patients at the Royal Oldham Hospital. Those arrangements do not cover in-patients who are from outside of the Oldham area unless and until they become ‘emergency dermatological cases’ and meet the criteria for input from dermatology at Salford Royal Hospital.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Drive completion of acute dermatology service actions and obtain quality and safety assurances through locality oversight of the service-level agreement.
Verbatim wording from the response “Dermatology specialist input for an inpatient within the Oldham Care Organisation, regardless of area of residence, is a provision within the block contract for services and therefore is an expected provision by the hospital. The Oldham hospital site has never directly provided dermatology services, and the Clinical Commissioning Group, now an NHS GM locality team, has on several occasions raised this with the care organisation as a concern and this has been amplified by the findings in this case. The proposed approach was a service level agreement (SLA) with Salford Royal NHS Foundation Trust (SRFT). This has been actioned by the Oldham Care Organisation Divisional Managing Director Medicine and is being monitored by the Oldham ICB Locality Team.” Source location Response from NHS Greater Manchester Integrated Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing block-contract arrangements should provide dermatology services for all inpatients, including those from outside Oldham.
Verbatim wording from the response “Regarding out-of-area cover, this should be provided via the block contract as described above. As a locality, services are commissioned from HCRG Care Group. HCRG are commissioned to deliver a community based secondary care dermatology service from the Integrated Care Centre. This service is an outpatient, diagnostic and 2 week-wait service which serves the registered population of Oldham hence the reason why the GP referral was declined and raises concerns as to why this was the chosen route given the arrangements in place.” Source location Response from NHS Greater Manchester Integrated Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Oldham Care Organisation is responsible for providing inpatient dermatology services and addressing the provision gap through an SLA.
Verbatim wording from the response “The service is not commissioned to supply in-reach services into the NCA, and therefore the Oldham Care Organisation are bound under the existing contract to provide the necessary service which should cover all levels of dermatology requirements for inpatients within the care organisation, not just those deemed to be dermatological emergencies.” Source location Response from NHS Greater Manchester Integrated Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The concern reflects a gap in acute dermatology provision, not a commissioning gap.
Verbatim wording from the response “Dermatology specialist input for an inpatient within the Oldham Care Organisation, regardless of area of residence, is a provision within the block contract for services and therefore is an expected provision by the hospital. The Oldham hospital site has never directly provided dermatology services, and the Clinical Commissioning Group, now an NHS GM locality team, has on several occasions raised this with the care organisation as a concern and this has been amplified by the findings in this case. The proposed approach was a service level agreement (SLA) with Salford Royal NHS Foundation Trust (SRFT). This has been actioned by the Oldham Care Organisation Divisional Managing Director Medicine and is being monitored by the Oldham ICB Locality Team.” Source location Response from NHS Greater Manchester Integrated Care
Open published response
Concerns raised 3 Failure to recognise and flag the most appropriate antibiotic formulation for vulnerable patients View source Failure to provide face-to-face GP assessment when deterioration may be present View source ASK MY GP system making communication harder for vulnerable patients and their families View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alphonso Alexander Shearer · 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
Alphonso Alexander Shearer, who had oesophageal cancer and poor swallowing, was discharged with a catheter after treatment for acute urinary retention. He developed symptoms consistent with a urinary tract infection, was prescribed antibiotics he could not swallow, and later collapsed and died while being transferred to an ambulance; post-mortem examination confirmed urosepsis. Concerns included the lack of a system to identify the need for liquid antibiotics, difficulties with the ASK MY GP communication system, and the absence of a face-to-face GP assessment before his deterioration was recognised.
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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and flag the most appropriate antibiotic formulation for vulnerable patients
Wider context from the report “1. The inquest heard that Mr Shearer was frail and vulnerable with very poor swallow. When prescribing the clinicians did not recognise or have a system to flag up the need for liquid antibiotics rather than tablet antibiotics . This led to him not being able to commence antibiotics on the day he was identified as needing them . The inquest heard that it is important that in the community particularly for the vulnerable there is a system for recognising what form of antibiotics are most appropriate to prescribe for avoid delay .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide face-to-face GP assessment when deterioration may be present
Wider context from the report “3. The inquest heard that he had not been seen face to face by a GP and that meant that the full extent of his deterioration was not recognised until he was seen by a paramedic from the practice who called an ambulance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation ASK MY GP system making communication harder for vulnerable patients and their families
Wider context from the report “2. The inquest heard that the ASK MY GP system had been challenging for those involved with Mr Shearer and had made communication harder . The evidence identified that this was a particular issue for more vulnerable patients and their families .
” 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 Use quarterly educational events to disseminate system changes and learning from safety events to Trafford practice staff.
Verbatim wording from the response “The practice Medicines Management Team are also supporting this work to help avoid any unnecessary delays in a patient’s medication. As a CCG we offer support with EMISWeb system to develop system alerts as well as other system capabilities and all our practices have had the training to be able to manage this system on a day to day basis. Whilst we are not responsible for the monitoring of the operational systems of our practices, we use our quarterly educational events which practice staff attend to share any changes to the system and share learning from events such as this. We are really pleased that the practice is undertaking this exercise to ensure that patients with specific needs are managed appropriately.” Source location Response from Tafford Clinical Commissioning Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review patient experience of AskmyGP to assess satisfaction and identify access concerns.
Verbatim wording from the response “During May 2021 the CCG also undertook a review of the patient experience of AskmyGP and 90% of the patients who had used the system were highly satisfied with it. With this said we are also currently undertaking a piece of work to establish who is using the digital systems, and more importantly who isn’t? This will enable us to reduce the inequalities in digital access across the borough. We will ensure that any learning is shared with our practices as part of this work.” Source location Response from Tafford Clinical Commissioning Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the balance between remote and face-to-face consultations across Greater Manchester general practices.
Verbatim wording from the response “• In October 2021, NHS England set out a plan for improving access for patients and supporting general practice. This sets out how we will increase and optimise capacity, address variation, encourage good practice, and improve access, including face-to-face appointments with GPs.” Source location Response from NHS Greater Manchester
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Progress the Greater Manchester access action plan to increase general-practice capacity and appointments, expand face-to-face GP access, reduce avoidable demand, and improve healthcare inequalities.
Verbatim wording from the response “• Greater Manchester integrated care system has completed an action plan with further steps to support improved access and address healthcare inequalities. The plan includes how each of our 10 local systems will tackle variation in general practice, which is our utmost priority. This will continue to be progressed following the establishment of NHS Greater Manchester Integrated Care and the closure of local clinical commissioning groups on 1 July:” Source location Response from NHS Greater Manchester
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with digital and GP service providers to ensure technologies accommodate digitally excluded people and patients with complex conditions.
Verbatim wording from the response “We acknowledge that those with the greatest health needs are sometimes also the most at risk of being left behind by the ability to access, manage and contribute to digital tools, information and services. We continue to work with our digital and GP service providers to ensure these technologies work for everyone, from the most digitally literate to the most technology averse, and that they reflect the needs of people trying to stay healthy, as well as those with complex conditions.” Source location Response from NHS Greater Manchester
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 Reiterate standardised medication-requirement recording and safety-netting requirements in prescribing protocols, particularly when patients are not seen face-to-face.
Verbatim wording from the response “To share the learning from this case we will also reiterate the importance of standardised and consistent recording of medication requirements on the patient record, and ensuring that protocols for prescribing, particularly when the patient has not been seen face-to-face by the practice, include a safety netting element.” Source location Response from NHS Greater Manchester
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 Monitoring how GP practices operate their systems is outside the CCG’s responsibility.
Verbatim wording from the response “The practice Medicines Management Team are also supporting this work to help avoid any unnecessary delays in a patient’s medication. As a CCG we offer support with EMISWeb system to develop system alerts as well as other system capabilities and all our practices have had the training to be able to manage this system on a day to day basis. Whilst we are not responsible for the monitoring of the operational systems of our practices, we use our quarterly educational events which practice staff attend to share any changes to the system and share learning from events such as this. We are really pleased that the practice is undertaking this exercise to ensure that patients with specific needs are managed appropriately.” Source location Response from Tafford Clinical Commissioning Group
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing digital systems provide clinician-triaged access to telephone, video, face-to-face consultations or home visits, with alternatives for patients unable to use them.
Verbatim wording from the response “The adoption of AskmyGP during 2020 was planned as part of the NHS Long Term Plan to improve digital access for patients. This was expedited during the COVID-19 pandemic due to the advantages it offered in remote working. 70% of our practices in Trafford use this system which has enabled patients to access their practice without the need to physically attend on site which was encouraged during the pandemic where possible. The remaining 30% of our practices use similar digital systems with the same capabilities. These digital systems do not mean that that face to face appointments are not available. Each request on these systems are reviewed by a clinician and a decision is made on the method of consultation, which could be by telephone, email, video consultation, face to face or a home visit.” Source location Response from Tafford Clinical Commissioning Group
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 CQC and NHS England will make required improvements across practices that do not meet patients’ reasonable needs.
Verbatim wording from the response “Alongside this we are also working with the Care Quality Commission (CQC), which will work with NHS England to support systems in this process and to make the required improvements across those practices which are not meeting reasonable needs of patients. The CQC is rapidly developing an inspection methodology with a particular focus on access to GP services.” Source location Response from NHS Greater Manchester
Open published response
Concerns raised 16 Under-reporting of eating disorder deaths to the coroner View source Lack of clear responsibility for monitoring and co-ordinating community eating disorder care View source Absence of an acute hospital liaison psychiatry service View source Poor and inaccurate compilation of clinical documentation View source Poor nursing care for patients with eating disorders View source Lack of dissemination and understanding of MARSIPAN guidance among medical professionals View source Lack of appropriate investigation and learning from eating disorder deaths View source Failures and delays in maintaining and re-referring patients on the Priory waiting list View source Unclear Priory referral and admission criteria for medically stable patients with low BMI View source Absence of an allocated consultant psychiatrist for CEDS in Bury and six other Manchester boroughs View source Failure to conduct incident reviews of referral failures View source Failure to closely monitor food intake and purging behaviours View source Absence of pathways for acute clinicians to access specialist eating disorder advice View source Lack of formally commissioned community monitoring provision for moderate- or high-risk eating disorder patients View source Exclusion of patients with BMI below 14 from the Community Eating Disorder Service View source Failure to maintain nutrition and fluid charts View source See 13 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Nichola Jane Lomax · 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
Nichola Jane Lomax had a long history of an eating disorder and attended hospital several times in 2020 with severe malnutrition and electrolyte imbalance. She died on 3 August 2020 after delays and failings involving hospital treatment, specialist referral, communication, monitoring, nutritional care and access to appropriate services. The report identified concerns about inadequate eating-dis disorder training, access to specialist advice, referral criteria, critical services, community monitoring, nursing care and investigation of 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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Under-reporting of eating disorder deaths to the coroner
Wider context from the report “7) Lack of Recognition of the need to Investigate
For National Medical Examiner
It was of concern to the court that the only reason Nichola’s death was referred to HM Coroner was her initial medical cause of death had incorrectly included paracetamol toxicity. It was not until the court investigated this case, that there was any recognition by any of the agencies that there had been failings in the care of Nichola. If this death had not been reported to the Coroner, none of the above failings or the need for learning would have been identified. The court is extremely concerned that there is the real potential for under reporting of such cases and a lack of appropriate investigation to ensure learning is captured so as to prevent future deaths. This is important given the court heard eating disorders have the highest mortality rate of any mental disorder.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of clear responsibility for monitoring and co-ordinating community eating disorder care
Wider context from the report “3) Referral Criteria for the Priory and Community Eating Disorder Service
For GMMH, PRIORY, BURY CLINICAL COMMISSIONING, ICB
In Greater Manchester the Community Eating Disorder Service (CEDS) do not accept patients who have a BMI of less than 14. The court heard this is in part due to the structure and commissioning of the service. Adherence to this criteria had the following implications for Nichola’s care:
• As the only service who can refer to the Priory, CEDS became aware of Nichola. CEDS involvement created the impression that they were providing care to her. This created a confused picture as to who was co-ordinating her care .
• This meant that monitoring of Nichola was undertaken by the GP practice who were not specialists and had limited knowledge of eating disorders . It would have been more clinically appropriate for CEDS to have taken on this role and the court heard that in many other areas of the country the CEDS accept patients with BMIs lower than 14 and have responsibility for the monitoring and co-ordination of patients.
The Court heard evidence from a number of practitioners as to their understanding of the referral criteria for Nichola to be admitted to The Priory. The clear impression given by The Priory was that Nichola would not be accepted until 1) a bed became available but also 2) her BMI increased to somewhere around 12/13. The Court was told that the rationale for this is that a patient with a BMI below 13 is at high risk of refeeding according to MARSIPAN and more likely to require an acute hospital admission.
This impression meant that hospital clinicians and the GP understood that Nichola would not be accepted by the Priory until her weight had increased. However the court heard that the Priory can take someone with a BMI of less than 13 if medically stable and the benefits of specialist care outweigh the risks of refeeding. Given the impression created by the Priory no attempt was made to obtain an emergency bed for Nichola who was medically stable for some time after the 11th June.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Absence of an acute hospital liaison psychiatry service
Wider context from the report “4) Lack of Critical Services
For BURY CCG / ICB / GMHSCP
The Court heard evidence that despite FGH having a 24/7 Emergency Department, adherence had not been paid to NICE guidance which recommends the establishment of an Acute Liaison Psychiatry service. In this case the court heard that such a service would have provided continuity of care and psychiatric input. The only available psychiatry input at Fairfield hospital for the acute staff is either within the A&E department where there are psychiatric nurses or using the on-call psychiatrist, this post being on call for all psychiatry matters within the whole of Bury. There is no specific liaison psychiatric service for the Acute Hospital .
The evidence was that there is no Consultant Psychiatrist allocated to the CEDS in Bury or the 6 other boroughs of Manchester. However even though the CEDS is provided by the same mental health trust, it is only one of Manchester that does have an allocated Consultant Psychiatrist.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Poor and inaccurate compilation of clinical documentation
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care. There were no nutrition / fluid charts on her first admission in June. There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting information .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Poor nursing care for patients with eating disorders
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care . There were no nutrition / fluid charts on her first admission in June. There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of dissemination and understanding of MARSIPAN guidance among medical professionals
Wider context from the report “1) Inadequate Training of doctors and other medical professionals re eating disorders
For National / NCA / Royal College of Psychiatrists
Over 30 members of the medical profession saw Nichola during her three admissions to FGH in 2020. Of those, only one had knowledge of MARSIPAN and his understanding of MARSIPAN was extremely limited. This is not a question of lack of familiarity by professionals, it reflects a complete absence of any understanding that MARSPAN exists and indeed how to implement it in respect of the emergency treatment of an anorexic patient .
Previous Regulation 28 reports suggests this remains an ongoing concern nationally and MARSIPAN is not being disseminated to practitioners on the ground .
Whilst MARSIPAN can be accessed via a link in the NICE guidance on Eating Disorders. My concern is that Acute Trusts may not have sufficient regard to Guidance issued by Royal College of Psychiatry which is relevant to the medical care which they provide.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate investigation and learning from eating disorder deaths
Wider context from the report “7) Lack of Recognition of the need to Investigate
For National Medical Examiner
It was of concern to the court that the only reason Nichola’s death was referred to HM Coroner was her initial medical cause of death had incorrectly included paracetamol toxicity. It was not until the court investigated this case, that there was any recognition by any of the agencies that there had been failings in the care of Nichola. If this death had not been reported to the Coroner, none of the above failings or the need for learning would have been identified. The court is extremely concerned that there is the real potential for under reporting of such cases and a lack of appropriate investigation to ensure learning is captured so as to prevent future deaths . This is important given the court heard eating disorders have the highest mortality rate of any mental disorder.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failures and delays in maintaining and re-referring patients on the Priory waiting list
Wider context from the report “7) Delay in Re-Referral
For GMMH/PRIORY
Due to a misunderstanding following the telephone discussion between the Priory and FGH on 11th June Nichola was clearly removed from the Priory waiting list . This led to confusion for the GP practice who did not know why she had been removed. There was then a delay by the CEDS in re-referring Nichola which meant only one bed being available. This should not have occurred and more worryingly had not been noted as there had been no incident review of this case by either the Priory or the CEDS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unclear Priory referral and admission criteria for medically stable patients with low BMI
Wider context from the report “3) Referral Criteria for the Priory and Community Eating Disorder Service
For GMMH, PRIORY, BURY CLINICAL COMMISSIONING, ICB
In Greater Manchester the Community Eating Disorder Service (CEDS) do not accept patients who have a BMI of less than 14. The court heard this is in part due to the structure and commissioning of the service. Adherence to this criteria had the following implications for Nichola’s care:
• As the only service who can refer to the Priory, CEDS became aware of Nichola. CEDS involvement created the impression that they were providing care to her. This created a confused picture as to who was co-ordinating her care.
• This meant that monitoring of Nichola was undertaken by the GP practice who were not specialists and had limited knowledge of eating disorders. It would have been more clinically appropriate for CEDS to have taken on this role and the court heard that in many other areas of the country the CEDS accept patients with BMIs lower than 14 and have responsibility for the monitoring and co-ordination of patients.
The Court heard evidence from a number of practitioners as to their understanding of the referral criteria for Nichola to be admitted to The Priory. The clear impression given by The Priory was that Nichola would not be accepted until 1) a bed became available but also 2) her BMI increased to somewhere around 12/13 . The Court was told that the rationale for this is that a patient with a BMI below 13 is at high risk of refeeding according to MARSIPAN and more likely to require an acute hospital admission.
This impression meant that hospital clinicians and the GP understood that Nichola would not be accepted by the Priory until her weight had increased. However the court heard that the Priory can take someone with a BMI of less than 13 if medically stable and the benefits of specialist care outweigh the risks of refeeding . Given the impression created by the Priory no attempt was made to obtain an emergency bed for Nichola who was medically stable for some time after the 11th June.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Absence of an allocated consultant psychiatrist for CEDS in Bury and six other Manchester boroughs
Wider context from the report “4) Lack of Critical Services
For BURY CCG / ICB / GMHSCP
The Court heard evidence that despite FGH having a 24/7 Emergency Department, adherence had not been paid to NICE guidance which recommends the establishment of an Acute Liaison Psychiatry service. In this case the court heard that such a service would have provided continuity of care and psychiatric input. The only available psychiatry input at Fairfield hospital for the acute staff is either within the A&E department where there are psychiatric nurses or using the on-call psychiatrist, this post being on call for all psychiatry matters within the whole of Bury. There is no specific liaison psychiatric service for the Acute Hospital.
The evidence was that there is no Consultant Psychiatrist allocated to the CEDS in Bury or the 6 other boroughs of Manchester . However even though the CEDS is provided by the same mental health trust, it is only one of Manchester that does have an allocated Consultant Psychiatrist.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct incident reviews of referral failures
Wider context from the report “7) Delay in Re-Referral
For GMMH/PRIORY
Due to a misunderstanding following the telephone discussion between the Priory and FGH on 11th June Nichola was clearly removed from the Priory waiting list. This led to confusion for the GP practice who did not know why she had been removed. There was then a delay by the CEDS in re-referring Nichola which meant only one bed being available. This should not have occurred and more worryingly had not been noted as there had been no incident review of this case by either the Priory or the CEDS .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to closely monitor food intake and purging behaviours
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care. There were no nutrition / fluid charts on her first admission in June. There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Absence of pathways for acute clinicians to access specialist eating disorder advice
Wider context from the report “2) Accessing Specialist Advice
For National, NCA/GMMH/PRIORY
None of the practitioners in Nichola’s case knew how to access specialist eating disorder advice including medical or dietetic advice . There are no pathways to assist acute clinicians in how to access this specialist advice . To this day the clinicians told the Court they would not know where to go other than to try and contact the Priory. The Court heard from the Priory they are not commissioned to provide advice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of formally commissioned community monitoring provision for moderate- or high-risk eating disorder patients
Wider context from the report “5) Community Monitoring of patients with an Eating Disorder
For BURY CCG / NATIONAL / ICB/ GMHSCP
There is a lack of clarity as to whether there is any formally commissioned provision for the monitoring of moderate or high risk Eating Disorder patients within the community . The Court heard from GMHSCP that this was the responsibility of primary care however it was unclear whether this was known by those working in primary care and whether this service had ever been commissioned .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Exclusion of patients with BMI below 14 from the Community Eating Disorder Service
Wider context from the report “3) Referral Criteria for the Priory and Community Eating Disorder Service
For GMMH, PRIORY, BURY CLINICAL COMMISSIONING, ICB
In Greater Manchester the Community Eating Disorder Service (CEDS) do not accept patients who have a BMI of less than 14 . The court heard this is in part due to the structure and commissioning of the service. Adherence to this criteria had the following implications for Nichola’s care:
• As the only service who can refer to the Priory, CEDS became aware of Nichola. CEDS involvement created the impression that they were providing care to her. This created a confused picture as to who was co-ordinating her care.
• This meant that monitoring of Nichola was undertaken by the GP practice who were not specialists and had limited knowledge of eating disorders. It would have been more clinically appropriate for CEDS to have taken on this role and the court heard that in many other areas of the country the CEDS accept patients with BMIs lower than 14 and have responsibility for the monitoring and co-ordination of patients.
The Court heard evidence from a number of practitioners as to their understanding of the referral criteria for Nichola to be admitted to The Priory. The clear impression given by The Priory was that Nichola would not be accepted until 1) a bed became available but also 2) her BMI increased to somewhere around 12/13. The Court was told that the rationale for this is that a patient with a BMI below 13 is at high risk of refeeding according to MARSIPAN and more likely to require an acute hospital admission.
This impression meant that hospital clinicians and the GP understood that Nichola would not be accepted by the Priory until her weight had increased. However the court heard that the Priory can take someone with a BMI of less than 13 if medically stable and the benefits of specialist care outweigh the risks of refeeding. Given the impression created by the Priory no attempt was made to obtain an emergency bed for Nichola who was medically stable for some time after the 11th June.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain nutrition and fluid charts
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care. There were no nutrition / fluid charts on her first admission in June . There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting information.
” Open source report
Concerns raised 2 Lack of local guidance mandating referral to a pain specialist View source Lack of local guidance on safe GP oversight of high-dose multiple analgesic prescribing in the community View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michelle Jeffries · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michelle Jeffries had a complex medical history involving chronic, debilitating pain and had been prescribed large quantities of analgesic medication, including opiates. The report raised concern about the absence of local guidance on safely overseeing high-dose multiple analgesic prescriptions in the community and on when referral to a pain specialist should be required.
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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of local guidance mandating referral to a pain specialist
Wider context from the report “It is a matter of concern that there is an absence of local guidance as to:
1. The circumstances in which GPs can safely oversee the prescription of multiple analgesics at high doses in the community, attempting to reduce reliance on such medication as indicated; and
2. When referral to a pain specialist is mandated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of local guidance on safe GP oversight of high-dose multiple analgesic prescribing in the community
Wider context from the report “It is a matter of concern that there is an absence of local guidance as to:
1. The circumstances in which GPs can safely oversee the prescription of multiple analgesics at high doses in the community, attempting to reduce reliance on such medication as indicated ; and
2. When referral to a pain specialist is mandated.
” 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 Trafford’s repeat-prescribing guidance, with completion scheduled by 31 March 2022.
Verbatim wording from the response “Pain management and NICE guidance have previously been discussed at Trafford local GP Education sessions, held quarterly. Please see documents attached below for further information on the Trafford CCG local guidance on Repeat Prescribing as well the National Institute for Clinical Excellence (NICE) guidance in relation to assessing and managing chronic pain in the over 16’s. The Repeat Prescribing guidance is currently under review and will be complete by 31st March 2022.” Source location Response from NHS Greater Manchester
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 Ask Greater Manchester CCGs to report through the Quality Board on reducing overprescribing, including analgesia, and supporting implementation of DHSC guidance.
Verbatim wording from the response “4. CCGs across Greater Manchester will be asked to provide through Quality Board, a report on how they are reducing overprescribing, including analgesia and support the implementation of “Department of Health and Social Care (DHSC) guidance; Good For You, Good For Us, Good for Everybody - A plan to reduce overprescribing to make patient care better and safer, support the NHS, and reduce carbon emissions.”” Source location Response from NHS Greater Manchester
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide high-risk medication review support through Medicines Optimisation processes and practice-based pharmacists conducting structured medication reviews.
Verbatim wording from the response “Point 1 – the circumstances in which GP’s can safely oversee the prescription of multiple analgesics in high doses in the community, attempting to reduce reliance on such medications as indicated.
The Trafford CCG Medicines Optimisation team support prescribers with many aspects of prescribing including repeat prescribing to ensure robust and safe processes for managing patients repeat medication are in place. Included as part of this are systems for reviewing patients on “high risk” medication, which supports prescribers to ensure that patients on these medicines have regular medication reviews, including blood and physical healthcare monitoring. All practices in Trafford now have a practice based pharmacist working with them and as part of their work they undertake structured medication reviews.” Source location Response from NHS Greater Manchester
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 Prioritise patients taking high doses or multiple analgesics for structured medication review through collaboration between medicines optimisation and practice-based teams.
Verbatim wording from the response “All practices in Trafford now have a practice based pharmacist working with them and as part of their work they undertake structured medication reviews. The CCG Medicines Optimisation Team and practice based teams have been working together to prioritise patients requiring a medication review, with patients on high doses or multiple analgesia being highlighted.” Source location Response from NHS Trafford Clinical Commissioning Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide every Trafford practice with a practice-based pharmacist to undertake structured medication reviews.
Verbatim wording from the response “All practices in Trafford now have a practice based pharmacist working with them and as part of their work they undertake structured medication reviews. The CCG Medicines Optimisation Team and practice based teams have been working together to prioritise patients requiring a medication review, with patients on high doses or multiple analgesia being highlighted.” Source location Response from NHS Trafford Clinical Commissioning Group
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 Complete the review of Trafford’s repeat-prescribing guidance by 31 March 2022.
Verbatim wording from the response “Pain management and NICE guidance have previously been a topic at our local GP Education sessions, held quarterly. Please see documents attached below for further information on the Trafford CCG local guidance on Repeat Prescribing as well the National Institute for Clinical Excellence (NICE) guidance in relation to assessing and managing chronic pain in the over 16’s. The Repeat Prescribing guidance is currently under review and will be complete by 31st March 2022.” Source location Response from NHS Trafford Clinical Commissioning Group
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 Disseminate the case’s prescribing risks, clinical guidance and available chronic-pain resources to Trafford primary-care staff through the Practice Briefing.
Verbatim wording from the response “Fortunately the culture in pain management is changing with patients being offered non-pharmacological help and support, in preference, to manage their long term condition rather than medicines to try to “kill the pain”. This report gives us a real example to use in reminding all GPs in Trafford about those risks, what clinicians should be considering in terms of guidance and the resources available to support clinicians in the management of patients with chronic pain. We have therefore included this in our “Practice Briefing”; an email update which is sent out to over 400 Primary Care staff in Trafford twice a week. The information in the briefing also includes a link to the guidance documents we have shared with you above.” Source location Response from NHS Trafford Clinical Commissioning Group
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 No specific pain-management referral pathway mandates specialist referral; commissioned services are available when GPs consider referral necessary using clinical judgment.
Verbatim wording from the response “Point 2 - when referral to a pain specialist is mandated.
In terms of when to refer patients to pain specialists, there is no specific pain management pathway that offers GPs guidance on when exactly to refer to a pain specialist. However, in Trafford, there is a commissioned Musculoskeletal (MSK) service available to patients as well as the Manchester Pain Service should any Trafford GP, based on their own clinical judgement, decide a referral is necessary.” Source location Response from NHS Greater Manchester
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual GPs decide, using clinical judgment, whether referral to a pain specialist is necessary; no specific pathway mandates referral.
Verbatim wording from the response “In terms of when to refer patients to pain specialists, there isn’t a specific pain management pathway that offers GP’s guidance on when exactly to refer to a pain specialist. However, in Trafford, there is a commissioned Musculoskeletal (MSK) service available to patients as well as the Manchester Pain Service should any Trafford GP, based on their own clinical judgement, decide a referral is necessary.” Source location Response from NHS Trafford Clinical Commissioning Group
Open published response
Concerns raised 6 Poor documentation in GP referrals to secondary care View source Lack of GP referral follow-up systems to identify increased patient risk View source Delays in secondary-care appointments for gynaecological referrals View source Failure of GP referral follow-up systems to escalate referrals when required View source Lack of GP referral follow-up systems to identify referrals that have not taken place View source Failure in General Practice to understand and apply guidance on heavy premenstrual bleeding and expedite specialist referral View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Serena Naomi Roberts · 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
Serena Naomi Roberts experienced recurrent very heavy vaginal bleeding and delays in referral, triage and follow-up for specialist gynaecological assessment. She was later found to have ovarian cancer with extensive peritonitis and died from complications including septic shock and intra-abdominal sepsis. The principal concerns included delays in secondary care, poor recognition and application of guidance on heavy bleeding and risk factors, inadequate referral information, and a lack of clear systems to follow up referrals.
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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Poor documentation in GP referrals to secondary care
Wider context from the report “3. The quality of the documentation in the referral to secondary care form the GP was poor and the inquest was told that this hampered the triage of her case by secondary care . Standardisation of GPs referrals in relation to detail and guidance regarding key information for referral would assist with effective triage and identification of high risk patients by secondary 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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of GP referral follow-up systems to identify increased patient risk
Wider context from the report “4. There was no evidence available that GP practices had clear systems of follow up in relation to referrals to identify where they had not taken place or identify if the risk had increased and to escalate the referral.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in secondary-care appointments for gynaecological referrals
Wider context from the report “1. The inquest heard that there were significant delays in patients being seen in secondary care for gynaecological referrals from GPs . The inquest was told that these delays had now increased . In November 2020 the wait time for an appointment was 1 month for an urgent appointment and 4 months for a routine appointment. The wait times now in Tameside for gynaeocology were 8 months for a routine appointment and 4 months for urgent appointments. The increase in wait times reflected a national picture the inquest was told and reflected a significant backlog and a rising demand across the NHS .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of GP referral follow-up systems to escalate referrals when required
Wider context from the report “4. There was no evidence available that GP practices had clear systems of follow up in relation to referrals to identify where they had not taken place or identify if the risk had increased and to escalate the referral .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of GP referral follow-up systems to identify referrals that have not taken place
Wider context from the report “4. There was no evidence available that GP practices had clear systems of follow up in relation to referrals to identify where they had not taken place or identify if the risk had increased and to escalate the referral.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure in General Practice to understand and apply guidance on heavy premenstrual bleeding and expedite specialist referral
Wider context from the report “2. The inquest heard that understanding and application of the NICE guidance on heavy premenstrual bleeding in General Practice was a factor in recognising the risk to her health and that the risks around heavy premenstrual bleeding were not well understood in General Practice and in particular where it was necessary to expedite referral to specialist services .
” Open source report
6 Sep 2021 Bituin Pizzaro Pimlott · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Lack of clear guidance on when GPs should directly refer patients to the crisis team View source Failure to provide face-to-face mental health assessment when clinically needed View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Bituin Pizzaro Pimlott · 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
Bituin Pizzaro Pimlott was found suspended from a ligature at the garage of her home on 22 February 2021. The inquest heard that she had been struggling with her mental health and that telephone consultations were used instead of face-to-face appointments during the pandemic. Concerns included the lack of referral by her GP practice to the crisis team and uncertainty about the guidance for making such referrals.
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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance on when GPs should directly refer patients to the crisis team
Wider context from the report “The inquest heard evidence that Mrs Pimlott had been struggling with her mental health in the weeks preceding her death and had contacted her GP on a number of occasions with anxiety and depression. She was prescribed medication but expressed concerns about the impact of the medication. Telephone consultations rather than face to face appointments continued to be used with her due to the pandemic. Pre Covid it was accepted she would have been seen face to face which would have allowed a more comprehensive assessment of her mental health and her reluctance to use medication.
Her GP practice did not refer her to the crisis team, and it was unclear what guidance the practice had for their GPs about when they should refer directly to the crisis team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide face-to-face mental health assessment when clinically needed
Wider context from the report “The inquest heard evidence that Mrs Pimlott had been struggling with her mental health in the weeks preceding her death and had contacted her GP on a number of occasions with anxiety and depression. She was prescribed medication but expressed concerns about the impact of the medication. Telephone consultations rather than face to face appointments continued to be used with her due to the pandemic. Pre Covid it was accepted she would have been seen face to face which would have allowed a more comprehensive assessment of her mental health and her reluctance to use medication.
Her GP practice did not refer her to the crisis team, and it was unclear what guidance the practice had for their GPs about when they should refer directly to the crisis team.
” 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 Reintroduce advance booking of face-to-face GP appointments across Stockport practices.
Verbatim wording from the response “Many patients informed us that they preferred to be able to book a face-to-face appointment in advance so as to enable them to manage their healthcare around other commitments and forward booking of appointments has therefore been re-introduced across the Stockport patch.” Source location Response from Stockport Clinical Commissioning Group
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 Circulate mental-health referral-options information to Stockport GP practices and distribute it to patients.
Verbatim wording from the response “I am satisfied that in addition to the offer of face-to-face consultations where appropriate / requested, there is a robust process of triage, to include safety netting, in circumstances where a patient presents via the telephone reporting mental health concerns. Many such patients are offered same day face-to-face appointments and an information sheet detailing options for referral has been re-circulated to all GP Practices in Stockport. This document was developed as a single sheet which can be shared with patients, setting down referral options. I have attached a copy of the document which has been delivered to every Stockport address.” Source location Response from Stockport Clinical Commissioning Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide patients with access to face-to-face GP consultations where clinically appropriate or directly requested.
Verbatim wording from the response “• Access to blended appointments and patient choice in relation to the way in which they wish to consult with their GP” Source location Response from Stockport Clinical Commissioning Group
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 telephone triage with safety netting and same-day face-to-face appointments for patients reporting mental health concerns.
Verbatim wording from the response “Appropriate consultations with safety netting” Source location Response from Stockport Clinical Commissioning Group
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing appointment systems provide face-to-face consultations where clinically appropriate or directly requested, so further access changes are unnecessary.
Verbatim wording from the response “• Access to blended appointments and patient choice in relation to the way in which they wish to consult with their GP” Source location Response from Stockport Clinical Commissioning Group
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing triage and safety-netting processes adequately manage telephone mental-health presentations, including same-day assessment and referral information.
Verbatim wording from the response “Appropriate consultations with safety netting” Source location Response from Stockport Clinical Commissioning Group
Open published response
Concerns raised 2 Failure to address continued prescription of liquid morphine despite non-adherence to dosage instructions View source Failure to account for significant alcohol use when prescribing powerful painkillers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Elaine Michelle Inns · 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
Elaine Michelle Inns was found dead at her home on 18 January 2021. The inquest heard that she continued to be prescribed powerful painkillers despite significant alcohol use and use of liquid morphine without clearly following dosage instructions; the medical cause of death involved the combined toxic effects of ethanol and prescribed medicines.
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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to address continued prescription of liquid morphine despite non-adherence to dosage instructions
Wider context from the report “The inquest heard that Elaine Inns continued to be prescribed a combination of medication including a number of powerful painkillers although it was well understood that she was also using alcohol in significant quantities whilst taking her prescribed medication. The evidence before the court also indicated that she would use the prescribed liquid morphine without clearly following the recommended dosage instructions . She continued to be prescribed it .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to account for significant alcohol use when prescribing powerful painkillers
Wider context from the report “The inquest heard that Elaine Inns continued to be prescribed a combination of medication including a number of powerful painkillers although it was well understood that she was also using alcohol in significant quantities whilst taking her prescribed medication . The evidence before the court also indicated that she would use the prescribed liquid morphine without clearly following the recommended dosage instructions. She continued to be prescribed it.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with system colleagues to ensure adherence to best-practice opiate prescribing guidance.
Verbatim wording from the response “Having reviewed this overall investigation and the circumstances which led to the issue of your Regulation 28 report, I reach the conclusion that the key issue is the prescribing of opiates and I am satisfied that appropriate steps have been taken to ensure the safe prescribing of opiate medication at the individual practice and across the wider Stockport GP community. I will ensure that the most up to date opiate prescribing guidance is shared across our practices and work with colleagues across our system to ensure adherence to best practice guidance.” Source location 2021-0285-Response-from-Stockport-CCG_Published.pdf
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 Share up-to-date opiate prescribing guidance across Stockport practices.
Verbatim wording from the response “Having reviewed this overall investigation and the circumstances which led to the issue of your Regulation 28 report, I reach the conclusion that the key issue is the prescribing of opiates and I am satisfied that appropriate steps have been taken to ensure the safe prescribing of opiate medication at the individual practice and across the wider Stockport GP community. I will ensure that the most up to date opiate prescribing guidance is shared across our practices and work with colleagues across our system to ensure adherence to best practice guidance.” Source location 2021-0285-Response-from-Stockport-CCG_Published.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing prescribing safeguards are considered sufficient to ensure safe opiate prescribing across the individual practice and wider Stockport GP community.
Verbatim wording from the response “Having reviewed this overall investigation and the circumstances which led to the issue of your Regulation 28 report, I reach the conclusion that the key issue is the prescribing of opiates and I am satisfied that appropriate steps have been taken to ensure the safe prescribing of opiate medication at the individual practice and across the wider Stockport GP community. I will ensure that the most up to date opiate prescribing guidance is shared across our practices and work with colleagues across our system to ensure adherence to best practice guidance.” Source location 2021-0285-Response-from-Stockport-CCG_Published.pdf
Open published response
Concerns raised 2 Delays in offering mental health support View source Failure of GP consultation arrangements to support effective communication about deteriorating health View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stanislaw Wieslaw ZIELINSKI · 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
Stanislaw Wieslaw Zielinski’s mental health deteriorated after he reported anxiety and insomnia, with care provided through telephone GP appointments and delays in mental health support. On 20 October 2020, he fell from an upstairs window and sustained multiple fractures and a subdural haematoma; he later died from a cardiac arrest due to a pulmonary embolism following hospitalisation and surgery. The concerns included difficulties communicating his deteriorating condition through telephone consultations and delays in receiving mental health support during the Covid-19 period.
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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in offering mental health support
Wider context from the report “2. Mental health services were experiencing delays due to operating under the constraints of Covid and staffing issues . As a result there was a delay in offering him support which would have assisted him. The inquest heard that the existing challenges pre Covid for mental health services had been exacerbated by Covid due to an increased need for their services in part as a result of the impact on mental health of isolation during lockdown.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of GP consultation arrangements to support effective communication about deteriorating health
Wider context from the report “1. Pre Covid Mr Zielinski would have been seen face to face rather than through a series of telephone consultations. The inquest heard that he and his family struggled to communicate with the GP to explain his deteriorating health position as a result of how his GP practice was delivering health care . The inquest heard evidence that as a consequence his deteriorating picture was not fully understood by his GP and he was additional anxious as a result of an inability to express his concerns in person.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the IAPT provider to optimise access times for people seeking psychological support.
Verbatim wording from the response “Mr Zielinski self-referred to the Tameside and Glossop Improving Access to Psychological Therapies (IAPT) Service and was triaged on 01 October 2020. He was subsequently sent an appointment letter on 15 October 2020 and offered a first appointment for 21 October 2020. The national timeframes for response for IAPT services are that 75% of all referrals commence treatment within 6 weeks and 95% within 18 weeks. While Mr Zielinski’s referral and subsequent appointment were within the stated, and expected, national timeframes it is regretful that this did not meet Mr Zielinski’s needs at the time. Tameside and Glossop CCG will work with the provider to ensure access times are optimised for all trying to access support during these challenging times.” Source location 2021-0277-Response-from-Tameside-Metropolitan-Borough-Tameside-and-Glossop-CCG_Published.pdf
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 Introduce six-monthly patient surveys at individual practices from October 2021 to assess primary-care access and delivery.
Verbatim wording from the response “As part of the planned update to Locally Commissioned Services, delivered by general practice, and to further support practice reflection on whether each individual practice has the appropriate blend of face to face and telephone consultations for their individual patient lists, from 1 October 2021, practices will survey their patients and clinicians every six months to understand how both parties experience delivering primary care during the ongoing and evolving pandemic. Tameside and Glossop CCG has been working to improve patient experience and access throughout the pandemic and will implement an action plan as part of this work that will also respond to the concerns raised by this Prevention of Future Deaths letter. Due to the nature of the available data this will be a rolling, ongoing action plan involving continual review of data and experiences.” Source location 2021-0277-Response-from-Tameside-Metropolitan-Borough-Tameside-and-Glossop-CCG_Published.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct an individual practice clinician survey in October 2021 to assess primary-care delivery during the pandemic.
Verbatim wording from the response “As part of the planned update to Locally Commissioned Services, delivered by general practice, and to further support practice reflection on whether each individual practice has the appropriate blend of face to face and telephone consultations for their individual patient lists, from 1 October 2021, practices will survey their patients and clinicians every six months to understand how both parties experience delivering primary care during the ongoing and evolving pandemic. Tameside and Glossop CCG has been working to improve patient experience and access throughout the pandemic and will implement an action plan as part of this work that will also respond to the concerns raised by this Prevention of Future Deaths letter. Due to the nature of the available data this will be a rolling, ongoing action plan involving continual review of data and experiences.” Source location 2021-0277-Response-from-Tameside-Metropolitan-Borough-Tameside-and-Glossop-CCG_Published.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review patient experience feedback monthly to identify poor primary-care experiences and access inequalities.
Verbatim wording from the response “Work is also ongoing to understand negative patient experiences of primary care so that we can mitigate and reduce similar incidents going forward by sharing the learning across all general practices within Tameside and Glossop. This work involves reviewing appointment data on a” Source location 2021-0277-Response-from-Tameside-Metropolitan-Borough-Tameside-and-Glossop-CCG_Published.pdf
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 Discuss negative patient feedback with relevant practices to support learning and improvement.
Verbatim wording from the response “monthly basis in conjunction with any feedback from patients highlighting poor experiences. We then have conversations with practices regarding those poor experiences to support learning and improvement across all general practice within Tameside and Glossop. As such we encourage all patients to share their experiences – positive as well as negative – to reduce any inequality of access.” Source location 2021-0277-Response-from-Tameside-Metropolitan-Borough-Tameside-and-Glossop-CCG_Published.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The CCG cannot determine how GP consultations are undertaken because it lacks legal powers and is not party to the nationally negotiated contract.
Verbatim wording from the response “Nonetheless, whilst the CCG seeks to raise and maintain high standards it has no legal powers to determine how such consultations are undertaken. The contract with GPs – which is negotiated nationally and which the CCG isn’t actually a party to – doesn’t allow for specifying how consultations are delivered. At best the CCG can share data, share best practice and share any negative feedback with practices to understand why it has been received and encouraging changes that may want to consider to improve patient care and/or lived experience.” Source location 2021-0277-Response-from-Tameside-Metropolitan-Borough-Tameside-and-Glossop-CCG_Published.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The IAPT referral and appointment were within national response timeframes, so the access delay did not exceed expected standards.
Verbatim wording from the response “Mr Zielinski self-referred to the Tameside and Glossop Improving Access to Psychological Therapies (IAPT) Service and was triaged on 01 October 2020. He was subsequently sent an appointment letter on 15 October 2020 and offered a first appointment for 21 October 2020. The national timeframes for response for IAPT services are that 75% of all referrals commence treatment within 6 weeks and 95% within 18 weeks. While Mr Zielinski’s referral and subsequent appointment were within the stated, and expected, national timeframes it is regretful that this did not meet Mr Zielinski’s needs at the time. Tameside and Glossop CCG will work with the provider to ensure access times are optimised for all trying to access support during these challenging times.” Source location 2021-0277-Response-from-Tameside-Metropolitan-Borough-Tameside-and-Glossop-CCG_Published.pdf
Open published response
14 Jun 2021 Ian Hall · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of pharmacy checks to prevent inadvertent dispensing to vulnerable adults View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ian Hall · 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
Ian Hall, who had Alzheimer’s disease and was vulnerable, was admitted to hospital after a fall. A medicines reconciliation identified that amitriptyline had been dispensed instead of his prescribed atenolol; he subsequently choked on medication, developed aspiration pneumonia, tested positive for Covid-19, and died from aspiration pneumonia and Covid-19 pneumonitis. Concerns included the unclear cause of the dispensing error and the checks in place to prevent inadvertent dispensing to vulnerable adults whose carers administered the medication.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of pharmacy checks to prevent inadvertent dispensing to vulnerable adults
Wider context from the report “2. It was unclear what checks the pharmacy in question had or any pharmacy has to avoid the inadvertent dispensing to a vulnerable adult where the carers role is to administer whatever medications are collected from the pharmacy in the name of the individual. The inquest was told that the carers in this situation generally will have no clinical training. Therefore, their role is to check the medication is in an individual’s name and give it to the individual in compliance with what is on the label. It is not part of their role to cross check previous medications or query changes to medication.
” 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 NHS England is responsible for community pharmacy services.
Verbatim wording from the response “Community Pharmacy Services are the responsibility of NHS England and I have therefore liaised with my colleagues at Greater Manchester Health & Social Care Partnership (GMHSCP) to address the issues raised.” Source location 2021-0202-Stockport-CCG_Redacted
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 Community pharmacy services fall outside the respondent’s responsibility.
Verbatim wording from the response “Community Pharmacy Services are the responsibility of NHS England and I have therefore liaised with my colleagues at Greater Manchester Health & Social Care Partnership (GMHSCP) to address the issues raised.” Source location 2021-0202-Stockport-CCG_Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The key safety issue is pharmacy dispensing, not carers’ clinical qualifications or medication-administration responsibilities.
Verbatim wording from the response “You refer to the role of a carer in the administering of medications to a vulnerable adult, making the point that as carer staff are not clinically qualified, their responsibility when giving a medication is to simply check that the medication is correctly labelled for the patient they are attending. Having carefully considered this point, I reach the conclusion that the key issue is the pharmacy process as the dispensing of an incorrect medication should not happen if all procedures are correctly followed. My focus has therefore been to address the issue of dispensing and I am satisfied that appropriate steps have been taken to reduce the likelihood of incorrect medications being labelled and dispensed for administering by a carer.” Source location 2021-0202-Stockport-CCG_Redacted
Open published response
Concerns raised 4 Unclear identification of high-risk potential Covid-19 cases View source Failure to consider Covid-19 in patients with consistent symptoms View source Lack of tools to identify when particularly vulnerable patients require additional assessment View source Predominant use of telephone appointments instead of face-to-face or video appointments View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Brian Fredrick Mottram · 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
Brian Fredrick Mottram was found unresponsive at home on 15 November 2020 after feeling unwell for over a week. He had reported symptoms including shortness of breath, cough and a tight chest during a telephone GP consultation, but was not seen face to face. The concerns included the predominantly telephone-based appointment policy, the possible failure to identify Covid-19, and uncertainty about how high-risk patients were identified for additional assessment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unclear identification of high-risk potential Covid-19 cases
Wider context from the report “2. It was unclear during the inquest how GPs in Tameside were identifying high risk potential Covid 19 cases or the tools that they had to assist with identifying when to bring in for additional assessment patients who were particularly vulnerable to the effect of Covid 19 to check, for example oxygen levels consistent with silent hypoxia.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to consider Covid-19 in patients with consistent symptoms
Wider context from the report “1. The inquest heard that the GP surgery in common with surgeries across Tameside had a policy of predominantly using telephone appointments rather than face to face or video appointments. It was accepted at the inquest that Brian Mottram’s symptoms were consistent with Covid 19 but not there was no evidence before the Court that they were considered as such by the GP . A face to face appointment and testing in such a scenario may well have led to identification of Covid 19 and different 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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of tools to identify when particularly vulnerable patients require additional assessment
Wider context from the report “2. It was unclear during the inquest how GPs in Tameside were identifying high risk potential Covid 19 cases or the tools that they had to assist with identifying when to bring in for additional assessment patients who were particularly vulnerable to the effect of Covid 19 to check, for example oxygen levels consistent with silent hypoxia.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Predominant use of telephone appointments instead of face-to-face or video appointments
Wider context from the report “1. The inquest heard that the GP surgery in common with surgeries across Tameside had a policy of predominantly using telephone appointments rather than face to face or video appointments . It was accepted at the inquest that Brian Mottram’s symptoms were consistent with Covid 19 but not there was no evidence before the Court that they were considered as such by the GP. A face to face appointment and testing in such a scenario may well have led to identification of Covid 19 and different treatment.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission and operate a Covid Home Oximetry Management Service for monitoring and escalating deteriorating community patients.
Verbatim wording from the response “The CCG has commissioned a Covid Home Oximetry Management Service to monitor COVID-19 positive patients considered mild or moderate risk in the community who can be safely managed at home to:” Source location 2021-0201-Response-from-Tameside-and-Glossop-CCG-Redacted
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 Encourage general practices to provide face-to-face consultations where clinically appropriate alongside remote triage.
Verbatim wording from the response “The current national guidance states that practices should still triage all patients, and while Covid-19 is still a risk, a balance is still required to ensure the safety of staff in general practice, while ensuring that patients can still have consultations. This blended approach has seen more appointments in Tameside and Glossop taking place face to face than remotely.” Source location 2021-0201-Response-from-Tameside-and-Glossop-CCG-Redacted
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 Maintain and update monthly the local GP guidance providing routes for managing patients with and without Covid symptoms.
Verbatim wording from the response “To support this national guidance Tameside and Glossop CCG also developed the Tameside and Glossop CCG/LMC GP Guidance, which is updated monthly. At the time of Mr Mottram’s death v19, October 2020, was in force. This guidance provides practices with routes to manage patients who require consultations based on whether they have covid symptoms or not.” Source location 2021-0201-Response-from-Tameside-and-Glossop-CCG-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National and local guidance already required remote triage, risk stratification, oximetry and escalation pathways for potentially high-risk Covid-19 patients.
Verbatim wording from the response “The General Practice in the Context of Coronavirus Standard Operating Procedure v3.4 stated that practices should be open for delivery of face to face care, whilst triaging patients remotely in advance where possible, using remote consultations where appropriate.” Source location 2021-0201-Response-from-Tameside-and-Glossop-CCG-Redacted
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 General practices were not predominantly using telephone appointments; over half of appointments were face to face, with additional home visits.
Verbatim wording from the response “Between April 2020 to March 2021 Tameside and Glossop general practices have delivered over 1 million appointments, this includes 563 286 (or 51.6%) face to face appointment and 19,096 home visits.” Source location 2021-0201-Response-from-Tameside-and-Glossop-CCG-Redacted
Open published response
Concerns raised 2 Failure to adequately challenge additional replacement prescriptions View source Failure to account for addiction, self-harm and poor substance use when prescribing medication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Steven Terence Allen · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Steven Terence Allen was found unresponsive at home on 25 October 2020, and toxicology found a fatal level of prescribed medication; the medical cause of death was recorded as combined drug toxicity. Concerns included prescribing oxycodone and other medications despite a history of addiction, self-harm and poor use of substances, with telephone consultations during Covid-19 and additional replacement prescriptions sometimes issued with little challenge.
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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately challenge additional replacement prescriptions
Wider context from the report “The inquest heard that he had a chaotic lifestyle and a history of drug addiction. He was in significant pain and was prescribed medication to manage his pain including oxycodone. He was prescribed this and additional medications although there was a history of addiction, self-harm and poor use of prescribed and illicit substances. Prescribing of these medications was done through telephone consultations due to Covid 19 and on occasion additional replacement prescriptions were given with little challenge .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to account for addiction, self-harm and poor substance use when prescribing medication
Wider context from the report “The inquest heard that he had a chaotic lifestyle and a history of drug addiction. He was in significant pain and was prescribed medication to manage his pain including oxycodone. He was prescribed this and additional medications although there was a history of addiction, self-harm and poor use of prescribed and illicit substances. Prescribing of these medications was done through telephone consultations due to Covid 19 and on occasion additional replacement prescriptions were given with little challenge.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue discussions with Primary Care Network leads to explore Stockport Integrated Pharmacy Service support for optimising medication reviews.
Verbatim wording from the response “• The Medicines Management Team is currently in discussion with the Primary Care Network (PCN) Leads to explore how the Stockport Integrated Pharmacy Service (SIPS) can support GP Practices in optimising medication reviews for this patient cohort.” Source location 2021-0190-Response-from-Stockport-Clinical-Commissioning-Group-Redacted
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 Remind Stockport GPs about available opioid-prescribing resources and how to seek support through the next pharmacy newsletter.
Verbatim wording from the response “Greater Manchester Medicines Management Group (GMMMG) Opioid Prescribing for Chronic Pain: Resource Pack” Source location 2021-0190-Response-from-Stockport-Clinical-Commissioning-Group-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing prescribing guidance and clinician adherence are considered sufficient because the incident is regarded as isolated.
Verbatim wording from the response “The Practice take on board the comments included within the Regulation 28 Report and have undertaken a review of this case and looked at their processes for the management of prescribing for patients in this vulnerable cohort. The practice are satisfied that this was an isolated case and that all clinicians do adhere to guidance in relation to informed prescribing and support of this patient group.” Source location 2021-0190-Response-from-Stockport-Clinical-Commissioning-Group-Redacted
Open published response
21 May 2021 Martin Gibbons · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Delays in cross-trust mental health bed allocation for patients outside the assessing trust’s commissioned area View source Lack of a shared definition of high-risk mental health patients between acute and mental health trusts View source Failure to provide detailed and documented shared risk assessments and care plans in acute settings View source Insufficient availability of mental health beds View source Lack of national or regional guidance for shared care planning View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Martin Gibbons · 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
Martin Gibbons attempted to take his own life on 19 March 2020 and was taken to hospital, where he was assessed as needing admission to a psychiatric ward. While waiting for a bed, he left the hospital unobserved and was found dead on 24 March 2020; the inquest concluded suicide. Concerns included differing assessments of risk between acute and mental health trusts, the absence of shared risk assessments and care plans, and delays in obtaining a mental health bed.
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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in cross-trust mental health bed allocation for patients outside the assessing trust’s commissioned area
Wider context from the report “3. It was during the prolonged wait in the Emergency Department for a mental health bed that Mr Gibbons left. The inquest heard that this wait was contributed to by a number of factors in particular
• A national lack of mental health beds;
• The fact that although he had presented to Tameside Hospital and had been assessed by Pennine Care staff because he was a resident of a neighbouring borough covered by a different NHS Mental Health Trust that other Trust had to be contacted ,given all of the information and find him a bed . The inquest was told that this was as a result of how services were commissioned and that the workers who had assessed him had no choice other than to follow this process notwithstanding the additional delay it created .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a shared definition of high-risk mental health patients between acute and mental health trusts
Wider context from the report “1. During the course of the inquest evidence was heard that the acute and mental health trusts involved had assessed the level of risk he presented differently in part due to there being no shared definition of risk or the factors that triggered a patient being treated as high risk . The inquest heard that across the NHS there is in relation to mental health no shared definition between acute and mental health trusts of what constitutes a high risk patient . The two trusts involved in this inquest had since Mr Gibbon’s death identified that as an issue and work was underway between them to develop and implement a shared definition locally in the absence of any shared national definition.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide detailed and documented shared risk assessments and care plans in acute settings
Wider context from the report “2. The inquest heard evidence that since Mr Gibbon’s death both trusts had recognised that to reduce risk there needed to be detailed and documented shared risk assessments and care plans for patients such as him in an acute setting . The inquest heard that there was no national or regional guidance in place in relation to this shared care plan approach.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of mental health beds
Wider context from the report “3. It was during the prolonged wait in the Emergency Department for a mental health bed that Mr Gibbons left. The inquest heard that this wait was contributed to by a number of factors in particular
• A national lack of mental health beds ;
• The fact that although he had presented to Tameside Hospital and had been assessed by Pennine Care staff because he was a resident of a neighbouring borough covered by a different NHS Mental Health Trust that other Trust had to be contacted ,given all of the information and find him a bed. The inquest was told that this was as a result of how services were commissioned and that the workers who had assessed him had no choice other than to follow this process notwithstanding the additional delay it created.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of national or regional guidance for shared care planning
Wider context from the report “2. The inquest heard evidence that since Mr Gibbon’s death both trusts had recognised that to reduce risk there needed to be detailed and documented shared risk assessments and care plans for patients such as him in an acute setting. The inquest heard that there was no national or regional guidance in place in relation to this shared care plan approach .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a triage assessment tool guiding emergency-department nurses toward appropriate pathways based on patient risk and presentation.
Verbatim wording from the response “• The LMHT has now completed a joint piece of work with their ED colleagues at TGICFT. A triage assessment tool has been implemented which guides the triage nurse to consider the most appropriate pathway for the patient based on their risk/presentation at that time.” Source location 2021-0166-Response-from-GMCA_Published.pdf
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 Embed a standard operating procedure across both organisations reflecting shared-care principles.
Verbatim wording from the response “As an outcome of the investigation both trusts recognised the need to develop shared care principles and an agreed risk stratification/triage tool, including actions required should a person present to the emergency department (ED) who is considered a high risk to themselves. This document also needed to specify who is responsible for caring for the patient at given times when in the ED and include” Source location 2021-0166-Response-from-GMCA_Published.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a joint risk-assessment tool that stratifies risk and determines the level of emergency-department observation required.
Verbatim wording from the response “• A joint risk assessment tool has now been implemented. This is initially completed by the triage nurse and guides them into rating the patient’s risk at that time in terms of high (red), medium (amber) and low (green). This then informs the level of observation required for the patient whilst in the ED.” Source location 2021-0166-Response-from-GMCA_Published.pdf
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 Use joint assessment, handover and working-plan documentation to record risk, observation levels, clinical plans and handovers between liaison and emergency-department teams.
Verbatim wording from the response “• On assessment by the LMHT, the risk assessment is reviewed alongside a suicide risk screen being completed. The practitioner is then asked to rate the level of risk again using the same levels described above and agree an observation level for the patient. This joint working document then details the outcome of the assessment and the plan for the patient (inclusive of plan should they be waiting for a bed in the ED) which is agreed and signed by the LMHT practitioner and the ED team leader. This evidences the handover and working plan for the patient. Additionally, both teams have a handover sheet in use. PCFT’s handover sheet requests the name of the ED practitioner that a handover has been given to.” Source location 2021-0166-Response-from-GMCA_Published.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest significantly in community and crisis services to provide a holistic offer and manage demand for mental-health beds.
Verbatim wording from the response “There has been an overarching reduction in the mental health bed base capacity across the country over a number of years. This is having an ongoing impact in terms of local systems having the necessary capacity to meet the ever-increasing demand on services. In Greater Manchester we are investing significantly into our community and crisis services so that we have a holistic service offer, which will ensure that the demand on mental health beds is manageable.” Source location 2021-0166-Response-from-GMCA_Published.pdf
Open published response
Concerns raised 2 Failure to complete annual medication reviews View source Failure to ask patients about over-the-counter medication during medication reviews View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Bruce Lee Houghton · 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
Bruce Lee Houghton died at home on 16 April 2020 from combined drug toxicity, with excess paracetamol likely causing liver damage and accumulation of his other medications. The report states that he had not had his annual medication review, and that these reviews did not ask patients about over-the-counter medicines they purchased in addition to prescribed medication.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to complete annual medication reviews
Wider context from the report “2. The Court heard the deceased had not had his annual medication review . The court heard evidence that at these reviews the patients are not asked about any over the counter medication they may purchase in addition to their prescribed 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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ask patients about over-the-counter medication during medication reviews
Wider context from the report “2. The Court heard the deceased had not had his annual medication review. The court heard evidence that at these reviews the patients are not asked about any over the counter medication they may purchase in addition to their prescribed medication .
” 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 Provide local teams with advice and guidance supporting shared decision-making and appropriately timed medication reviews.
Verbatim wording from the response “• GM Medicines Management Group (GMMMG) to provide advice and guidance for local teams to implement, including support to ensure shared decision making with patients and medication reviews occurring on an ideally annual (or sooner if required) basis.” Source location 2021-0160-Response-from-GMCA_Published
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 teams are responsible for implementing Greater Manchester medicines advice and guidance, while GMMMG provides supporting advice.
Verbatim wording from the response “• GM Medicines Management Group (GMMMG) to provide advice and guidance for local teams to implement, including support to ensure shared decision making with patients and medication reviews occurring on an ideally annual (or sooner if required) basis.” Source location 2021-0160-Response-from-GMCA_Published
Open published response
Concerns raised 3 Failure of the asthma triage script to require direct questioning about ineffective breathing View source Failure to provide timely Category 2 ambulance responses during periods of high demand View source Failure of the MPDS algorithm to account for the cumulative effect of multiple symptoms View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Martin Keith 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
Martin Keith Sullivan, aged 15, died on 24 November 2019 after experiencing a severe asthma attack. He was prioritised as Category 2 during two 999 calls, and his father was not asked about taking him directly to hospital; ambulance delays followed before Martin was taken to hospital, where resuscitation was unsuccessful. Concerns included whether the MPDS algorithm and call-handler script recognised the severity of his symptoms, whether Category 2 response times could be met, and whether direct transport to hospital should have been discussed.
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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of the asthma triage script to require direct questioning about ineffective breathing
Wider context from the report “2. Rule 6 of the MPDS Protocol recognises that asthma patients are generally very experienced in managing their disease. Noting that statements such as can’t breathe and unable to breathe or a similar description should be considered as ineffective breathing. Ineffective breathing eliciting a Category 1 response.
It is not clear whether this requires a direct question from the EMD or whether it falls into the volunteered category of factors. There was no direct question from the EMD in this case.
Given the significance of breathing problems in an asthma attack, and the inevitable progression without intervention, it is imperative in my view that the script seeks more detail and should not rely on information being ‘volunteered’.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely Category 2 ambulance responses during periods of high demand
Wider context from the report “3. This was clearly a busy shift for NWAS, notwithstanding that the service was at 97% of commissioned capacity. 111 ambulances instead of 112 – having increased from 67 circa one hour previously, and it is likely that this was probably building from the reduced numbers of ambulance over the earlier period.
The EA that eventually arrived was outside the 90ᵗʰ percentile target of 40mins.
There is a clear history of NWAS being unable to meet NHS Cat 2 target times, in particular during Qs 3 & 4.
NWAS Annual reports
2018/19
Yearly Category 2 targets: mean - 24.14mins and 90% - 52.31, with increased times for Qs 3&4.
The Category 1,3 &4 targets are generally well met.
2019/20
Yearly Category 2 targets: mean – 26 mins and 90% - 56.27 mins, with increased times for Qs 3&4.
The Category 1,3 &4 targets are generally well met.
I understand that resource funding was applied for in November 19 and has been utilised from February 2020.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of the MPDS algorithm to account for the cumulative effect of multiple symptoms
Wider context from the report “1. The MPDS script and algorithm, it seems, were inadequate in this instance to recognise the life-threatening situation that Martin was in.
On the Paediatric evidence this acute attack was only going to end in one way without medical intervention. The evidence before me was that delay in treatment is the main cause of asthma deaths in children.
The algorithm does not account for the cumulative effect of more than one symptom. In this instance; difficulty breathing between sentences, clammy/sweaty and changes in colour.
The Paediatric evidence was that these symptoms in a well-controlled asthmatic whose home remedies are not working are indicative of a severe and life threatening condition.
” Open source report
11 Feb 2021 Carole Mitchell · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Insufficient local mental health inpatient bed capacity View source Delays in access to psychology assessment and therapies View source Failure to fully utilise information gathering from family due to misunderstanding of confidentiality View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Carole Mitchell · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Carole Mitchell died at home on 22 November 2019 after taking a fatal amount of her prescribed medication; the inquest conclusion was suicide. The report identifies concerns about delays in accessing psychological assessment and support-worker services, limited mental health bed capacity, and difficulties gathering information from her family because of concerns about confidentiality.
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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient local mental health inpatient bed capacity
Wider context from the report “2. Mrs Mitchell on two occasions could not be accommodated locally when an inpatient stay was required . The evidence heard at the inquest was that this was due to limited national mental health bed capacity against the demand within mental health services . The inquest heard evidence that suggested that this impacted on how she could be supported by her family and overall 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 Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in access to psychology assessment and therapies
Wider context from the report “1. The inquest heard that psychology assessment and therapies can be very beneficial to those with mental health issues in secondary services as well as primary services. The evidence given was that the delay that Mrs Mitchell experienced in accessing that service was reflective of both the regional and national backlog for appointments . The inquest was told that the position had worsened since 2019 and for example someone in Mrs Mitchell’s position today would be more likely to wait 9 months than the 7 months in 2019 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to fully utilise information gathering from family due to misunderstanding of confidentiality
Wider context from the report “3. It was accepted at the inquest that information gathering from family could be beneficial. However, there was a reluctance by health professionals to fully utilise information gathering due to concerns about breaching patient confidentiality . This appeared to stem from a misunderstanding between the concept of information sharing and information gathering and how they inter related with the principle of patient confidentiality .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a bespoke mental health workforce strategy to increase recruitment and address service waiting times.
Verbatim wording from the response “There is both local and national (NHSE/I) acknowledgement that this is one of the most significant challenges we face in mental health. The NHS Long Term Plan has identified a number of strategies by which we both upskill the current workforce and increase the size of the workforce. In GM we are in the process of developing a bespoke workforce strategy/plan that will ensure we see a significant surge in new recruits into mental health services which we believe will pointedly reduce the current waiting time for services.” Source location 2021-0037-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted
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 Mobilise the Delayed Transfer of Care programme, including 36 schemes funded to reduce bed blockage and out-of-area placements.
Verbatim wording from the response “As a consequence, we have mobilised a number of initiatives to ensure that GM patients are, in the main, treated locally:” Source location 2021-0037-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations