Concerns raised 3 Additional telephone triage causing delays in admission for elderly patients View source Lack of adequate audit of the Alternative to Transfer service’s net benefit and adverse outcomes View source Lack of clarity in Alternative to Transfer eligibility and responsibility criteria View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Cyril Cheetham · 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
Cyril Cheetham, aged 91 and resident in a care home, became unwell on 20.02.19, was admitted to hospital later that day, placed on an end-of-life pathway, and died on 25.02.19. The principal concern was that unclear responsibility between Mastercall and his own GP resulted in no same-day GP attendance, alongside concerns that the ATT service lacked adequate auditing and that its triage arrangements could delay hospital admission and contribute to future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Additional telephone triage causing delays in admission for elderly patients
Wider context from the report “The ATT services introduces an additional layer of triage based on a telephone conversation between a clinician at Mastercall and someone at the care home, who may be a carer or a nurse, and may be experienced or inexperienced, rather than that person calling 999. It is of concern to me that this additional layer may result in a delay in admission, which for an elderly patient with likely co-morbidities, will affect their prospects.
It was accepted that there was no audit or research carried out in respect of any deaths arising from delay in admission where the ATT service was used. The net benefit seems to have been calculated by reference to resource savings alone.
I am concerned that the ATT service is being resourced and provided (nationally) without any adequate or true audit of its perceived net benefit, and that its use may be costing lives, either at all or at an unacceptable level.
” Open source report × Source evidence
How 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 adequate audit of the Alternative to Transfer service’s net benefit and adverse outcomes
Wider context from the report “The ATT services introduces an additional layer of triage based on a telephone conversation between a clinician at Mastercall and someone at the care home, who may be a carer or a nurse, and may be experienced or inexperienced, rather than that person calling 999. It is of concern to me that this additional layer may result in a delay in admission, which for an elderly patient with likely co-morbidities, will affect their prospects.
It was accepted that there was no audit or research carried out in respect of any deaths arising from delay in admission where the ATT service was used. The net benefit seems to have been calculated by reference to resource savings alone.
I am concerned that the ATT service is being resourced and provided (nationally) without any adequate or true audit of its perceived net benefit , and that its use may be costing lives, either at all or at an unacceptable level.
” Open source report × Source evidence
How 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 clarity in Alternative to Transfer eligibility and responsibility criteria
Wider context from the report “Issue Two
The inquest highlighted a lack of clarity as to the criteria for the ATT service.
The conversation between Mastercall and the own GP highlighted the ‘grey area’ that exists between a routine (no risk of admission) attendance and a ‘risk of admission’ attendance. It is clear from the events that unfolded that Mr Cheetham clearly was at risk of admission. In my view the lack of clarity resulted in Mr Cheetham not being seen by a GP that afternoon while there was likely no difference in outcome in his case, it is clear that this existence of a ‘grey area’ of responsibility might result in future deaths.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with Mastercall and wider primary care colleagues to remove ambiguity and associated risk in ATT referral criteria.
Verbatim wording from the response “I will be working with the Deputy Medical Director at Mastercall and also with my colleagues within the wider primary care system; and I am confident that the steps we are taking across the system will remove the ‘grey area’ and any associated risk.” Source location 2021-0022-Response-from-Stockport-CCG-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement revised ATT visit criteria requiring Mastercall visits after telephone assessment, unless the patient’s GP elects to visit the same day.
Verbatim wording from the response “This issue has been addressed through a system wide discussion; essentially the issue as described within your report arose due to a view taken on ‘at risk of admission’. It has therefore been agreed that any visit required following initial ATT telephone assessment will be performed by Mastercall. The only exception to this will be in circumstances where a GP expresses a preference to undertake the visit which must happen on the same day. This process provides assurance that the patient will be seen the same day but does allow the flexibility of the patient’s own GP, who knows the patient best, to remain involved as appropriate.” Source location 2021-0022-Response-from-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 Existing specifications, guidance and senior-clinician triage are considered sufficient to redirect inappropriate ATT calls to 999.
Verbatim wording from the response “The Service Specifications are rigorous with excellent performance by Mastercall and communications provide clear guidance in relation to which patients are suitable for their service and which should be directed to 999. Calls into the service are triaged by a senior clinician and I am therefore confident that any inappropriate call to the ATT service from a care home or ambulance crew would be promptly redirected to 999.” Source location 2021-0022-Response-from-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 Unable to comment on national evaluation of the ATT service, while providing information about local evaluation and monitoring.
Verbatim wording from the response “Whilst I am unable to comment on any national evaluation I am able to provide information and reassurance in relation to local evaluation and monitoring of the ATT service in Stockport.” Source location 2021-0022-Response-from-Stockport-CCG-Redacted
Open published response
17 Dec 2020 Philip Taylor · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Failure to recognise dehydration risk View source Limited care-home staff ability to recognise and respond to escalating dehydration risk View source National pathfinder tool failing to clearly direct immediate expedited hospital transfer for sepsis View source Delays and omissions in recording GP visit observations View source Lack of national guidance for care-home staff on recognising, responding to and escalating dehydration risk View source Failure to ascertain temperature during care-home GP assessments View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Philip Taylor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Philip Taylor, who had Lewy Body Dementia and lived in a residential care home, became severely dehydrated during a chest infection and died in hospital on 6 January 2020 after developing an acute kidney injury. Concerns included failure to recognise and respond to dehydration, delayed ambulance transfer and hospital assessment, inadequate monitoring, and limited national guidance for care home staff and paramedics.
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 dehydration risk
Wider context from the report “1. Mr Taylor was seen by a GP the day before he died. His risk of dehydration was not recognised. The precise observations of the GP were difficult to ascertain at the inquest for a number of reasons.
• The inquest was told that the GP had been called as the care home had concerns about Mr Taylor. However, the GP did not ascertain his temperature because the inquest was told that he did not routinely carry or use a thermometer when he saw patients in a care home. The explanation provided to the inquest was that as a GP he did was not equipped with medical gadgets in the way for example NWAS staff were.
• The notes relating to the visit had not been written up until the next day and the GP could not recall all of any observations. It was unclear why that had occurred.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Limited care-home staff ability to recognise and respond to escalating dehydration risk
Wider context from the report “3. The staff in the care home were not medically qualified. The inquest heard that their ability to recognise and respond to an escalating risk of dehydration was limited . There was no national guidance to assist care home staff in understanding how to recognise; respond and escalate the risk of dehydration.
” Open source report × Source evidence
How 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 National pathfinder tool failing to clearly direct immediate expedited hospital transfer for sepsis
Wider context from the report “2. The paramedic attending was a newly qualified paramedic and as a result was using the national pathfinder tool. Mr Taylor was scoring for sepsis on the NWAS observations. However, the crew took well over an hour to leave the care home . The inquest heard that newly qualified paramedics relied on the national pathfinder tool which did not make it clear the need for an immediate expedited transfer to hospital in such circumstances . More experienced paramedics used the Manchester triage tool which was far more explicit. The inquest was told that NWAS had recognised the issue with the national tool and were adjusting their practices to avoid the risk. However, it was not clear if other Ambulance Trusts had made similar adjustments for newly qualified paramedics.
” Open source report × Source evidence
How 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 and omissions in recording GP visit observations
Wider context from the report “1. Mr Taylor was seen by a GP the day before he died. His risk of dehydration was not recognised. The precise observations of the GP were difficult to ascertain at the inquest for a number of reasons.
• The inquest was told that the GP had been called as the care home had concerns about Mr Taylor. However, the GP did not ascertain his temperature because the inquest was told that he did not routinely carry or use a thermometer when he saw patients in a care home. The explanation provided to the inquest was that as a GP he did was not equipped with medical gadgets in the way for example NWAS staff were.
• The notes relating to the visit had not been written up until the next day and the GP could not recall all of any observations . It was unclear why that had occurred.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for care-home staff on recognising, responding to and escalating dehydration risk
Wider context from the report “3. The staff in the care home were not medically qualified. The inquest heard that their ability to recognise and respond to an escalating risk of dehydration was limited. There was no national guidance to assist care home staff in understanding how to recognise; respond and escalate the risk of dehydration.
” Open source report × Source evidence
How 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 ascertain temperature during care-home GP assessments
Wider context from the report “1. Mr Taylor was seen by a GP the day before he died. His risk of dehydration was not recognised. The precise observations of the GP were difficult to ascertain at the inquest for a number of reasons.
• The inquest was told that the GP had been called as the care home had concerns about Mr Taylor. However, the GP did not ascertain his temperature because the inquest was told that he did not routinely carry or use a thermometer when he saw patients in a care home . The explanation provided to the inquest was that as a GP he did was not equipped with medical gadgets in the way for example NWAS staff were.
• The notes relating to the visit had not been written up until the next day and the GP could not recall all of any observations. It was unclear why that had occurred.
” 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 Ensure appropriate checks that the GP carries basic equipment and updates records at consultation where possible.
Verbatim wording from the response “I am mindful that steps taken now cannot undo what happened in this case, and I am satisfied that from a clinical perspective, the failure to carry equipment / update records did not impact on the outcome for this gentleman. However my expectation is that all Stockport GPs do carry basic equipment to enable the recording of clinical observations and for patient records to be updated at the point of consultation, wherever possible. I am sorry that this did not happen in this case and I will ensure that appropriate checks are made to ensure that Dr ████████ adheres to this standard of practice.” Source location 2020-0289-Response-from-NHS-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 failure to carry equipment and update records did not impact the patient's outcome.
Verbatim wording from the response “I am mindful that steps taken now cannot undo what happened in this case, and I am satisfied that from a clinical perspective, the failure to carry equipment / update records did not impact on the outcome for this gentleman. However my expectation is that all Stockport GPs do carry basic equipment to enable the recording of clinical observations and for patient records to be updated at the point of consultation, wherever possible. I am sorry that this did not happen in this case and I will ensure that appropriate checks are made to ensure that Dr ████████ adheres to this standard of practice.” Source location 2020-0289-Response-from-NHS-Stockport-CCG-Redacted
Open published response
Concerns raised 2 Delays in cardiology tests being carried out View source Delays in patients being referred to the cardiology clinic View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Brian Richard Murphy · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Brian Richard Murphy had congestive cardiac failure and significant coronary artery narrowing, deteriorated suddenly after being referred to cardiology, and died at Stepping Hill Hospital on 17 February 2020 following an acute myocardial infarction. The inquest heard that delays in the cardiology test referral system delayed tests and referrals to cardiology clinics.
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 cardiology tests being carried out
Wider context from the report “The inquest heard that the system for referrals for cardiology tests meant that there were delays in tests being carried out which led to delays in patients being referred to the cardiology clinic to see a cardiologist.
” Open source report × Source evidence
How 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 patients being referred to the cardiology clinic
Wider context from the report “The inquest heard that the system for referrals for cardiology tests meant that there were delays in tests being carried out which led to delays in patients being referred to the cardiology clinic to see a cardiologist .
” 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 the changed NT-proBNP testing and referral pathway, including urgency thresholds for echocardiography and heart failure services.
Verbatim wording from the response “The test has subsequently changed to a NT-proBNP for which the values are different:-” Source location 2020-0193-Response-from-NHS-Stockport-CCG_Redacted.pdf
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There were no delays; investigations and referrals followed correct, timely processes and pathways, so the reported cardiology-timescale risk did not arise in this case.
Verbatim wording from the response “Your report asks for an account of steps that we will be taking in relation to cardiology investigation timescales in order to reduce potentially avoidable deaths. I find myself in an unusual position in that whilst I am keen to respond appropriately to your request, my review identified that there were no delays in this case and that the correct processes and pathways were followed from the point of consultation with the GP through to the ordering of the echocardiogram and referral to specialist cardiology services.” Source location 2020-0193-Response-from-NHS-Stockport-CCG_Redacted.pdf
Open published response
Concerns raised 1 Failure of psychiatrists to comply with the shared care protocol when requesting GP initiation of Lithium prescriptions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
SAM ROBSON PRINGLE · 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
Sam Pringle had a long history of mental health problems and died by suicide by hanging on 3 November 2018. The report raised concern that inconsistent prescribing practices and the shared care protocol could delay or prevent access to Lithium for mentally ill patients, with potentially fatal results.
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 psychiatrists to comply with the shared care protocol when requesting GP initiation of Lithium prescriptions
Wider context from the report “(1) The inquest heard evidence that some psychiatrists are asking GPs to instigate prescriptions of Lithium , knowing that the shared care protocol (should) prevent GPs from doing so ; as a result the provision of Lithium to mentally ill patients is either not happening or is being delayed, with potentially fatal results.
” 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 all Greater Manchester Shared Care Protocols using risk-based prioritisation, agreed review timescales, COVID-related practice changes and relevant stakeholder learning.
Verbatim wording from the response “• A full review of the content of all Shared Care Protocols is required so as to ensure consistency, improve safety and prevent any delay for patients accessing their medications as occurred in Mr Pringle’s case.
o Agree a risk based prioritisation of SCP review
o Agree timescale for review with GMMMG and GM Directors of Commissioning” Source location 2020-0101-Response-from-Greater-Manchester-Medicines-Management-Group-NHS-Stockport-Clinical-Commission-Groupw.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate the shared-care communication failure to general-practice colleagues and require similar problems to be escalated to the CCG.
Verbatim wording from the response “Stockport CCG have a quality scheme in place, which facilitates shared care and Dr Woodworth has communicated to colleagues in General Practice to highlight this issue and ensure that any similar problems with a shared care process are highlighted to the CCG, such that there is oversight and an opportunity to ensure patients get their treatment safely and in a timely manner.” Source location 2020-0101-Response-from-Greater-Manchester-Medicines-Management-Group-NHS-Stockport-Clinical-Commission-Groupw.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 Provide assurance that Greater Manchester Shared Care Protocol implementation standards are followed, including assurance where local processes deviate.
Verbatim wording from the response “• Make recommendations for a unified GM position on implementation of SCPs.
o This will ideally be a de minimus, standardised GM process.
o Where a GM standard is not adopted due to local commissioning considerations, clinicians must have access to an agreed local process, which is clearly documented and communicated.
o GMMMG to assure implementation of standards.” Source location 2020-0101-Response-from-Greater-Manchester-Medicines-Management-Group-NHS-Stockport-Clinical-Commission-Groupw.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 Develop recommendations for a unified Greater Manchester process for implementing Shared Care Protocols, including clearly documented local arrangements where the standard is not adopted.
Verbatim wording from the response “• Make recommendations for a unified GM position on implementation of SCPs.
o This will ideally be a de minimus, standardised GM process.
o Where a GM standard is not adopted due to local commissioning considerations, clinicians must have access to an agreed local process, which is clearly documented and communicated.
o GMMMG to assure implementation of standards.” Source location 2020-0101-Response-from-Greater-Manchester-Medicines-Management-Group-NHS-Stockport-Clinical-Commission-Groupw.pdf
Open published response
Concerns raised 4 Lack of alert notes for prescribed medication View source Failure to ensure prescribers are aware of high alcohol use View source Lack of follow-up review appointments for prescribed medication View source Failure to assess the risk of mixing alcohol with prescribed medication 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
Wendy Margaret Wilkes · 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
Wendy Margaret Wilkes was found at her home on 6 August 2019, with toxicology showing a fatal level of ethanol and concomitant use of gabapentin, zopiclone, diazepam and amitriptyline. Concerns were raised about the absence of a clear system for alert notes and follow-up reviews, and about whether prescribers were aware of her high alcohol use and assessed the risks of mixing alcohol with her 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 alert notes for prescribed medication
Wider context from the report “The inquest heard that there was no clear system of alert notes /follow up review appointments at her GP practice despite the extent of the 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 ensure prescribers are aware of high alcohol use
Wider context from the report “The inquest heard that the GP practice did not appear to have a system to ensure that prescribers were aware that her alcohol use was high and to assess the risk of mixing alcohol with the 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 Lack of follow-up review appointments for prescribed medication
Wider context from the report “The inquest heard that there was no clear system of alert notes/follow up review appointments at her GP practice despite the extent of the 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 assess the risk of mixing alcohol with prescribed medication
Wider context from the report “The inquest heard that the GP practice did not appear to have a system to ensure that prescribers were aware that her alcohol use was high and to assess the risk of mixing alcohol with the 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 Flag patients at risk from neuropathic medication and alcohol dependence, conduct medication reviews, and contact them about medication and alcohol consumption.
Verbatim wording from the response “Alert Note/Review System effective from 25 February 2020
The practice has identified relevant existing patients by running reports for patients coded on the practice’s clinical system as using neuropathic medication, cross referenced with patients coded with alcohol dependency who have had an intentional or accidental overdose. A “flag” is now placed on these patients’ medical records and a medication review is undertaken. The patients are then contacted to discuss their medication and their alcohol consumption.” Source location 2020-0095-Response-from-Tameside-Glossop_Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train non-clinical staff to share intentional or accidental overdose information with practice GPs.
Verbatim wording from the response “To further support this process, non-clinical staff have been trained to ensure that information related to intentional or accidental overdoses are shared with the General Practitioners in the practice; so the process described above can be followed.” Source location 2020-0095-Response-from-Tameside-Glossop_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 Develop and distribute guidance to practices on identifying and managing patients prescribed neuropathic drugs or opioids who may be alcohol-dependent.
Verbatim wording from the response “Tameside and Glossop Clinical Commissioning Group (CCG) actions
████████, Director of Commissioning, is accountable to ensure that in line with the Coroner’s request, the following actions will be undertaken:” Source location 2020-0095-Response-from-Tameside-Glossop_Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue an alert to all GP practices about alert notes, follow-up reviews and considering systems to identify high alcohol use during prescribing.
Verbatim wording from the response “3. An alert will be issued to all GP practices to ensure that they have clear systems of alert notes/follow up review appointments for individuals with extensive prescribed medications. The alert also requests GP practices consider how their systems can alert prescribers to patients with high alcohol usage when prescribing medications to ensure effective risk assessments can be carried out.” Source location 2020-0095-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The named Clinical Commissioning Group is responsible for addressing the concerns raised about GP practice alert systems and prescribing risk assessment.
Verbatim wording from the response “I have noted that your Regulation 28 letter has also been sent to the Clinical Commissioning Group concerned and I will leave it to the named respondent to address the concerns which you have addressed. My letter therefore addresses the issues that fall within the remit of GMHSCP.” Source location 2020-0095-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership
Open published response
Concerns raised 5 Delay in intervening in response to concerns about the GP practice View source Insufficient GP capacity to see patients View source Lack of a clear nurse-to-doctor escalation process View source Poor quality of written medical notes View source Failure to recognise risks associated with patients' background health issues when they show signs of being unwell 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
George Townsend · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
George Townsend, who was receiving long-term antibiotic therapy, developed worsening diarrhoea and was later diagnosed in hospital with Clostridium difficile infection and pneumonia. He died at Trafford General Hospital on 30 August 2019 from multi-organ failure due to bronchopneumonia. The concerns included delayed GP assessment and testing, inadequate escalation from the nurse to a doctor, failure to recognise the risks associated with his health conditions, poor medical record-keeping, and longstanding concerns about GP practice capacity and oversight.
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 Delay in intervening in response to concerns about the GP practice
Wider context from the report “4. The inquest heard that there had been concerns locally within the area about the GP practice. They were now being acted upon by the CCG but the situation had been an issue for some time before there was intervention .
” Open source report × Source evidence
How 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 GP capacity to see patients
Wider context from the report “1. The inquest heard that Mr Townsend should have seen a GP and had further tests prior to his admission to Salford Royal Hospital. The inquest heard that at the GP practice in question there were insufficient GPs to see patients . In addition there was no evidence of a clear escalation process from the Nurse to a Doctor within the practice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear nurse-to-doctor escalation process
Wider context from the report “1. The inquest heard that Mr Townsend should have seen a GP and had further tests prior to his admission to Salford Royal Hospital. The inquest heard that at the GP practice in question there were insufficient GPs to see patients. In addition there was no evidence of a clear escalation process from the Nurse to a Doctor within the practice .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Poor quality of written medical notes
Wider context from the report “3. The quality of the written medical notes at the GP practice was poor .
” Open source report × Source evidence
How 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 risks associated with patients' background health issues when they show signs of being unwell
Wider context from the report “2. The particular risks he presented with his background health issues were not recognised when he showed signs of being unwell .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct scheduled quality visits to Trafford practices, prioritising practices needing resilience or other additional support.
Verbatim wording from the response “Engaging with Practices” Source location 2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake a practice diagnostic and progress its resulting organisational action plan with the CCG’s primary-care leadership.
Verbatim wording from the response “September 2018
Following meetings between Dr ████████ and the CCG’s Medical Director, Dr ████████ (MJ), Dr ████████ agreed for the CCG to undertake a “practice diagnostic”. The diagnostic took place on the 25th & 26th September 2018. The report made 14 recommendations, which were mainly organisational issues. The report concluded that the clinical care was generally safe and this was based on triangulating a number of nationally available data sources. The report also noted that the practices were offering more appointments per 1000 population than the evidence suggested, however the report advised Dr ████████ to appoint two additional full time GPs.” Source location 2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.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 Provide enhanced Medicines Management support to the practice, focused primarily on safety issues.
Verbatim wording from the response “Between August and the 30th September 2019
Dr ████████ had the right to appeal the CQC’s decision to terminate his registration and duly started to do so, and whilst the CCG could not appoint a caretaker nor formally intervene in the day to day running of the practice (this remained the responsibility of Dr ████████) the CCG did provide the usual general support which included engagement with the ANP directly on a number of occasions for assurance around competence and that she would seek clinical supervision from the GP’s in the practice if she felt unsure about any issues. The CCG also provided additional Medicines Management support from the end of July to mid-September, primarily focusing on safety issues. This was over and above what a practice this size would normally receive (3 days a week as opposed to one).” Source location 2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.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 Lead the Greater Manchester GP Retention Scheme to promote flexible working and support retention of general-practice clinicians.
Verbatim wording from the response “An example of an area of work undertaken by this group includes leading on the GM GP Retention Scheme which aims to facilitate initiatives to enable clinicians to stay in the workforce, through promoting new ways of working and providing a more flexible offer that will create a sustainable model within general practice. The CCG is keen to attract, train and retain clinical roles and so part of Trafford’s allocated funding for 2020/21 has been used to secure placements on the Basic Trainer Course for 5 Trafford GPs, increasing the number of training environments within the borough. This initiative not only provides placements for training clinicians but also supports the professional development of our existing workforce.” Source location 2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.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 Gather workforce data and identify Trafford primary-care areas needing workforce-model support through the Primary Care Workforce Delivery Group.
Verbatim wording from the response “To offer further assurance around GP availability generally, the CCG has a Primary Care Workforce Delivery Group which has a remit to review current primary care workforce supply and demand in Trafford, and to make recommendations for improvement and sustainability, aligned to integrated commissioning principles. Some of its key actions include:” Source location 2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.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 Request and participate in a multi-agency quality summit to obtain regulatory assurances about the practice.
Verbatim wording from the response “May 2019
The CCG became aware of staff raising more concerns about Dr ████████s practice in May 2019, in particular in relation to the financial management of the practice and his commitment to the day to day running. In addition, this was at a time when Primary Care Networks were being established and Dr ████████ had become the Clinical Director of the North Primary Care Clinical Network. As the practice issues became an escalating situation, the CCG requested a Quality summit with NHS England and the CQC, this is a review undertaken by a number of regulatory bodies to seek assurances around regulatory obligations. The practice was also part of the agenda’s for the weekly Primary Care MDT meetings so updates were provided and discussed every week whilst concerns were being managed.” Source location 2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.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 the Primary Care Quality Assurance and Improvement Framework to support ongoing quality improvement in Trafford GP practices.
Verbatim wording from the response “The CCG is also responsible for the monitoring of quality of care provided for the healthcare services that it commissions. To support this there has been a Primary Care Quality Assurance and Improvement Framework (PCQAIF) in place since July 2019. The framework describes two approaches to support ongoing improvements in quality in GP practices in Trafford.” Source location 2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.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 Operate Tableau practice profiles and an early-warning surveillance dashboard using routine primary-care data to identify significant variation and potential support needs.
Verbatim wording from the response “Proactive
This is the routine monitoring of practice profiles, these are individual profiles set up in the CCG intelligence system “Tableau” which is the data system that holds a wide range of primary care data, a sub-set of indicators has been determined to create a surveillance dash board which acts as an Early Warning System (EWS) which indicates key areas to focus on to improve.” Source location 2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.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 Work with NHS England to organise longer-term arrangements for Gloucester House Medical Centre.
Verbatim wording from the response “On 1st October 2019 Firsway Medical Centre formally took over the contract to care take Gloucester House Medical Centre and this contract is in place to this day and working well and engaging with the CCG on a regular basis in particular during the COVID-19 period. The CCG is working with NHSE to organise longer term plans for the practice.” Source location 2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.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 practices with significant surveillance variation through the monthly Primary Care Quality Assurance Group and discuss appropriate support or escalation.
Verbatim wording from the response “Those practices with the highest number of metrics showing significant variation are flagged for further analysis and discussion at the monthly Primary Care Quality Assurance group (PCQAG), and whilst the data allows some indication where support may be needed, this is not solely relied on. Soft intelligence is also gained from the PCQAG members prior to any engagement with a practice and this includes areas such as prescribing, safeguarding, and complaints.” Source location 2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.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 Provide Trafford practice nurses with access to formal clinical supervision through the Practice Nurse Development Lead.
Verbatim wording from the response “To offer some wider assurance around escalation and nursing support, the CCG confirms that all Practice Nurses in Trafford are given the opportunity to gain clinical supervision which is a formal systematic and continuous process of professional support and learning for practicing nurses. This is provided by the CCG Practice Nurse Development Lead, who is also a qualified practice nurse herself. This is a self-referral process which relies on the Practice Nurses contacting the Practice Nurse Development Lead directly and arranging a clinical supervision appointment. In the case of an Advanced Nurse Practitioner the expectation is that they would seek clinical supervision from any of the GP’s in their practices.” Source location 2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.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 2020/21 Trafford funding to secure Basic Trainer Course placements for five GPs, increasing local training capacity.
Verbatim wording from the response “An example of an area of work undertaken by this group includes leading on the GM GP Retention Scheme which aims to facilitate initiatives to enable clinicians to stay in the workforce, through promoting new ways of working and providing a more flexible offer that will create a sustainable model within general practice. The CCG is keen to attract, train and retain clinical roles and so part of Trafford’s allocated funding for 2020/21 has been used to secure placements on the Basic Trainer Course for 5 Trafford GPs, increasing the number of training environments within the borough. This initiative not only provides placements for training clinicians but also supports the professional development of our existing workforce.” Source location 2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.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 practice had slightly more GP appointments available than average, disputing that insufficient GP cover caused the concern.
Verbatim wording from the response “Whilst there are general guiding principles and different methodologies for calculating the number of GPs to cover the number of patients a practice has, GP cover varies from practice to practice. The earlier diagnostic workup that the practice had slightly more GP appointments available to patients than average.” Source location 2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.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 could not recruit additional GPs, appoint a caretaker or formally intervene because operational responsibility remained with the practice contract holder.
Verbatim wording from the response “inspections, Dr ████████ CQC registration was suspended from his Old Trafford contract meaning he would be unable to practice. In the case of GH his registration was not suspended meaning, whilst he could not practice he was still responsible for the day to day operational running of that practice, including the adequate clinical cover for patients registered at GH. The CCG were unable to intervene with recruiting with more GP’s and other support generally as this was the responsibility of Dr ████████ at that time.” Source location 2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.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 Although record keeping could have been better, the medical notes contained sufficient documentation to form a clinical view.
Verbatim wording from the response “3. The quality of the written medical notes at the GP practice was poor.” Source location 2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.pdf
Open published response
Concerns raised 3 Failure to provide reliable overnight detection of residents getting up and wandering View source Failure to escalate incidents involving residents putting non-food items in their mouths and undertake further risk assessment View source Failure to restrict access to gloves for residents who may place items in their mouths 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
Christine Rosemary Neild · 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
Christine Rosemary Neild had significant learning difficulties, dysphagia, and required feeding support. She became very unwell and died at Meade Close on 31 January 2020; the medical cause of death was a sub-acute bowel obstruction associated with an incisional hernia. Concerns included accessible gloves and other non-food items, a failure to escalate an earlier ingestion incident or undertake further risk assessment, and the lack of regular sensors to alert staff when residents got up at night.
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 provide reliable overnight detection of residents getting up and wandering
Wider context from the report “3. The inquest heard that in care settings such as this one for those with learning disabilities there was no regular use of sensors to alert night staff of a resident getting up and wandering . Staff relied on hearing a resident getting up despite this being difficult if they were delivering personal care onto another resident .
” Open source report × Source evidence
How 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 escalate incidents involving residents putting non-food items in their mouths and undertake further risk assessment
Wider context from the report “2. There had been an earlier incident when Christine Neild had put non-food items in her mouth. The carer did not escalate this and there was no further risk assessment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict access to gloves for residents who may place items in their mouths
Wider context from the report “1. During the course of the inquest evidence was heard that gloves were in open and easily accessible locations throughout the home including in rooms and the kitchen area . The inquest was told that this is standard practice in care settings for people with learning disabilities even where residents do not have insight into what items can safely be placed in their mouths .
” Open source report
Concerns raised 4 Failure to recognise and escalate significant pressure-ulcer deterioration promptly View source Unavailability or non-use of required wound dressings View source Failure of pressure-ulcer forms to capture deterioration and require detailed monitoring View source Lack of a system to follow up unanswered specialist referrals 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
Arnold Fletcher Ward · 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
Arnold Fletcher Ward was a resident at Fernlea Nursing Home who developed a deteriorating grade 4 sacral pressure ulcer, later associated with osteomyelitis, and died in hospital on 21 January 2019 from a myocardial infarction. Concerns included inadequate monitoring and escalation of the pressure ulcer, failure to follow up a referral to the Tissue Viability Nursing Team, and the resulting lack of appropriate wound dressing.
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 escalate significant pressure-ulcer deterioration promptly
Wider context from the report “The inquest heard that within the home the forms used did not capture the deterioration of the pressure ulcer or require detailed monitoring/use of photographs to track its progress. This meant that the significant and steep deterioration was not recognised and escalated at an early opportunity to the Tissue Viability Nursing team for expert wound management input. As a result the type of wound dressing he required were not utilised/available.
It had been captured in the notes that there had been a referral to the Tissue Viability Nursing team in October. There was no system in the home to chase up the team after a number of weeks had elapsed and there had been no response. The inquest heard that even in non-urgent cases the Tissue Viability Nursing team would contact a home requesting support in at least 10 days and more quickly in an urgent case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability or non-use of required wound dressings
Wider context from the report “The inquest heard that within the home the forms used did not capture the deterioration of the pressure ulcer or require detailed monitoring/use of photographs to track its progress. This meant that the significant and steep deterioration was not recognised and escalated at an early opportunity to the Tissue Viability Nursing team for expert wound management input. As a result the type of wound dressing he required were not utilised/available .
It had been captured in the notes that there had been a referral to the Tissue Viability Nursing team in October. There was no system in the home to chase up the team after a number of weeks had elapsed and there had been no response. The inquest heard that even in non-urgent cases the Tissue Viability Nursing team would contact a home requesting support in at least 10 days and more quickly in an urgent case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of pressure-ulcer forms to capture deterioration and require detailed monitoring
Wider context from the report “The inquest heard that within the home the forms used did not capture the deterioration of the pressure ulcer or require detailed monitoring/use of photographs to track its progress . This meant that the significant and steep deterioration was not recognised and escalated at an early opportunity to the Tissue Viability Nursing team for expert wound management input. As a result the type of wound dressing he required were not utilised/available.
It had been captured in the notes that there had been a referral to the Tissue Viability Nursing team in October. There was no system in the home to chase up the team after a number of weeks had elapsed and there had been no response. The inquest heard that even in non-urgent cases the Tissue Viability Nursing team would contact a home requesting support in at least 10 days and more quickly in an urgent case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a system to follow up unanswered specialist referrals
Wider context from the report “The inquest heard that within the home the forms used did not capture the deterioration of the pressure ulcer or require detailed monitoring/use of photographs to track its progress. This meant that the significant and steep deterioration was not recognised and escalated at an early opportunity to the Tissue Viability Nursing team for expert wound management input. As a result the type of wound dressing he required were not utilised/available.
It had been captured in the notes that there had been a referral to the Tissue Viability Nursing team in October. There was no system in the home to chase up the team after a number of weeks had elapsed and there had been no response . The inquest heard that even in non-urgent cases the Tissue Viability Nursing team would contact a home requesting support in at least 10 days and more quickly in an urgent case.
” 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 Require Fernlea staff to obtain email read receipts, telephone the service the following day, and record confirmed visit dates.
Verbatim wording from the response “It is now standard practice for Fernlea nursing home to ensure a read receipt is requested so that the referring home can check to ensure that the email has been accessed / read by the Tissue Viability Team. In addition a follow up telephone call is made to the service the following day, irrespective of the pressure ulcer urgency status; during this call the date for a visit from the team is confirmed and added to the nursing home diary.” Source location 2019-0433-Response-from-Stockport-NHS-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 Implement electronic pressure-ulcer photography at identification and regular intervals to monitor deterioration.
Verbatim wording from the response “• Record Keeping Review in response to the issue that documentation in relation to the pressure ulcer failed to reflect the deterioration, and that photographs were not used to track the progress.” Source location 2019-0433-Response-from-Stockport-NHS-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 Adopt the Stockport pressure-ulcer monitoring form for consistent, regular monitoring.
Verbatim wording from the response “I am pleased to note that the nursing home has now adopted the Stockport NHS Foundation Trust pressure ulcer monitoring form to ensure consistent and regular monitoring of pressure ulcers.” Source location 2019-0433-Response-from-Stockport-NHS-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 Change Tissue Viability referrals from fax to email and add prompts to follow up referrals not actioned within two working days.
Verbatim wording from the response “• Refresh of the requirements of the referral to Tissue Viability service process in response to the issues of the delay in escalation to the specialist Tissue Viability Nursing Team despite clear signs of deterioration, and No evidence of a robust system to track the status of a referral to the Tissue Viability Nursing Team” Source location 2019-0433-Response-from-Stockport-NHS-Redacted
Open published response
Concerns raised 1 Failure to adequately assess overdose risk before changing prescription frequency View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Clive Miles · 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
Clive Miles was found dead at his home on 31 May 2019. Toxicology found toxic amounts of morphine, codeine and sertraline, and the pathologist concluded that the combination caused his death. The principal concern was that his prescriptions had been changed from weekly to monthly despite limited evidence of assessment of the risk, leaving him with a significantly increased quantity of 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 adequately assess overdose risk before changing prescription frequency
Wider context from the report “The inquest was told that previously Clive Miles had been changed to weekly prescriptions because he had overdosed on prescribed medication when on monthly prescriptions. In the week before his death his General Practitioner had moved him back to monthly prescribing believing that the risk no longer existed based on a discussion with him about how he was at that time. There was limited evidence of any assessment of the risk or the need to change the prescribing pattern. As a result he was in possession of a significantly increased quantity of medication in comparison to the amount he had been restricted to on weekly prescriptions.
” 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 Remind all Stockport GPs to record clear, detailed reasons and factors supporting changes to prescribing frequency.
Verbatim wording from the response “Stockport CCG is committed to learning and with this case in mind I will ensure that all GPs across the Stockport patch are reminded of the importance of recording clear and detailed notes explaining the basis on which any change to prescribing frequency has been made.” Source location 2019-0432-Response-from-NHS-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 The decision to change prescribing frequency rests on the treating clinician’s judgement at the consultation.
Verbatim wording from the response “The decision to amend the frequency of prescribing is based on the clinician’s judgement at the time of the consultation. Unfortunately, there is no standard risk assessment tool that is currently evidenced to be effective. The tools that are available are either not specific enough or not sensitive enough. This essentially means that assessment of risk is a clinical” Source location 2019-0432-Response-from-NHS-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 No standard risk assessment tool can be adopted because available tools lack sufficient specificity or sensitivity and are not evidenced as effective.
Verbatim wording from the response “The decision to amend the frequency of prescribing is based on the clinician’s judgement at the time of the consultation. Unfortunately, there is no standard risk assessment tool that is currently evidenced to be effective. The tools that are available are either not specific enough or not sensitive enough. This essentially means that assessment of risk is a clinical” Source location 2019-0432-Response-from-NHS-Stockport-Clinical-Commissioning-Group
Open published response
Concerns raised 1 Failure to control prescribed opiate dosage 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
Catherine Mary McNamara · 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
Catherine Mary McNamara was found dead at home on 11 May 2019, having probably died in the early hours of 9 May 2019. She had been prescribed high levels of opiates over a number of years, and the inquest heard that prescribed opiate toxicity, in combination with over-the-counter medication, contributed to her death; efforts to reduce the dosage had been challenging.
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 control prescribed opiate dosage
Wider context from the report “The inquest heard that over a number of years the amount of prescribed opiates had increased to a level where they led her to fall asleep and fall over . After concerns were raised by her family, the General Practitioner and the pain clinic began to work with her to decrease the amount of prescribed opiates she received. This was challenging due to the high dose she had been on . At the time of her death she was on a high level (although it had decreased from the previous higher level) . The coroner was advised how she had reached such high levels initially and the understanding of the impact this had on her.
” Open source report
Concerns raised 6 Failure to engage families and work with them to support people in the community View source Lack of a clear CMHT policy for effectively engaging families View source Failure to provide regular CMHT contact in the community View source Failure to escalate or discuss very limited post-discharge contact View source Failure to make a follow-up appointment at discharge View source Failure to allocate people moving between borough teams to a community psychiatrist 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
Steven Keith Marsland · 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 Keith Marsland, who had a complex mental health background, was found suspended from a ligature on 10 June 2019; the inquest conclusion was suicide and the medical cause of death was hanging. Concerns included insufficient engagement with his family after discharge, failure to arrange a community psychiatric follow-up appointment, and limited contact with the Community Mental Health Team without escalation or discussion.
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 engage families and work with them to support people in the community
Wider context from the report “1. The inquest heard that his family were very supportive and had attended MDT meetings whilst he was an in-patient. Following his discharge there was no attempt to engage his family and obtain information from them or work with them to support him in the community. There was no clear policy about how a family could be effectively engaged by the CMHT;
” Open source report × Source evidence
How 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 clear CMHT policy for effectively engaging families
Wider context from the report “1. The inquest heard that his family were very supportive and had attended MDT meetings whilst he was an in-patient. Following his discharge there was no attempt to engage his family and obtain information from them or work with them to support him in the community. There was no clear policy about how a family could be effectively engaged by the CMHT ;
” Open source report × Source evidence
How 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 regular CMHT contact in the community
Wider context from the report “3. The inquest heard that it was recognised as part of his discharge planning that there should be regular contact in the community with the CMHT. That did not happen and there was no escalation or discussion about the picture of very limited contact as it evolved post discharge.
” Open source report × Source evidence
How 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 escalate or discuss very limited post-discharge contact
Wider context from the report “3. The inquest heard that it was recognised as part of his discharge planning that there should be regular contact in the community with the CMHT. That did not happen and there was no escalation or discussion about the picture of very limited contact as it evolved post discharge .
” Open source report × Source evidence
How 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 make a follow-up appointment at discharge
Wider context from the report “2. The inquest heard that he was treated as an in-patient by the Pennine Care team within Stockport MBC. His consultant whilst he was an in-patient was part of the Stockport Team. If he had been a Stockport Resident he would have been discharged under the care of that consultant in the community and had a follow up appointment booked with that Doctor at discharge. However because he was a Tameside Resident at discharge his care moved to the Tameside Borough Pennine Care Team. That meant he had to be allocated to a community psychiatrist based there. That did not happen and no follow up appointment was made ;
” Open source report × Source evidence
How 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 allocate people moving between borough teams to a community psychiatrist
Wider context from the report “2. The inquest heard that he was treated as an in-patient by the Pennine Care team within Stockport MBC. His consultant whilst he was an in-patient was part of the Stockport Team. If he had been a Stockport Resident he would have been discharged under the care of that consultant in the community and had a follow up appointment booked with that Doctor at discharge. However because he was a Tameside Resident at discharge his care moved to the Tameside Borough Pennine Care Team. That meant he had to be allocated to a community psychiatrist based there. That did not happen and no follow up appointment was made;
” Open source report
Concerns raised 11 Failure to ensure pharmacists and clinical teams apply consistent ferritin-checking expectations View source Lack of regular independent peer review of coronial autopsy reports and processes View source Lack of a documented and recorded referral process between District Nurses and Tissue Viability Nurses View source Shortage of staff within the Tissue Viability Nurse team View source Failure to produce accurate and satisfactory coronial post-mortem reports View source Inadequate emergency response arrangements for out-patient iron infusions View source Failure to obtain ferritin levels for anaemia management View source Insufficient access to appropriate dressings for severe pressure sores View source Unclear Royal College of Nursing instructions on continuous observation during iron infusions View source Unclear instructions on continuous observation during iron infusions View source Failure to record pharmacist-clinician discussions and advice View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Christopher Byron · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher Byron, who had multiple sclerosis and had become bedbound, developed infected pressure sores and was admitted to hospital. He received a second intravenous iron infusion on 9 January 2017 without adequate consideration of the risks and was not observed for 30 minutes afterwards; he suffered cardiac arrest within minutes and died. Concerns included inadequate continuity and documentation of nursing and pharmacy care, shortages of staff and dressings, unclear observation guidance for iron infusions, and inaccurate post-mortem reporting that failed initially to identify anaphylaxis.
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 pharmacists and clinical teams apply consistent ferritin-checking expectations
Wider context from the report “2. In addition there was no evidence that on the 30th December or the 9th January 2017 the pharmacist checked Mr Byrons ferritin level . The Court heard from the Clinical lead pharmacist that he would expect this to be done. There was a clear difference between the advice and expectations of the pharmacist and the Clinical 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 Lack of regular independent peer review of coronial autopsy reports and processes
Wider context from the report “3. It is noted there is no regular (independent) peer review of coronial autopsy reports and processes in order to maintain consistency of agreed standards, governance and accountability as was advised within the 2006 National Confidential Enquiry into Patient Death and Outcome (NCEPOD) and reiterated within the Hutton review of forensic pathology of England and Wales in 2015.
” Open source report × Source evidence
How 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 documented and recorded referral process between District Nurses and Tissue Viability Nurses
Wider context from the report “1. The Court heard evidence that since the death of Mr Byron the District Nursing and Tissue Viability Nurses (TVNs) are now managed as part of the Northern Care Alliance and are jointly located. However there is no documented policy for the referring of patients from the District Nurses to the TVNs . “Unofficial” referrals could occur by way of conversations within the office and there is no policy to ensure these are recorded in writing and recorded in the patients notes . The Court heard evidence that such a referral was thought to have occurred in September 2016 but this was not documented anywhere.
2. Likewise if a referral is sent by email there no instruction to staff that such email must be uploaded into the patients records in order for it to be clearly seen by all workers that the patient has been referred.
” Open source report × Source evidence
How 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 Shortage of staff within the Tissue Viability Nurse team
Wider context from the report “3. Shortage of staff. One of the reasons there was a lack of continuity in the care of Mr Byron was the shortage of staff and the increased workload on the remaining staff. The Court was advised there remains a shortage of staff within the Tissue Viability Nurse 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 produce accurate and satisfactory coronial post-mortem reports
Wider context from the report “1. The quality of the post mortem examination report produced by ████████ was wholly unsatisfactory and proven inaccurate . This meant both the bereaved family and the Trust were initially provided with an inaccurate medical cause of death. As a direct consequence the ability to learn lessons in order to prevent future deaths was not captured in a timely manner. It was not until the Coroner obtained a report from ████████ in 2018 that anaphylaxis was offered as a potential cause of death. Even then, the Court was left having to consider the totality of the evidence and it was not until the inquest that a finding of fact as to the medical cause of death was made.
2. It should be noted the quality of ████████ post mortem practice has been and remains questionable in over 20 Inquests within the North Manchester Coronal area. This is not an isolated case. In this particular case there was clear evidence that the post mortem failings directly impacted on potential lack of clinical learning to prevent future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate emergency response arrangements for out-patient iron infusions
Wider context from the report “5. In addition for out-patients who may receive an iron infusion the Court received evidence that they would be handed a buzzer . The Court would question how this would be of use should a patient suffer a cardiac arrest such occurred with Mr Byron. Points 4 and 5 link into the Regulation 28 to the Royal College of Nursing also.
” Open source report × Source evidence
How 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 obtain ferritin levels for anaemia management
Wider context from the report “1. In this case the Trust Guideline ‘Patient Blood Management of Medical Patients’ sets out the Pathway for the Management of Anaemia. In addition to this Trust documents there is NICE guidance for Anaemia – iron deficiency (revised 2018). Both of these documents include as a key factor the obtaining of ferritin levels , albeit the question as to the interpretation of such results will be dependant on the patients presenting condition. On the 30th December 2016 no sample was taken to check the ferritin levels .
” Open source report × Source evidence
How 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 access to appropriate dressings for severe pressure sores
Wider context from the report “1. The Court heard evidence that at times there was a lack of appropriate dressings in order to treat Mr Byrons infected pressure sores. The Court heard evidence the District Nurses cannot order more than two weeks worth of dressings for any individual patient and cannot hold extra stock . In Mr Byrons case due to the severity and location of the pressure sores there were times when he used more dressings, especially if they came away from the wounds. This could lead to a shortage and meant him having to wait for dressings . In someone with severe pressures sores the requirement to have access to the appropriate dressings is important. The Court heard this instruction regarding the ordering of dressings is governed by the Clinical Commissioning Group.
” Open source report × Source evidence
How 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 Royal College of Nursing instructions on continuous observation during iron infusions
Wider context from the report “1. In the most recent guidance from the Royal College of Nursing dated May 2019, “Iron Deficiency and Anaemia in Adults” the instruction to nurses is for them to “observe the patient for 30 minutes”. The Court heard evidence from the Divisional Director of Nursing for the Northern Care Alliance who told the Court, in his view this instruction to nurses is unclear . This instruction was felt to be open to interpretation as to whether this means nurses should physically remain with the patient constantly for 30 minutes . If this is what is meant then it was suggested the instruction could be made more specific.
” Open source report × Source evidence
How 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 instructions on continuous observation during iron infusions
Wider context from the report “4. The Court heard the Trust Guideline ‘Patient Blood Management of Medical Patients’ indicated the patient was to be observed for 30 minutes during the administration of the iron infusion. Due to a lack of recording the nurse who administered the iron infusion on the 30th December 2017 could not be identified. The nurse on the 9th January 2017 gave evidence to the Court that this was the first time she had administered an iron infusion and she was advised by the Sister to “treat it as a blood transfusion” whereby his observations were taken before and immediately after commencement of the infusion and observations taken every 15 minutes. Hence Mr Byron was left alone during the administration of the iron infusion. The Court heard the policy was unclear as to whether it meant nurses had to remain with the patient constantly for 30 minutes .
” Open source report × Source evidence
How 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 record pharmacist-clinician discussions and advice
Wider context from the report “3. The Court heard of discussions which take place between the Pharmacists and clinicians. These can take place at times when the pharmacist is off the ward. In these circumstances there is no ability for the pharmacist to record such discussions . There was no record anywhere of any discussions on the 30th December 2016 or the 9th January 2017 and any such advice provided, so there was no way of confirming if such conversations had taken place.
” Open source report
1 Oct 2019 Oliver Sharp · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure of schools to recognise risks and early signs associated with acceleration ahead of chronological school age View source Additional challenge associated with disability labelling for ageing children with autism View source Long waiting lists for autism assessments View source Variation and limited transition provision in post-16 mental health 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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Oliver Sharp · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Oliver Sharp died after taking a fatal dose of heroin; his death was confirmed at Wythenshawe Hospital on 18 October 2018. The inquest identified concerns about failures by mental health services to recognise and respond to his increasing level of risk during his transition from child and adolescent mental health services to reduced post-16 provision, as well as concerns about delays in autism assessment and variation in post-16 services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of schools to recognise risks and early signs associated with acceleration ahead of chronological school age
Wider context from the report “During the inquest evidence was heard that acceleration ahead of a chronological school age might cause relatively few difficulties in peer relationships up to about year 9 but post that as children entered adolescence it could become a significant issue impacting a child’s mental health and ability to cope . Where it did happen, there needed to be an understanding by schools of the risks and early signs indicating a need for additional support to try to reduce the likelihood of self-harming behaviours and the potential need for additional support.
” Open source report × Source evidence
How 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 Additional challenge associated with disability labelling for ageing children with autism
Wider context from the report “The inquest heard that Oliver had found the autism label and the label of disability that was attached to it very difficult to accept as time went on . There was evidence that particularly with ageing children with autism the idea that they had a disability created additional challenge .
The language that it would have been more helpful to use widely would have been difference rather than disability.
” Open source report × Source evidence
How 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 Long waiting lists for autism assessments
Wider context from the report “The inquest was told that it is important for autism to be diagnosed as early as possible so that appropriate support can be put in place. Early diagnosis was impacted by a national picture of long waiting lists for ADOS assessments . In Stockport there was approximately a 6 month waiting list for assessment . This was against a national picture of 12-24 month waits in some areas .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Variation and limited transition provision in post-16 mental health services
Wider context from the report “The inquest was told that the provision of mental health services post 16 varies widely across the country . In some areas there is a CAMHS 16-25 mental health service provision similar to the national 16 and under service whereas in other areas there a limited transition service or move back to primary care for re-referral to adult services . The inquest was told that this creates a cliff edge high risk situation for adolescents . The reason for the difference was resources and decisions taken by CCGs.
” Open source report
30 Sep 2019 Kaiya Sonja Campbell · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Lack of GP practice records of recent medication prescribing View source Failure to identify high-risk status when determining consultant appointment urgency View source Failure of clinical staff to seek urgent neurology guidance on ongoing prescribing 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
Kaiya Sonja Campbell · 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
Kaiya Sonja Campbell was born at Tameside General Hospital on 28 September 2019 following her mother’s extensive bleeding and early rupture of the membranes. She lived briefly and died soon after birth, with the medical cause recorded as extreme prematurity at 19 weeks and 6 days’ gestation. Concerns included gaps in records of her mother’s anticonvulsant prescriptions, failure to seek urgent neurology guidance, and the offering of a routine rather than appropriately identified high-risk consultant appointment.
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 GP practice records of recent medication prescribing
Wider context from the report “Her GP practice did not have any records of recent medication being prescribed although there was clear evidence given to the inquest of regular request for repeat prescriptions being requested and dispensed by a local pharmacy. It was not possible to establish at the inquest why this gap in records existed ;
” Open source report × Source evidence
How 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 identify high-risk status when determining consultant appointment urgency
Wider context from the report “Despite her mother falling into the high risk category, a routine consultant appointment was offered . There was no clarity as to how this need was not picked up at the time .
” Open source report × Source evidence
How 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 clinical staff to seek urgent neurology guidance on ongoing prescribing
Wider context from the report “When Kaiya's mother attended at her GP appointment and her midwifery booking-in appointment, the clinical staff involved did not appreciate the need to seek urgent guidance themselves from the neurology department regarding ongoing prescribing to reduce the risk of foetal abnormalities to the unborn child;
” Open source report
Concerns raised 5 Failure of GPs to recognise the link between the therapy and Pulmonary Fibrosis View source Failure to seek early guidance from the prescribing secondary care physician View source Failure to refer prescription amendments to the secondary care doctor for medication not started in primary care View source CCG classification of the drug as green despite known side effects View source Lack of GP awareness of escalation procedures for medication side effects View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Graham Earl · 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
Graham Earl had pulmonary fibrosis diagnosed while receiving Amiodarone therapy and was not referred back to the cardiologist. He later developed influenza, deteriorated, and died at Stepping Hill Hospital on 16 February 2019. The principal concerns were that the link between Amiodarone and pulmonary fibrosis was not recognised promptly, the medication was amended without reference to secondary care, and there was insufficient awareness of escalation procedures for side effects.
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 GPs to recognise the link between the therapy and Pulmonary Fibrosis
Wider context from the report “1. The GPs involved did not understand or recognise the known link between the therapy and Pulmonary Fibrosis and did not seek guidance from the prescribing secondary care physician at an early stage. The evidence was that the advice would have been to stop prescribing immediately;
” Open source report × Source evidence
How 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 seek early guidance from the prescribing secondary care physician
Wider context from the report “1. The GPs involved did not understand or recognise the known link between the therapy and Pulmonary Fibrosis and did not seek guidance from the prescribing secondary care physician at an early stage . The evidence was that the advice would have been to stop prescribing immediately;
” Open source report × Source evidence
How 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 refer prescription amendments to the secondary care doctor for medication not started in primary care
Wider context from the report “2. A GP amended the prescription subsequently without reference to the secondary care doctor despite the fact that this is not a medication started in primary 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 CCG classification of the drug as green despite known side effects
Wider context from the report “4. The drug is currently green on the CCG classification . In other CCG areas it is amber given the known side effects .
” Open source report × Source evidence
How 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 awareness of escalation procedures for medication side effects
Wider context from the report “3. The indication was that GPs involved were not aware of what they should do if there were side effects from the medication in terms of escalation ;
” Open source report
Concerns raised 2 Failure to discontinue promazine after specialist advice to stop it View source Failure of information sharing between GPs and psychiatrists about sedative and antipsychotic medication decisions 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
Miriam Tighe · 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
Miriam Tighe became a resident of Edge Hill Residential Home in August 2016 and later received hospital and residential nursing care before passing away on 28 February 2017. The report identified concerns that promazine and other sedative or antipsychotic medication continued to be prescribed and administered despite advice to stop promazine, and that communication between GPs and a psychiatrist was insufficient, leading to unsafe prescribing. The investigation recorded that her death followed naturally occurring disease, with high levels of sedation and immobility in the preceding months worsening her frailty.
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 discontinue promazine after specialist advice to stop it
Wider context from the report “Promazine was sought by the home manager at Edge Hill Residential Home and prescribed by the GPs at Royton & Crompton family practice after ████████ (Psychiatrist working in the Memory Clinic (part of Pennine Care NHS Foundation Trust)) had advised that such medication be stopped on the 16th November 2016 and, again on the 16th December 2016 . On both occasions, promazine continued to be prescribed by the GP and continued to be administered under the control of the manager at Edge Hill Residential Home . In the event, I found that Miriam Tighe had been over-sedated during her time as a resident at Edge Hill Residential Home. The psychiatrist had recommended alternative sedative and antipsychotic medication, which was also administered to Miriam Tighe. It was clear that the GPs and the Psychiatrist were not aware of decisions being made by each other in October to December 2016, which led to unsafe prescribing of sedatives and antipsychotic 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 of information sharing between GPs and psychiatrists about sedative and antipsychotic medication decisions
Wider context from the report “Promazine was sought by the home manager at Edge Hill Residential Home and prescribed by the GPs at Royton & Crompton family practice after ████████ (Psychiatrist working in the Memory Clinic (part of Pennine Care NHS Foundation Trust)) had advised that such medication be stopped on the 16th November 2016 and, again on the 16th December 2016. On both occasions, promazine continued to be prescribed by the GP and continued to be administered under the control of the manager at Edge Hill Residential Home. In the event, I found that Miriam Tighe had been over-sedated during her time as a resident at Edge Hill Residential Home. The psychiatrist had recommended alternative sedative and antipsychotic medication, which was also administered to Miriam Tighe. It was clear that the GPs and the Psychiatrist were not aware of decisions being made by each other in October to December 2016 , which led to unsafe prescribing of sedatives and antipsychotic medication .
” Open source report
Concerns raised 4 Failure to communicate clinically significant butane gas use and consumption amount to the GP practice View source Failure to transfer the full medical records and past medical history to the new substance misuse service View source Failure to conduct a full review of all prescribed medications View source Failure to respond to and action clinical information requests from the substance misuse service 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
Beverley Shaw · 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
Beverley Shaw was found deceased in her bed at home in Oldham in the early hours of 11 December 2018. The inquest heard that she had multiple prescribed medicines, was receiving methadone, and was using cocaine and butane gas. Concerns included inadequate communication between the substance misuse service and GP practice about her butane gas use, lack of a full medication review, and incomplete transfer of medical records.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate clinically significant butane gas use and consumption amount to the GP practice
Wider context from the report “○ There was a lack of communication between Turning Point and the GP practice specifically in respect of Ms Shaw’s use of butane gas. There was no information contained in the evidence before the Court to indicate her GP was aware of the use of butane gas , which was significant (ie 5 cans a day). This was described in evidence by Turning Point as her most significant addiction which was not amenable to treatment with medication. There was one 4 page letter dated the 15th May 2018 from Turning Point to the GP practice, in the summary section this simply recorded, “Uses butane gas daily.” In the section headed “Current Reported Substance Use” there is no mention of butane gas. The remainder of this letter deals with other matters. No information was shared with the GP with regards to the amount of gas being used by Ms Shaw.
” Open source report × Source evidence
How 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 transfer the full medical records and past medical history to the new substance misuse service
Wider context from the report “○ The Court heard evidence that following the transition from another provider to Turning Point a decision was taken that all medical records relating to users of the substance misuse service do not need to be carried over to Turning Point . Unlike other medical records ie GP records which go with the patient when they move surgery the new substance misuse service only receives the last 6 months records hence they do not have the full past medical history 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 to conduct a full review of all prescribed medications
Wider context from the report “○ A medication review took place in the GP practice in August 208, this only documented a review of her olanzapine medication and the fact that she was in receipt of methadone and using cocaine. There is no evidence that there was a full review of all the medications prescribed to Ms Shaw. When questioned it was accepted in Court it was unclear as to why she was still being prescribed a number of medications.
” Open source report × Source evidence
How 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 respond to and action clinical information requests from the substance misuse service
Wider context from the report “○ There is no record of a response from the GP practice to Turning Point following their letter dated the 15th May 2018. This had a number of requests for actions by the GP including the sharing of any blood results (LFT, FC and U&E), together with information confirming whether there was any blood disorders of drugs which may interact with methadone. There was no evidence that this information was shared or actioned.
” 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 Communicate the butane-misuse EMIS code to all Oldham GP practices as a review lesson.
Verbatim wording from the response “In respect of the butane gas use, the appropriate electronic code has been identified to flag misuse of butane on the EMIS system. This will be communicated to all practices as part of the lessons learned from this review to ensure that all Oldham GP practices are aware of this code.” Source location 2019-0191-Response-by-Oldham-NHS-CCG
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 Identify the EMIS electronic code for flagging butane misuse.
Verbatim wording from the response “In respect of the butane gas use, the appropriate electronic code has been identified to flag misuse of butane on the EMIS system. This will be communicated to all practices as part of the lessons learned from this review to ensure that all Oldham GP practices are aware of this code.” Source location 2019-0191-Response-by-Oldham-NHS-CCG
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 Address identified locum GP competency issues through appropriate channels.
Verbatim wording from the response “From a system perspective, there is clear learning in reviewing the medication and prescribing issues identified in Ms Shaw’s situation. This has highlighted some locum GP competency issues within the practice that have been addressed through the appropriate channels. The learning that has arisen from reviewing this lady’s care as a significant event has emphasised the importance of careful consideration of methadone use and subsequent or potential prescribed medication interactions. There is the facility for medications prescribed external to the practice (i.e. hospital or externally commissioned service such as Turning Point) to be entered into the EMIS system and therefore prompt alerts. This will also be highlighted to all practices and supported through the clinical pharma in-reach into all clusters.” Source location 2019-0191-Response-by-Oldham-NHS-CCG
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 wider uptake of Focussed Care across Oldham practices to support substance-use-related care.
Verbatim wording from the response “The events surrounding Ms Shaw’s death highlight the requirement for effective and up to date ‘Did Not Attend’ policies to be followed in Primary Care and to initiate discussion in practice meetings to ensure holistic information is shared and reviewed by the team in a manner which supports clinicians to make decisions based on the full facts and influencing factors. Such discussions can trigger communication back to secondary providers such as Turning Point to clarify and/or share information. The presence of Focussed Care within a number of Oldham practices has been seen to support such instances where substance use influences existing co-morbidities and as a CCG we are promoting wider uptake of this across the Oldham footprint.” Source location 2019-0191-Response-by-Oldham-NHS-CCG
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 Highlight recording externally prescribed medicines in EMIS, and associated interaction alerts, to all practices through clinical-pharmacist cluster support.
Verbatim wording from the response “From a system perspective, there is clear learning in reviewing the medication and prescribing issues identified in Ms Shaw’s situation. This has highlighted some locum GP competency issues within the practice that have been addressed through the appropriate channels. The learning that has arisen from reviewing this lady’s care as a significant event has emphasised the importance of careful consideration of methadone use and subsequent or potential prescribed medication interactions. There is the facility for medications prescribed external to the practice (i.e. hospital or externally commissioned service such as Turning Point) to be entered into the EMIS system and therefore prompt alerts. This will also be highlighted to all practices and supported through the clinical pharma in-reach into all clusters.” Source location 2019-0191-Response-by-Oldham-NHS-CCG
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 Clinical Pharmacists cannot reconcile every patient’s medications because current resources do not permit it; entering external prescriptions is considered safer.
Verbatim wording from the response “From a system perspective, there is clear learning in reviewing the medication and prescribing issues identified in Ms Shaw’s situation. This has highlighted some locum GP competency issues within the practice that have been addressed through the appropriate channels. The learning that has arisen from reviewing this lady’s care as a significant event has emphasised the importance of careful consideration of methadone use and subsequent or potential prescribed medication interactions. There is the facility for medications prescribed external to the practice (i.e. hospital or externally commissioned service such as Turning Point) to be entered into the EMIS system and therefore prompt alerts. This will also be highlighted to all practices and supported through the clinical pharma in-reach into all clusters.” Source location 2019-0191-Response-by-Oldham-NHS-CCG
Open published response
Concerns raised 1 Unavailability of integrated mental health counselling and alcohol detoxification services View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Alan Price · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Alan Price had a long history of alcohol use to cope with mental health difficulties and was found at home on 12 November 2018. The inquest heard that he would have benefited from an integrated mental health counselling and detoxification service, which was not available in Stockport.
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 Unavailability of integrated mental health counselling and alcohol detoxification services
Wider context from the report “The inquest heard evidence that David Alan Price had a long standing problem with alcohol which he used to self-medicate his anxiety in particular. He made a number of attempts to give up alcohol. These were ultimately unsuccessful. The inquest heard that one of the challenges was to provide support which would enable him to treat his mental health difficulties e.g. anxiety alongside detoxification and supporting him in staying alcohol free. The inquest heard that he would have benefited from an integrated mental health counselling/detoxification service. This would have enabled joint treatment. Such a programme is not available in Stockport.
” 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 Existing services are considered sufficient to meet the needs of people with co-occurring mental health and alcohol problems.
Verbatim wording from the response “We recognise that with these services in place Mr Price should have been able to benefit from them, but did not. The CCG and Local Authority have reviewed and are recommending the following actions:” Source location 2019-0145-Response-by-Stockport-NHS-CCG
Open published response
14 Feb 2019 John Andrew Mellor · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3 Failure to establish shared care arrangements or identify an organisation for blood sampling for drug monitoring View source Failure to ensure required blood tests for individuals under specialist secondary care for renal failure View source Failure to communicate referral responses, referral updates and community test requests directly to primary care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
John Andrew Mellor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Andrew Mellor had diabetes mellitus, chronic kidney disease and deep vein thrombosis, and died on 3 October 2018 after collapsing at home following the discovery of a very low blood count requiring urgent transfusion. The report describes repeated difficulties in arranging required blood tests, with responsibility passed between agencies and no clear shared-care or testing arrangement. It also raises concern that communications about referrals and test requests were not sent directly to primary care, relying instead on the patient to pass on vital information.
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 establish shared care arrangements or identify an organisation for blood sampling for drug monitoring
Wider context from the report “That there appears to have been a systematic failure to ensure that blood tests are conducted, where required, for individuals under specialist, secondary care for renal failure. Individual patients, who may not be local to the specialist centre, will inevitably fail to have the appropriate assessments, care and treatment, in the absence of a clear line of responsibility.
The failure to establish a shared care arrangement, or at least to ensure that an organisation was identified in order to undertake blood sampling for drug monitoring, is insecure and unsafe.
It is also concerning that responses or updates to referrals, as well as requests for tests in the community, have not been communicated to primary care directly, with the sole reliance on a patient to pass vital documentation on to his primary healthcare provider.
” Open source report × Source evidence
How 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 required blood tests for individuals under specialist secondary care for renal failure
Wider context from the report “That there appears to have been a systematic failure to ensure that blood tests are conducted, where required, for individuals under specialist, secondary care for renal failure . Individual patients, who may not be local to the specialist centre, will inevitably fail to have the appropriate assessments, care and treatment, in the absence of a clear line of responsibility .
The failure to establish a shared care arrangement, or at least to ensure that an organisation was identified in order to undertake blood sampling for drug monitoring, is insecure and unsafe.
It is also concerning that responses or updates to referrals, as well as requests for tests in the community, have not been communicated to primary care directly, with the sole reliance on a patient to pass vital documentation on to his primary healthcare provider.
” Open source report × Source evidence
How 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 communicate referral responses, referral updates and community test requests directly to primary care
Wider context from the report “That there appears to have been a systematic failure to ensure that blood tests are conducted, where required, for individuals under specialist, secondary care for renal failure. Individual patients, who may not be local to the specialist centre, will inevitably fail to have the appropriate assessments, care and treatment, in the absence of a clear line of responsibility.
The failure to establish a shared care arrangement, or at least to ensure that an organisation was identified in order to undertake blood sampling for drug monitoring, is insecure and unsafe.
It is also concerning that responses or updates to referrals, as well as requests for tests in the community, have not been communicated to primary care directly , with the sole reliance on a patient to pass vital documentation on to his primary healthcare provider .
” Open source report
Concerns raised 3 Insufficient psychotherapy capacity causing prolonged waits View source Lack of available in-patient psychotherapy View source Inappropriate waiting-time target for urgent psychotherapy View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Heather Louise Carey · 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
Heather Louise Carey was admitted to mental health services in July 2017, later took an overdose of paracetamol, and was placed on a 24-week waiting list for Cognitive Analytical Therapy. She hanged herself at home on 20 December 2017. The principal concern was that lengthy waits for psychotherapy and inadequate action to address her high suicide risk may have contributed to her 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 Insufficient psychotherapy capacity causing prolonged waits
Wider context from the report “The inquest identified a number of issues which likely contributed to Heather's decision to end her life. One of those issues related to the long wait following discharge before psychotherapy would begin.
At the time of Heather's admission to TGH there was no psychotherapy available to her as an in-patient because there were insufficient funds available to provide the same. I was told that had been addressed by further funding being made available.
At the time of Heather's assessment on 22.11 staffing levels were reduced, through illness and a vacancy, and there was only one psychotherapist available . That was the reason given for the 24 weeks wait .
At the inquest I heard evidence that the target waiting list was 18 weeks. Further, that by the time of the inquest that target time was being met. A target waiting time of 18 weeks, I was told, was comparable to ‘cancer waiting times’. However, it transpires that those are the maximum waiting times for non-urgent consultant led treatment for any treatment from the point of referral. Heather was already in receipt of consultant led care. Her need was urgent. Thus such a comparator on waiting times to justify an 18 weeks wait for psychotherapy is not an appropriate measure.
By letter dated 3rd January 2019 Pennine Care responded to my concerns about the long waiting list as follows,
“The CCG are currently in dialogue with Pennine Care in relation to waiting times for Secondary Care psychological therapies to ensure that existing (emphasis added) resources are effectively utilised and capacity and demand is reviewed to inform commissioning requirements.”
It was clear from the evidence heard, not only from Heather's mother and partner but from those involved in her care, that Heather had placed great faith in psychotherapy as the means by which she would bring mental stability back to her life, a release from the increasingly extreme mood swings of her bi-polar disorder. It is not difficult to imagine the despair and distress felt by Heather to be told that it would be almost 6 months before she could even begin the help/treatment she was seeking on voluntary admission some 4 months previously.
A target waiting list of 18 weeks is far too long but I was told that this was a funding issue.
Unless adequate and sufficient measures are taken to significantly reduce waiting times for acute mental ill-health, comparable to physical life threatening illnesses, NOT simply a redistribution of existing resources, more patients with mental health issues will end their lives while on a waiting list for treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of available in-patient psychotherapy
Wider context from the report “The inquest identified a number of issues which likely contributed to Heather's decision to end her life. One of those issues related to the long wait following discharge before psychotherapy would begin.
At the time of Heather's admission to TGH there was no psychotherapy available to her as an in-patient because there were insufficient funds available to provide the same . I was told that had been addressed by further funding being made available.
At the time of Heather's assessment on 22.11 staffing levels were reduced, through illness and a vacancy, and there was only one psychotherapist available. That was the reason given for the 24 weeks wait.
At the inquest I heard evidence that the target waiting list was 18 weeks. Further, that by the time of the inquest that target time was being met. A target waiting time of 18 weeks, I was told, was comparable to ‘cancer waiting times’. However, it transpires that those are the maximum waiting times for non-urgent consultant led treatment for any treatment from the point of referral. Heather was already in receipt of consultant led care. Her need was urgent. Thus such a comparator on waiting times to justify an 18 weeks wait for psychotherapy is not an appropriate measure.
By letter dated 3rd January 2019 Pennine Care responded to my concerns about the long waiting list as follows,
“The CCG are currently in dialogue with Pennine Care in relation to waiting times for Secondary Care psychological therapies to ensure that existing (emphasis added) resources are effectively utilised and capacity and demand is reviewed to inform commissioning requirements.”
It was clear from the evidence heard, not only from Heather's mother and partner but from those involved in her care, that Heather had placed great faith in psychotherapy as the means by which she would bring mental stability back to her life, a release from the increasingly extreme mood swings of her bi-polar disorder. It is not difficult to imagine the despair and distress felt by Heather to be told that it would be almost 6 months before she could even begin the help/treatment she was seeking on voluntary admission some 4 months previously.
A target waiting list of 18 weeks is far too long but I was told that this was a funding issue.
Unless adequate and sufficient measures are taken to significantly reduce waiting times for acute mental ill-health, comparable to physical life threatening illnesses, NOT simply a redistribution of existing resources, more patients with mental health issues will end their lives while on a waiting list for treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inappropriate waiting-time target for urgent psychotherapy
Wider context from the report “The inquest identified a number of issues which likely contributed to Heather's decision to end her life. One of those issues related to the long wait following discharge before psychotherapy would begin.
At the time of Heather's admission to TGH there was no psychotherapy available to her as an in-patient because there were insufficient funds available to provide the same. I was told that had been addressed by further funding being made available.
At the time of Heather's assessment on 22.11 staffing levels were reduced, through illness and a vacancy, and there was only one psychotherapist available. That was the reason given for the 24 weeks wait.
At the inquest I heard evidence that the target waiting list was 18 weeks . Further, that by the time of the inquest that target time was being met. A target waiting time of 18 weeks, I was told, was comparable to ‘cancer waiting times’. However, it transpires that those are the maximum waiting times for non-urgent consultant led treatment for any treatment from the point of referral. Heather was already in receipt of consultant led care. Her need was urgent . Thus such a comparator on waiting times to justify an 18 weeks wait for psychotherapy is not an appropriate measure .
By letter dated 3rd January 2019 Pennine Care responded to my concerns about the long waiting list as follows,
“The CCG are currently in dialogue with Pennine Care in relation to waiting times for Secondary Care psychological therapies to ensure that existing (emphasis added) resources are effectively utilised and capacity and demand is reviewed to inform commissioning requirements.”
It was clear from the evidence heard, not only from Heather's mother and partner but from those involved in her care, that Heather had placed great faith in psychotherapy as the means by which she would bring mental stability back to her life, a release from the increasingly extreme mood swings of her bi-polar disorder. It is not difficult to imagine the despair and distress felt by Heather to be told that it would be almost 6 months before she could even begin the help/treatment she was seeking on voluntary admission some 4 months previously.
A target waiting list of 18 weeks is far too long but I was told that this was a funding issue.
Unless adequate and sufficient measures are taken to significantly reduce waiting times for acute mental ill-health, comparable to physical life threatening illnesses, NOT simply a redistribution of existing resources, more patients with mental health issues will end their lives while on a waiting list for 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 Develop a new psychological therapy model for people with complex mental health needs in Tameside and Glossop.
Verbatim wording from the response “The reviewing team are using this information alongside an exploration of alternative models of care to develop a new model of psychological therapy for people with complex mental health needs in Tameside and Glossop. This review will conclude by the 31 of July 2019.” Source location Response from Tameside Metropolitan Borough
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 Increase annual funding for psychological therapies by £673,000 by 2021.
Verbatim wording from the response “b. Improving access to psychological therapy – the Tameside and Glossop Strategic Commissioning Board has committed additional funding to increase access to psychological therapies. An additional £271,000 agreed in 2018/19 will be increased by an additional £673,000 per annum by 2021 to meet a range of pressures.” Source location Response from Tameside Metropolitan Borough
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 access and quality in psychological therapy services for people with complex mental health needs.
Verbatim wording from the response “a. Psychological Therapies Review - commenced in October 2018 this review focuses on access and quality of psychological therapy services for people with more complex needs including those under the care of the Community Mental Health Teams. The review identified that while NICE concordat therapy services are being provided waiting times for treatment are too long in some services.” Source location Response from Tameside Metropolitan Borough
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 £600,000 recurrently to improve staffing on Tameside Hospital inpatient mental health wards.
Verbatim wording from the response “The CCG has invested £600,000 recurrently to improve staffing on the inpatient mental health wards at Tameside Hospital with a focus on improving safety, patient experience and outcomes. The Trust has invested this funding in improving the skill mix of the teams, including additional clinical psychology and occupational therapy, as well as nursing and admin. The CCG is formally monitoring the impact of this investment through regular Safer Staffing Reports presented to the Pennine Care Quality Group. Reports from staff on the Tameside wards and the latest CQC report indicate that this is having a positive impact.” Source location Response from Tameside Metropolitan Borough
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 £271,000 of additional funding to increase access to psychological therapies during 2018/19.
Verbatim wording from the response “b. Improving access to psychological therapy – the Tameside and Glossop Strategic Commissioning Board has committed additional funding to increase access to psychological therapies. An additional £271,000 agreed in 2018/19 will be increased by an additional £673,000 per annum by 2021 to meet a range of pressures.” Source location Response from Tameside Metropolitan Borough
Open published response
Concerns raised 7 Failure to document and justify the volume of tramadol prescribed despite recorded non-compliance and self-medication View source Failure of the GP practice recording system to accurately distinguish repeat and acute prescriptions View source Failure to explore alternatives to repeated painkiller prescribing for persistent back pain View source Lack of continuity of care preventing a clinician from maintaining an overview of the patient and her health View source Lack of detail in GP and ANP consultation notes View source Failure to document the extent and issues considered during medication reviews View source Medication reviews failing to provide a full overview of prescribed long-term medication View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jacqueline Marie Elliott · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jacqueline Marie Elliott, who had a long-standing history of back pain, was found deceased at home on 9 August 2018. Post-mortem and toxicology findings identified reduced liver function and significant toxicity from a combination of drugs. Concerns included inaccurate prescription records, insufficient clinical notes and medication-review detail, prescribing of 100 tramadol tablets despite a recorded history of non-compliance and self-medication, and a lack of continuity of care.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to document and justify the volume of tramadol prescribed despite recorded non-compliance and self-medication
Wider context from the report “4. There was a recorded history of non-compliance and deliberate self-medication of painkillers by Mrs Elliott. Despite that a GP immediately before her death in a telephone consultation prescribed her with 100 tramadol tablets whilst recording that she needed an urgent review. The rationale for prescribing this volume of medication was unclear from the notes ;
” Open source report × Source evidence
How 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 GP practice recording system to accurately distinguish repeat and acute prescriptions
Wider context from the report “1. The GP practice computer recording system showed drugs that were clearly on repeat prescription as drugs that were acute prescriptions. As a result the inquest was told that the medication reviews carried out would not pick up on and would not review those prescriptions. The medication reviewer would not therefore have a full overview of her prescribed long term 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 explore alternatives to repeated painkiller prescribing for persistent back pain
Wider context from the report “5. There was a lack of continuity of care. Mrs Elliott saw a variety of different locum GPs. This meant that no clinician had an overview of her and her health. As a result, painkillers were repeatedly prescribed and other potential ways of managing her persistent back pain were not explored . This led to a significant reliance by Mrs Elliott on painkillers to manage her on going back problems. The inquest was told that the lack of continuity of care was due to a national shortage of GPs and was a national not local issue.
” Open source report × Source evidence
How 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 continuity of care preventing a clinician from maintaining an overview of the patient and her health
Wider context from the report “5. There was a lack of continuity of care. Mrs Elliott saw a variety of different locum GPs. This meant that no clinician had an overview of her and her health. As a result, painkillers were repeatedly prescribed and other potential ways of managing her persistent back pain were not explored. This led to a significant reliance by Mrs Elliott on painkillers to manage her on going back problems. The inquest was told that the lack of continuity of care was due to a national shortage of GPs and was a national not local issue.
” Open source report × Source evidence
How 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 detail in GP and ANP consultation notes
Wider context from the report “2. The notes made by GPs and the ANP who had seen her/had telephone consultations lacked detail and so it was difficult to assess what information had been provided previously and what advice she had been given ;
” Open source report × Source evidence
How 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 document the extent and issues considered during medication reviews
Wider context from the report “3. There was no detail provided in the notes at the inquest of the extent or issues considered during the medication reviews that were recorded as having taken place ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Medication reviews failing to provide a full overview of prescribed long-term medication
Wider context from the report “1. The GP practice computer recording system showed drugs that were clearly on repeat prescription as drugs that were acute prescriptions. As a result the inquest was told that the medication reviews carried out would not pick up on and would not review those prescriptions . The medication reviewer would not therefore have a full overview of her prescribed long term medication ;
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider running education sessions on non-pharmacological pain management and referral criteria for musculoskeletal services.
Verbatim wording from the response “Increase awareness of and consider running GP, nurse and pharmacist education sessions regarding non-pharmacological management of pain and criteria for referral to MSK service.” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-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 Educate GPs and pharmacists to review acute, repeat and recently issued medicines during medication reviews.
Verbatim wording from the response “Actions agreed with the CCG and in progress” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-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 Review clinical staffing numbers and clinical sessions to support patient continuity and existing staff.
Verbatim wording from the response “The CCG is working very closely with the practice including:” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-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 Liaise with EMIS to request medication-review fields and prompts, while assessing current functionality to improve recording.
Verbatim wording from the response “2. In the EMIS system a medication review is usually recorded by clicking on the medication review date at the bottom of the medication screen. This only allows recording of the read code for medication review and has no facility for recording the details of the review. The only way to record details of the review is to open” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-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 Provide GPs and non-medical prescribers with tools, information and education on safer prescribing and medication review.
Verbatim wording from the response “As a CCG we will offer advice to all GPs and Non-Medical Prescribers around these actions, this will be in the role of an enabler by providing appropriate tools and information/education. Our Medicines Optimisations team will continue to support practices to achieve and maintain the changes through an ongoing system of audit, against the Gold Standard Repeat Prescribing guidelines and medication review.” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-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 Document follow-up plans and dosage advice whenever medication is started.
Verbatim wording from the response “Actions agreed with the CCG and in progress” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-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 Add patient alerts for concerns about overuse of painkillers or other medicines.
Verbatim wording from the response “Actions agreed with the CCG and in progress” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-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 Share learning from the practice improvement plan with all Trafford practices to improve prescribing and repeat prescribing.
Verbatim wording from the response “The learning that the CCG has gained in working with Delamere practice on their improvement plan will be shared with all practices across Trafford to highlight the risks that have been identified in this case. This should also improve the quality of prescribing and repeat prescribing across all Trafford GP practices. Currently we are not aware of any other GP practices with the same level of risk. However to mitigate any potential risk we have now included the risks of repeat prescribing within our level three safeguarding training this commenced on 7th March 2019.” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide and document advice on non-pharmacological treatments when prescribing analgesia.
Verbatim wording from the response “Actions agreed with the CCG and in progress” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning on medication follow-up, dosage advice and non-pharmacological pain treatment with GPs through training and newsletters.
Verbatim wording from the response “1. When medication is started document the plan for follow-up/review and any advice given relating to the dose to take.” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit practices against repeat-prescribing and medication-review standards to support and maintain safety improvements.
Verbatim wording from the response “As a CCG we will offer advice to all GPs and Non-Medical Prescribers around these actions, this will be in the role of an enabler by providing appropriate tools and information/education. Our Medicines Optimisations team will continue to support practices to achieve and maintain the changes through an ongoing system of audit, against the Gold Standard Repeat Prescribing guidelines and medication review.” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-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 Require documentation of reasons and review plans when regular long-term medicines are issued acutely.
Verbatim wording from the response “2. If regular long-term medications are issued as acute – document the reason for this and the plan for review so that when they are issued other prescribers are aware of the plan. Otherwise there is a danger that acute items will be issued long-term without a review, with the person issuing assuming that because it is on acute someone else will review it next time.” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-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 Require medication reviews to record the medicines and content reviewed, with follow-up appointments when reviews are incomplete.
Verbatim wording from the response “The medication review date is primarily set to ensure that repeat medication gets reviewed at regular intervals. As previously stated this should also include a review of any medication on the acute list. A medication review may be a review of the medical notes or a review with the patient in a telephone consultation or face to face.” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-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 Make prescribers aware that EMIS can set review dates for individual medicines.
Verbatim wording from the response “For individual medicines that require an earlier review prescribers should be made aware of the facility to set a review date for that individual medicine (rather than authorisations which are less specific and can be overridden)” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
Open published response
Concerns raised 14 Failure to escalate welfare incidents to the on-call senior manager View source Lack of clarity about police powers and role for Section 136 from-home cases View source Lack of ward staff awareness of telephone restrictions affecting 111 calls View source Unavailability of an out-of-hours mental-health community response service for face-to-face assessment View source Unclear and delayed police-to-ambulance referral process for welfare concerns View source Delays in accepting and passing on welfare concerns because of confidentiality uncertainty View source Conflicting advice about which agency to contact for welfare concerns View source Failure to identify and disclose material call-handling information during investigation View source Absence of a documented Greater Manchester-wide process for welfare concerns involving risk to life View source Delays and failures in handling welfare concerns within acute inpatient psychiatric wards View source Incorrect completion of triage-system questions View source Insufficient investigation of deaths by NWAS View source Failure to provide face-to-face welfare assessment View source Mental-health telephone triage by staff with insufficient mental-health training View source See 11 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Gregory Rekowski · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Gregory Rekowski was detained under the Mental Health Act after being found trying to tie a ligature, discharged from hospital, and later posted “last goodbyes” on social media. He was found hanging at his home on 29 October 2017. The report identified concerns about delays, communication breakdowns, unclear responsibilities and procedures among Pennine Care NHS Trust, Greater Manchester Police and North West Ambulance Service, including the lack of a face-to-face 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 Failure to escalate welfare incidents to the on-call senior manager
Wider context from the report “No-one considered, at any stage the escalation of this incident to the on-call Senior manager when they were having difficulties contacting the emergency services or when GMP had provided the advice to contact NWAS.
” Open source report × Source evidence
How 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 clarity about police powers and role for Section 136 from-home cases
Wider context from the report “There is a lack of acknowledgment of the role of the police when dealing with people who are taken on a Section 136 from their own home. The Court did not explore the numbers of Section 136 patients who are taken to a place of safety from their home address. The Court heard how Mr Rekowski had been taken from his own home on the 17th September. Other agencies are clearly familiar with this process and how GM policiante this was also used as an explanation as to why GMP may have been restricted in what they could do on the 27th and 28th October ie, “...there is nothing we can do if we attend at his home own. We have no powers.” There appears to be a significant difference between the legal position and the practical reality of how police deal with such matters if they are called to a home address. This inconsistency is causing confusion amongst other agencies .
” Open source report × Source evidence
How 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 ward staff awareness of telephone restrictions affecting 111 calls
Wider context from the report “Non of the ward staff were aware of the restrictions on the ward telephones which prohibit 111 calls from being, this meant time was spent trying to make such calls .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of an out-of-hours mental-health community response service for face-to-face assessment
Wider context from the report “The Court heard evidence there is no Mental Health Community Response team available to deal with mental health issues out of hours . The only out of hours service is in A&E which would necessitate someone attending there. Evidence was given as to the substantial increase in such issues being reported to GMP. The Court heard how there is now a mental health professional within the GMP control room to assist with the calls received. However the main issues are in attending to conduct face to face assessments . The police are the service who have a power to enter property, unlike other services. Therefore whilst they may not be best placed in respect of the assessment they are often called. Given the issue in respect of resources laid throughout this Inquest the Court would question the lack of this Mental Health provision .
” Open source report × Source evidence
How 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 and delayed police-to-ambulance referral process for welfare concerns
Wider context from the report “In this case GMP did not call NWAS and asked the nurses to contact NWAS . The Court heard evidence from the Deputy Sector manager for NWAS as to how GMP will contact them to attend concerns for welfare. This was not a process PCT staff were familiar with . This also led to a delay in the call being made .
” Open source report × Source evidence
How 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 accepting and passing on welfare concerns because of confidentiality uncertainty
Wider context from the report “The Court heard the calls between NK and NWAS. Advice was provided to NK that a concern for welfare could not be taken by them due to a potential “breach of confidentiality” . This led to a further delay in this concern for welfare call being passed to NWAS.
” Open source report × Source evidence
How 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 Conflicting advice about which agency to contact for welfare concerns
Wider context from the report “Evidence was heard from the Inpatient Services Manager of PCT of their understanding, that the Police are the organisation to call in relation to concerns for welfare (regarding risk to life). The Court heard PCT are still advised the police are the contact . In addition this the advice within the acute trusts.
” Open source report × Source evidence
How 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 identify and disclose material call-handling information during investigation
Wider context from the report “In cases involving the engagement of Article 2 ECHR there is duty on agencies to investigate the circumstances of the death in order to learn lessons. There was little investigation conducted by NWAS in respect of this case. It was only through the evidence of NK the Court heard of the existence of the 111 telephone calls she had attempted to make and the information provided to her. In addition until the evidence of PR the Court had not been advised of the removal of the call from the allocation list and the decision made this could be triaged by urgent 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 documented Greater Manchester-wide process for welfare concerns involving risk to life
Wider context from the report “It was clear to the Court from all Senior Managers that there was a distinct lack of understanding across all three agencies of each agencies roles/responsibilities, systems of working and current practices in relation to concerns for welfare involving risk to life (not immediate to someone in the process of harming themselves). The evidence to the Court was of a confused picture across Greater Manchester with no clear guidance as to how to deal with such matters. Moreover it was apparent there is no documented GM wide process to allow staff on the ground clear information as to how to deal with such matters.
” Open source report × Source evidence
How 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 and failures in handling welfare concerns within acute inpatient psychiatric wards
Wider context from the report “The Court heard from the nurses who were tasked to raise a concern for welfare of the practical time difficulties in doing this , given they were working on an acute in-patient psychiatric ward. It was unclear why the clinical lead did not deal with this matter as she was the person to whom the information had initially been provided.
” Open source report × Source evidence
How 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 Incorrect completion of triage-system questions
Wider context from the report “The Court heard how the call was graded as a Grade 3 however when taken through the evidence in Court several questions on the triage system had been incorrectly completed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient investigation of deaths by NWAS
Wider context from the report “In cases involving the engagement of Article 2 ECHR there is duty on agencies to investigate the circumstances of the death in order to learn lessons. There was little investigation conducted by NWAS in respect of this case . It was only through the evidence of NK the Court heard of the existence of the 111 telephone calls she had attempted to make and the information provided to her. In addition until the evidence of PR the Court had not been advised of the removal of the call from the allocation list and the decision made this could be triaged by urgent 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 Failure to provide face-to-face welfare assessment
Wider context from the report “The decision to remove the concern for welfare call from the allocation list to be triaged by Urgent care meant no face to face assessment was conducted . Moreover the telephone triage call was conducted by a RGN who had limited mental health training.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Mental-health telephone triage by staff with insufficient mental-health training
Wider context from the report “The decision to remove the concern for welfare call from the allocation list to be triaged by Urgent care meant no face to face assessment was conducted. Moreover the telephone triage call was conducted by a RGN who had limited mental health training .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed the response protocols within partner agencies and cascade them across their workforces through the Responding to Crisis Board.
Verbatim wording from the response “Clearly, it is one thing to develop protocols, and quite another to embed them across the workforce. For this reason, we will now seek to embed these protocols within their respective agencies. I will ask them to agree to do so at a coming meeting of a new GM Responding to Crisis Board – a meeting I have convened in part in response to a common desire all partners have to enhance our broader offer around members of the community confronted with such risk. This Board will hold responsibility as part of its work programme for ensuring that these protocols are cascaded, rooted, and delivered upon.” Source location 2018-0411-Response-by-GMCA
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 pan-Greater Manchester response protocol defining roles, responsibilities, shared risk assessment, communication and escalation arrangements.
Verbatim wording from the response “We have now drawn together a pan-GM protocol for response, developed specifically in order to achieve a common understanding of roles and responsibilities; to ensure a shared view of risk; and to promote communication and escalation at the first point that a common understanding may falter.” Source location 2018-0411-Response-by-GMCA
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 the Greater Manchester Responding to Crisis Board to oversee cascading, embedding and delivery of the response protocols.
Verbatim wording from the response “Clearly, it is one thing to develop protocols, and quite another to embed them across the workforce. For this reason, we will now seek to embed these protocols within their respective agencies. I will ask them to agree to do so at a coming meeting of a new GM Responding to Crisis Board – a meeting I have convened in part in response to a common desire all partners have to enhance our broader offer around members of the community confronted with such risk. This Board will hold responsibility as part of its work programme for ensuring that these protocols are cascaded, rooted, and delivered upon.” Source location 2018-0411-Response-by-GMCA
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, revise and enhance multi-agency procedures through sessions involving all named partner organisations.
Verbatim wording from the response “Several distinct sessions were convened to review, revise and enhance our existing procedures from multiple perspectives. These sessions each included insight and oversight from all partner organisations named in this letter.” Source location 2018-0411-Response-by-GMCA
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 new GM Responding to Crisis Board will be responsible for ensuring the protocols are cascaded, embedded and delivered.
Verbatim wording from the response “Clearly, it is one thing to develop protocols, and quite another to embed them across the workforce. For this reason, we will now seek to embed these protocols within their respective agencies. I will ask them to agree to do so at a coming meeting of a new GM Responding to Crisis Board – a meeting I have convened in part in response to a common desire all partners have to enhance our broader offer around members of the community confronted with such risk. This Board will hold responsibility as part of its work programme for ensuring that these protocols are cascaded, rooted, and delivered upon.” Source location 2018-0411-Response-by-GMCA
Open published response
21 Dec 2018 Cady James Stewart · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Failure to remove palliative opiate medication from a bereaved person’s possession 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
Cady James Stewart · 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
Cady James Stewart was found dead at her home on 3 June 2018, and the post-mortem found a fatal combination of prescribed drugs. The concern was that opiate medication prescribed to her mother for palliative care remained in Cady Stewart’s possession after her mother’s death, including after Cady had attempted to take her own life, and was used with her own 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 remove palliative opiate medication from a bereaved person’s possession
Wider context from the report “1. The inquest heard that Cady Stewart’s mother had died a few months before from terminal cancer. Whilst her mother was on palliative care she had been prescribed a significant amount of opiate drugs. After her death the medication was not removed by the nursing team and remained in Cady Stewart’s possession. It remained in her possession even though she attempted to take her life immediately after her mother’s death. She used that in combination with medication prescribed to her to take her life.
” Open source report
Concerns raised 2 Prescribing patterns allowing access to significant amounts of prescribed medication View source Failure to refer patients with recognised addiction to prescribed medication for addiction support 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
Karen Moran · 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
Karen Moran was found at home on 7 April 2018 and died after unsuccessful resuscitation attempts at Tameside General Hospital. Toxicology showed raised levels of prescribed dihydrocodeine and gabapentin, and the inquest heard that her recognised addiction to prescribed medication was not addressed through referral while repeat prescriptions continued to provide access to significant amounts of 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 Prescribing patterns allowing access to significant amounts of prescribed medication
Wider context from the report “She had a long term addiction to prescribed medication that had been recognised. Medication continued to be prescribed on repeat prescriptions with no referral to address the addiction. The prescribing pattern meant she had access to significant amounts of 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 refer patients with recognised addiction to prescribed medication for addiction support
Wider context from the report “She had a long term addiction to prescribed medication that had been recognised. Medication continued to be prescribed on repeat prescriptions with no referral to address the addiction. The prescribing pattern meant she had access to significant amounts of prescribed medication.
” Open source report
Concerns raised 2 Failure of escalation mechanisms to enable early action on excessive CBT waiting lists View source Insufficient capacity for people referred for CBT View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
John Paul Derwent · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Paul Derwent was referred for cognitive behavioural therapy while the waiting time was 12 months against a six-week target. He expressed suicidal ideation, was admitted and later discharged into the community; on 13 November 2017 he was found suspended from a ligature at home. The report raised concerns about insufficient CBT capacity, the substantial waiting list and escalation mechanisms that did not allow early action.
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 escalation mechanisms to enable early action on excessive CBT waiting lists
Wider context from the report “The Inquest heard that the target time for an appointment for CBT should be 6 weeks. At the time Mr Derwent was referred, the waiting time was 12 months. There was a waiting list review in October 2017 when it was established that 500 people were on the waiting list for CBT. The waiting list time at the date of the Inquest remained 12 months. The Inquest heard that there was insufficient capacity for the number of people referred for CBT which is why the waiting list had become so significant. It was unclear why the list had been allowed to increase to this level. The mechanisms for escalation between the commissioning body and the service provider did not appear to allow for early action to address the issue.
” Open source report × Source evidence
How 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 capacity for people referred for CBT
Wider context from the report “The Inquest heard that the target time for an appointment for CBT should be 6 weeks. At the time Mr Derwent was referred, the waiting time was 12 months. There was a waiting list review in October 2017 when it was established that 500 people were on the waiting list for CBT. The waiting list time at the date of the Inquest remained 12 months. The Inquest heard that there was insufficient capacity for the number of people referred for CBT which is why the waiting list had become so significant . It was unclear why the list had been allowed to increase to this level. The mechanisms for escalation between the commissioning body and the service provider did not appear to allow for early action to address the issue.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations