Concerns raised 2 Failure to provide consistent levels of emergency mental health support and access routes across Greater Manchester View source Unavailability of out-of-hours GP referral routes for emergency mental health care in Trafford View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrew Reid · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Andrew Reid was found suspended from a ligature at Longford Park on 17 October 2017. The inquest concluded that his death was suicide and recorded the medical cause of death as hanging. Concerns related to differences in mental-health service provision and referral routes for residents of Manchester and Trafford, including the lack of out-of-hours emergency GP referrals in Trafford and the requirement for patients to attend A&E.
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 consistent levels of emergency mental health support and access routes across Greater Manchester
Wider context from the report “1. The inquest heard that when Mr Reid went to see his GP she was very concerned about the risk he posed to himself and wanted him to be seen urgently by the Home Based Treatment Team (HBTT). The initial call was to the Manchester team -because the GP practice was within the City Of Manchester-who accept referrals from GPs. The Manchester HBTT are commissioned to provide a 24/7 Urgent Assessment Team that GPs can refer into. However, as Mr Reid was a Trafford resident the referral was not accepted and the GP called the Trafford HBTT. Under the terms of their commissioned service they cannot accept referrals from GPs and contact is via the RAID team in A and E. In this case that meant Mr Reid was told he would have to go to A and E. The inquest was told that the differences in level of provision for those with mental health are based on the decisions made by each commissioning authority. As a result residents of GM with mental health issues have a different level of support and route to access services.
2. In Trafford the outcome of the commissioning is that there are no emergency GP referrals dealt with OOH. They can only be dealt with Monday to Friday by the CMHT. GPs outside these times dealing with emergency mental health issues for Trafford residents have to ask patients to make their way to A and E for assessment. If they are concerned that a patient may not make it to A and E then they have to ask the Police to check with A and E -as happened in the case of Mr Reid
” Open source report × Source evidence
How 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 out-of-hours GP referral routes for emergency mental health care in Trafford
Wider context from the report “1. The inquest heard that when Mr Reid went to see his GP she was very concerned about the risk he posed to himself and wanted him to be seen urgently by the Home Based Treatment Team (HBTT). The initial call was to the Manchester team -because the GP practice was within the City Of Manchester-who accept referrals from GPs. The Manchester HBTT are commissioned to provide a 24/7 Urgent Assessment Team that GPs can refer into. However, as Mr Reid was a Trafford resident the referral was not accepted and the GP called the Trafford HBTT. Under the terms of their commissioned service they cannot accept referrals from GPs and contact is via the RAID team in A and E. In this case that meant Mr Reid was told he would have to go to A and E. The inquest was told that the differences in level of provision for those with mental health are based on the decisions made by each commissioning authority. As a result residents of GM with mental health issues have a different level of support and route to access services.
2. In Trafford the outcome of the commissioning is that there are no emergency GP referrals dealt with OOH. They can only be dealt with Monday to Friday by the CMHT. GPs outside these times dealing with emergency mental health issues for Trafford residents have to ask patients to make their way to A and E for assessment. If they are concerned that a patient may not make it to A and E then they have to ask the Police to check with A and E -as happened in the case of Mr Reid
” 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 Align Manchester and Trafford mental health service specifications and agree clear cross-border arrangements with other Greater Manchester commissioners and trusts.
Verbatim wording from the response “An arrangement does exist between all GM mental health Trusts, which operates to ensure the most appropriate service for a patient resident or registered on or near the border of another service. This incident has highlighted the need to revisit this arrangement to reduce unnecessary variation in service commissioning and ensure that all providers are clear on service arrangements. Service provision must be based on a flexible, common-sense” Source location Andrew-REID-Response2
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain reciprocal commissioning arrangements so patients can access mental health services across Manchester and Trafford borders.
Verbatim wording from the response “The deceased was a registered patient with a Manchester GP at Chorlton Health Centre and he lived in Stretford in the borough of Trafford. This is important as NHS services are commissioned on the basis of GP registration (so Manchester in this case). Importantly, commissioners across both Manchester and Trafford CCGs have put in place reciprocal arrangements to cover mental health patients needing support but who are registered in separate areas to where they reside. In this case, therefore the GP should have been able to refer to either the Manchester service or the Trafford service.” Source location Andrew-REID-Response2
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 Escalate disputed referrals promptly to service managers for timely resolution and use the Cross Border Matrix to clarify registration and residency responsibilities.
Verbatim wording from the response “In Greater Manchester, required adherence with Responsible Commissioner principles has been communicated across all the GM MH Commissioners and Trusts. This included summary Cross Border Matrix tables to resolve any issues involving the service users registered and residency status shared with all specialist mental health out-of-hours and inpatient services.” Source location Andrew-REID-Response2
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 breakdown was not due to inappropriate differential commissioning models between Trafford CCG and Manchester commissioners.
Verbatim wording from the response “We appreciate that as the Coroner in this case you have noted concerns that despite this a difference in commissioning arrangements between Manchester and Trafford may have been contributory in the GPs experience of being passed between Trafford HBTT and Manchester UCAT – and then resulting in the service user needing to go to A&E for an assessment. We also note that it is this which prompted the Regulation 28 being issued.” Source location Andrew-REID-Response2
Open published response
Concerns raised 3 Lack of consistent and clear prescribing guidance across local and national lists View source Risk of patients obtaining melatonin from unlicensed internet sources View source Failure to communicate with community GPs before discharge about ongoing melatonin prescribing View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter STOJILJKOVIC · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter Stojiljkovic was discharged from hospital on 9 June 2017 after being prescribed melatonin and was later found suspended by a ligature at his home on 22 July 2017. The concerns included poor communication between the hospital, GP and Peter about community prescribing, differing prescribing policies, the complexity of prescribing guidance, and the possibility that he would need to obtain melatonin from unlicensed sources. There was also no evidence of communication with the GP before discharge to support a smooth transition into the community.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent and clear prescribing guidance across local and national lists
Wider context from the report “2. Whilst an in-patient the deceased was prescribed a drug melatonin that was on the Stockport CCG blacklist although not on all GM CCG blacklists . It was unclear why Stockport CCG took a different approach to other CCGs
3. The inquest heard that GPs are faced with a mixture of lists regarding prescribing. National and local. This results in GPs having to negotiate through a complex system when prescribing where there are grey areas that create uncertainty.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Risk of patients obtaining melatonin from unlicensed internet sources
Wider context from the report “4. The deceased was told he would have to source melatonin for himself over the internet if his GP would not prescribe it . This created a risk that he would have to access the drug from unlicensed sources.
” Open source report × Source evidence
How 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 with community GPs before discharge about ongoing melatonin prescribing
Wider context from the report “1. The deceased had been prescribed melatonin whilst an in-patient. The inquest heard that post his discharge communication between the hospital; GP and Mr Stojiljkovic was such that he was unaware that his GP was prepared to prescribe melatonin in the community ;
2. Whilst an in-patient the deceased was prescribed a drug melatonin that was on the Stockport CCG blacklist although not on all GM CCG blacklists. It was unclear why Stockport CCG took a different approach to other CCGs
3. The inquest heard that GPs are faced with a mixture of lists regarding prescribing. National and local. This results in GPs having to negotiate through a complex system when prescribing where there are grey areas that create uncertainty.
4. The deceased was told he would have to source melatonin for himself over the internet if his GP would not prescribe it. This created a risk that he would have to access the drug from unlicensed sources.
5. It was known whilst he was an in-patient that difficulties with prescribing melatonin in the community would arise. There was no evidence of any attempt to communicate with the GP prior to discharge to ensure a smooth discharge into the community.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the case with the practice to identify further learning.
Verbatim wording from the response “1. We accept that from the information in the letter that there has been a breakdown in communication with the patient. You have written to the practice and we assume they will respond to that issue. However, our Medical Director will review the case with the practice to identify any further learning.” Source location 2018-0077-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss inappropriate advice to access medication online with Pennine Care and identify further action.
Verbatim wording from the response “4. We would not expect anybody to be told that they should access medication via the internet and we will discuss this with Pennine Care, and identify any further action that needs to be taken in respect of this finding. However, as you have written to Pennine Care I assume that they will respond to you directly on this issue. In addition, we will raise the issue of how the provision of medication at discharge was handled by Pennine Care, and again identify any improvements that they need to make.” Source location 2018-0077-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise how medication provision at discharge was handled with Pennine Care and identify required improvements.
Verbatim wording from the response “4. We would not expect anybody to be told that they should access medication via the internet and we will discuss this with Pennine Care, and identify any further action that needs to be taken in respect of this finding. However, as you have written to Pennine Care I assume that they will respond to you directly on this issue. In addition, we will raise the issue of how the provision of medication at discharge was handled by Pennine Care, and again identify any improvements that they need to make.” Source location 2018-0077-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pennine Care is expected to respond directly on internet medication access and discharge medication provision because it has been separately contacted.
Verbatim wording from the response “4. We would not expect anybody to be told that they should access medication via the internet and we will discuss this with Pennine Care, and identify any further action that needs to be taken in respect of this finding. However, as you have written to Pennine Care I assume that they will respond to you directly on this issue. In addition, we will raise the issue of how the provision of medication at discharge was handled by Pennine Care, and again identify any improvements that they need to make.” Source location 2018-0077-Response-by-NHS-England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing CCG and Greater Manchester medication lists have the same interpretation, and practices may appropriately work with either list.
Verbatim wording from the response “2. Melatonin is on both the CCG and the GM restricted lists currently, and CCGs across Greater Manchester aim to have consistent lists as far as possible. Although worded differently the interpretation would be the same in this case. We have not tracked the position of the GM list at the time of the incident, and accept that they may not have been consistent at that time. I acknowledge your point about the difficulties that practices face in navigating through the various different lists, for this reason, as long as a practice works with one of the lists, we would support them in their decision.” Source location 2018-0077-Response-by-NHS-England
Open published response
Concerns raised 4 Limited information sharing between adult safeguarding board members View source Lack of regular medication reviews View source Failure to hold strategic safeguarding meetings at an adequate frequency View source Lack of guidelines to reduce the quantity of drugs available at one time 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
Russell Charles ROBB · 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
Russell Charles ROBB died at Manchester Royal Infirmary on 9 April 2016 after taking a fatal combination of prescribed and non-prescribed drugs with alcohol. The report identified inadequate monitoring and lack of regular medication reviews, no apparent guidelines to limit the quantity of drugs available, and limited information sharing between agencies involved in adult safeguarding.
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 Limited information sharing between adult safeguarding board members
Wider context from the report “which ultimately led to his death. There was no evidence of regular reviews of his medication. There appeared to be no guidelines in place to reduce the quantity of drugs available to Mr Robb at any one time. (CCG; Secretary of State for Health)
2. There was limited evidence of information sharing between the members of the Trafford Adult Safeguarding Board. This meant that the Local Authority were unaware of volume of interaction between the Police and Mr Robb .(Adult Safeguarding Board).As a result only 1 strategic meeting took place over a 6 year period
” Open source report × Source evidence
How 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 medication reviews
Wider context from the report “which ultimately led to his death. There was no evidence of regular reviews of his medication. There appeared to be no guidelines in place to reduce the quantity of drugs available to Mr Robb at any one time. (CCG; Secretary of State for Health)
2. There was limited evidence of information sharing between the members of the Trafford Adult Safeguarding Board. This meant that the Local Authority were unaware of volume of interaction between the Police and Mr Robb.(Adult Safeguarding Board).As a result only 1 strategic meeting took place over a 6 year period
” Open source report × Source evidence
How 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 hold strategic safeguarding meetings at an adequate frequency
Wider context from the report “which ultimately led to his death. There was no evidence of regular reviews of his medication. There appeared to be no guidelines in place to reduce the quantity of drugs available to Mr Robb at any one time. (CCG; Secretary of State for Health)
2. There was limited evidence of information sharing between the members of the Trafford Adult Safeguarding Board. This meant that the Local Authority were unaware of volume of interaction between the Police and Mr Robb.(Adult Safeguarding Board).As a result only 1 strategic meeting took place over a 6 year period
” Open source report × Source evidence
How 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 guidelines to reduce the quantity of drugs available at one time
Wider context from the report “which ultimately led to his death. There was no evidence of regular reviews of his medication. There appeared to be no guidelines in place to reduce the quantity of drugs available to Mr Robb at any one time. (CCG; Secretary of State for Health)
2. There was limited evidence of information sharing between the members of the Trafford Adult Safeguarding Board. This meant that the Local Authority were unaware of volume of interaction between the Police and Mr Robb.(Adult Safeguarding Board).As a result only 1 strategic meeting took place over a 6 year period
” Open source report
16 Nov 2017 John Haines · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3 Delays in access to Healthy Minds due to long waiting times View source Lack of access to qualified psychological therapy for mental health in-patients View source Lack of access to qualified psychological therapy for patients under the care of the Home Treatment Team 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 Haines · 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 Haines was admitted to a mental health ward in March 2017 after his anxiety and depression deteriorated, and was discharged on 14 June 2017 with planned follow-up. He was found deceased at home on 17 June 2017 after failing to respond to contact. The report raised concerns about in-patients and Home Treatment Team patients being unable to access qualified psychological therapy, including delays in accessing Healthy Minds.
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 access to Healthy Minds due to long waiting times
Wider context from the report “3. Timely access to Healthy Minds is also hindered by long waiting times .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of access to qualified psychological therapy for mental health in-patients
Wider context from the report “1. During the course of the evidence it became apparent that mental health in-patients still do not have access to therapy from a qualified Psychologist , despite the fact that this has been raised in previous Regulation 28 PFD Forms.
Notably, all clinicians were of the professional view that psychological therapy was critical to treatment, alongside psychiatric care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of access to qualified psychological therapy for patients under the care of the Home Treatment Team
Wider context from the report “2. Similarly, patients cannot access a qualified Psychologist whilst under the care of the Home Treatment Team (‘HTT’) etc. The only way for patients to get access to a Psychologist is through referral to ‘Healthy Minds’. Healthy Minds cannot provide access where the patient remains under the care of the HTT etc.
” Open source report
Concerns raised 7 Failure of Social Services to proactively pursue referrals and understand fire risks through joined-up interagency working View source Failure to identify people potentially at risk of fire in their premises View source Lack of a GPHA process to automatically consider fire risks and prevention View source Lack of automatic water suppression systems for blocks of flats and individuals at high risk View source Failure to refer people at risk of fire to GMFRS View source Failure of GPHA to make referrals to GMFRS for safe and well visits View source Lack of appropriate smoke alarms and assistive technology View source See 4 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
Mr Brian MacLean · 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 Brian MacLean died on 19 March 2016 from smoke inhalation contributed to by alcohol toxicity after a fire started while he was smoking on his sofa. The report raised concerns about insufficiently proactive social services involvement, failure to identify and refer him as being at risk of fire, and the absence of automatic processes for fire-risk assessment, referrals, sprinklers and other preventive measures.
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 Social Services to proactively pursue referrals and understand fire risks through joined-up interagency working
Wider context from the report “1. That Social Services did not take a more proactive role in pursuing any referral and understanding the risks presented by the deceased . This requires joined up thinking and working with GPs, the NHS locally, the housing provider and finally GMFRS .
” Open source report × Source evidence
How 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 people potentially at risk of fire in their premises
Wider context from the report “2. There was no identification of the deceased as being potentially at risk of a fire in his premises and no referral to GMFRS.
” Open source report × Source evidence
How 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 GPHA process to automatically consider fire risks and prevention
Wider context from the report “3. There was no process for GPHA to automatically consider fire risks and prevention and make referrals to GMFRS for safe and well visits.
” Open source report × Source evidence
How 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 automatic water suppression systems for blocks of flats and individuals at high risk
Wider context from the report “4. It is clear that GPHA did not have an automatic water suppression system (sprinklers) that could be fitted to properties which comprise blocks of flats and or for individuals at high risk . In addition appropriate smoke alarms and other assistive technology could have been installed.
5. The recipients of this report would be well advised to read and digest the detailed GMFRS Fire Investigation Report and its recommendations which are wholly endorsed by the court.
” Open source report × Source evidence
How 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 people at risk of fire to GMFRS
Wider context from the report “2. There was no identification of the deceased as being potentially at risk of a fire in his premises and no referral to GMFRS .
” Open source report × Source evidence
How 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 GPHA to make referrals to GMFRS for safe and well visits
Wider context from the report “3. There was no process for GPHA to automatically consider fire risks and prevention and make referrals to GMFRS for safe and well visits .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate smoke alarms and assistive technology
Wider context from the report “4. It is clear that GPHA did not have an automatic water suppression system (sprinklers) that could be fitted to properties which comprise blocks of flats and or for individuals at high risk. In addition appropriate smoke alarms and other assistive technology could have been installed .
5. The recipients of this report would be well advised to read and digest the detailed GMFRS Fire Investigation Report and its recommendations which are wholly endorsed by the court.
” Open source report
Concerns raised 9 Insufficient senior nursing staff in leadership roles View source Failure to complete required neurological or general observations View source Insufficient staffing levels or staff competence for safe care View source Failure to ensure completion or handover and documentation of outstanding A & E investigations View source Failure to accurately record and calculate neurological or general observations View source Failure to escalate neurological or general observations appropriately View source Lack of a clear handover and review process for transfer to AMU View source Failure to assess mental capacity during admission and transfer View source Failure to progress outstanding basic investigations and assessments View source See 6 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
Name not published · 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
A 79-year-old woman was admitted to hospital on 15 March 2015 with hypothermia, reduced responsiveness and reduced mobility. She developed pneumonia, sepsis and acute respiratory distress syndrome, and died on 23 March 2015. The principal concerns were failures in investigations and handover, mental-capacity assessment, monitoring and escalation of deterioration, and staffing competence and seniority.
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 senior nursing staff in leadership roles
Wider context from the report “6. Staffing levels, competence and seniority. The levels and competence of staff ( whether agency or Trust employees ) needed to deliver safe and appropriate care and with sufficient senior Nursing staff in leadership roles requires assessment and implementation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to complete required neurological or general observations
Wider context from the report “5. Ensuring that all neurological and/or general observations are appropriately undertaken , accurately recorded and calculated but also escalated as necessary. It is a fundamental part of basic medical and nursing care that a patient who requires neurological or general observations has them completed in a timely manner , accurately recorded and calculated and then appropriately escalated. This was simply not done and simple systems or protocols could be introduced to ensure that this is completed. It would seem that the primary responsibility for this should be shared between the Nurse in charge of the individual patient and the nurse in charge of the AMU.
” Open source report × Source evidence
How 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 staffing levels or staff competence for safe care
Wider context from the report “6. Staffing levels, competence and seniority. The levels and competence of staff ( whether agency or Trust employees ) needed to deliver safe and appropriate care and with sufficient senior Nursing staff in leadership roles requires assessment and implementation.
” Open source report × Source evidence
How 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 completion or handover and documentation of outstanding A & E investigations
Wider context from the report “2. Ensuring all investigations/assessments are completed before a patient leaves A & E and ensuring an appropriate handover. It is appreciated that it will not be possible for all investigations and tests to be performed before a patient leaves the A & E department but if that is the case then the receiving ward should be informed and there should be a clear documented audit trail so it is clear what is outstanding .
” Open source report × Source evidence
How 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 accurately record and calculate neurological or general observations
Wider context from the report “5. Ensuring that all neurological and/or general observations are appropriately undertaken, accurately recorded and calculated but also escalated as necessary. It is a fundamental part of basic medical and nursing care that a patient who requires neurological or general observations has them completed in a timely manner, accurately recorded and calculated and then appropriately escalated. This was simply not done and simple systems or protocols could be introduced to ensure that this is completed. It would seem that the primary responsibility for this should be shared between the Nurse in charge of the individual patient and the nurse in charge of the AMU.
” Open source report × Source evidence
How 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 neurological or general observations appropriately
Wider context from the report “5. Ensuring that all neurological and/or general observations are appropriately undertaken, accurately recorded and calculated but also escalated as necessary. It is a fundamental part of basic medical and nursing care that a patient who requires neurological or general observations has them completed in a timely manner, accurately recorded and calculated and then appropriately escalated . This was simply not done and simple systems or protocols could be introduced to ensure that this is completed. It would seem that the primary responsibility for this should be shared between the Nurse in charge of the individual patient and the nurse in charge of the AMU.
” Open source report × Source evidence
How 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 handover and review process for transfer to AMU
Wider context from the report “3. Transfer and hand over of a patient to AMU from A & E. There was no clear hand over process and review when the deceased arrived on the AMU . It would seem sensible that a Senior Nurse/Sister be informed and can then ensure appropriate care is 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 assess mental capacity during admission and transfer
Wider context from the report “1. Mental Capacity. There was no apparent consideration to the issue of whether or not the deceased had mental capacity from admission to A & E and transfer to AMU .
” Open source report × Source evidence
How 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 progress outstanding basic investigations and assessments
Wider context from the report “4. Ensuring investigations are progressed as appropriate. There was no progression of necessary basic assessments/tests which remained outstanding . For example, a chest X-ray.
” Open source report
Concerns raised 6 Failure to consider and action referrals to Adult General Psychiatry View source Lack of commissioned services for complex PTSD and complex presentations View source Insufficient detail in GP referral documentation to identify case complexity View source Lack of treatment plans addressing complex PTSD View source Inappropriate referral of complex PTSD presentations to Healthy Minds View source Lack of psychiatric follow-up after hospital discharge 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
Thomas Josef Green · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Thomas Josef Green died at home on 10 June 2016; the medical cause of death was asphyxiation secondary to hanging, and the inquest concluded that he had taken his own life. The principal concerns related to unclear or unactioned psychiatric referral, lack of psychiatric follow-up and treatment for complex PTSD after discharge, referral to an unsuitable service, and a commissioning gap for complex PTSD 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 to consider and action referrals to Adult General Psychiatry
Wider context from the report “1. It was unclear why a referral was made to Adult General Psychiatry whilst Mr Green remained an inpatient, there was no evidence that this referral was ever considered or actioned .
” Open source report × Source evidence
How 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 commissioned services for complex PTSD and complex presentations
Wider context from the report “5. The Court heard evidence that there is a commissioning gap for the provision of services for Complex PTSD and complex presentations such as that of Mr Green.
” Open source report × Source evidence
How 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 detail in GP referral documentation to identify case complexity
Wider context from the report “4. The Court heard evidence that the referral document completed by the GP was not particularly detailed and therefore the complexity of the case was not apparent and the case was accepted.
” Open source report × Source evidence
How 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 treatment plans addressing complex PTSD
Wider context from the report “2. Hence when Mr Green was discharged from hospital there was no psychiatric follow-up and no treatment plan in place to address the diagnosis of complex PTSD .
” Open source report × Source evidence
How 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 referral of complex PTSD presentations to Healthy Minds
Wider context from the report “3. When a referral was made this was made to Healthy Minds. The Court heard evidence how this was not a case which was suitable for Healthy Minds as it was complex and involved potentially complex PTSD .
” Open source report × Source evidence
How 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 psychiatric follow-up after hospital discharge
Wider context from the report “2. Hence when Mr Green was discharged from hospital there was no psychiatric follow-up and no treatment plan in place to address the diagnosis of complex PTSD.
” 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 Clarify the Individual Funding Request process and brief Pennine Care staff on applying for extraordinary care funding.
Verbatim wording from the response “1. The CCG will clarify the Individual Funding Request process to ensure that, where required, Pennine Care staff can apply for individual funding for extraordinary care, e.g. for Complex PTSD and ensure that PCFT staff are fully briefed about the process by 1/6/17.” Source location 2017-0057-Response-by-Tameside-and-Glossop-CCG-NHS-Trust
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 and establish clear mental-health support pathways for people with complex needs, identify gaps, and take findings forward in commissioning intentions.
Verbatim wording from the response “2. The CCG will work with PCFT and GPs to review and establish clear pathways into MH support for people with complex needs. This will identify any gaps which will be taken forward within commissioning intentions. We have commenced this work already and aim to conclude it within four months.” Source location 2017-0057-Response-by-Tameside-and-Glossop-CCG-NHS-Trust
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 A dedicated Complex PTSD service is not commissioned because the existing Individual Funding Request process can provide extraordinary individual care packages.
Verbatim wording from the response “Although we do not commission a Complex PTSD service, we do have an Individual Funding Request process, where extraordinary packages are commissioned for individuals. This would have been appropriate for Mr Green had it been used.” Source location 2017-0057-Response-by-Tameside-and-Glossop-CCG-NHS-Trust
Open published response
Concerns raised 11 Failure to involve the patient’s Primary/Associate Nurse in discharge View source Failure to review discharge decisions after material changes in patient presentation View source Inadequacy of the discharge policy View source Poor nursing advocacy for patients View source Absence of protocol or guidance for inpatient contact with emergency services View source Disjointed and uncoordinated discharge processes View source Poor nursing record keeping View source Failure to follow the discharge policy View source Unprofessional staff attitudes towards patients and care provision View source Unavailability of an inpatient Clinical Psychologist service View source Staff unawareness of how to support patients seeking a second medical opinion 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.
×
AI-generated summary
Susan Beverley George · 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
Susan Beverley George had longstanding mental health problems and was discharged from a mental health unit on 10 November 2014 despite concerns about her safety, anxiety, suicidal feelings and calls to emergency services. She left home the following day, went to Healey Dell and ingested an excessive quantity of prescribed medication, later being found deceased. Concerns included failures in reviewing and coordinating the discharge, inadequate record keeping and risk-management guidance, inappropriate staff attitudes, poor advocacy, and a gap in inpatient clinical psychology provision.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to involve the patient’s Primary/Associate Nurse in discharge
Wider context from the report “2. The discharge process was disjointed, lacked co-ordination and did not involve Susan’s Primary/Associate Nurse .
” Open source report × Source evidence
How 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 review discharge decisions after material changes in patient presentation
Wider context from the report “1. No review of the decision to discharge was sought or conducted when it became apparent that there had been a material change in Susan’s presentation on the 10th November. Had a review taken place then it is likely that the discharge would have been deferred or cancelled.
” Open source report × Source evidence
How 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 Inadequacy of the discharge policy
Wider context from the report “3. The Discharge Policy was perfunctory and staff failed to follow it in any event.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Poor nursing advocacy for patients
Wider context from the report “7. Poor advocacy on the part of the nursing staff whose decisions appear to have been clouded by the rigidity of the medical decision to 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 Absence of protocol or guidance for inpatient contact with emergency services
Wider context from the report “5. There is no protocol/guidance on what steps should be taken when an inpatient contacts the emergency services (e.g. police via 999). This is important as it goes to risk assessment/management.
” Open source report × Source evidence
How 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 Disjointed and uncoordinated discharge processes
Wider context from the report “2. The discharge process was disjointed, lacked co-ordination and did not involve Susan’s Primary/Associate Nurse.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Poor nursing record keeping
Wider context from the report “4. Poor record keeping, predominantly on the part of the nursing staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the discharge policy
Wider context from the report “3. The Discharge Policy was perfunctory and staff failed to follow it in any event.
” Open source report × Source evidence
How 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 Unprofessional staff attitudes towards patients and care provision
Wider context from the report “6. Unprofessional staff attitudes towards patient/care provision – two qualified nurses involved in Susan’s care used inappropriate language and demonstrated negative ways of thinking during both conversations with colleagues and the police communications operator. Prevailing attitudes such as this, particularly towards vulnerable adult, puts care standards at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of an inpatient Clinical Psychologist service
Wider context from the report “9. There is no inpatient Clinical Psychologist service available within Pennine Care . This is the second (possibly third) PFD Form on the same issue. The Trust maintains that this is as a result of commissioning issues. Without inpatient clinical psychology, there is a marked service gap that puts patients such as Susan at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Staff unawareness of how to support patients seeking a second medical opinion
Wider context from the report “8. Staff were unaware of how to support and advise patients on the issue of obtaining a second medical opinion where the patient disagrees with the first doctor’s decision (in this case, to proceed to discharge).
” Open source report
28 Sep 2015 Harry Pryal · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 8 Failure to record advice on medical treatment and care View source Failure of Lakeside Unit clinical notes to identify actions, times and clinicians View source Lack of triage procedures for urgent or unexpected significant x-ray findings View source Failure of Lakeside Unit clinicians to understand x-ray request and urgency requirements View source Failure of 5BP and WWL to maintain a shared understanding and interpretation of the Service Agreement View source Unavailability of electronic access to WWL x-rays for 5BP clinicians View source Unavailability of physiotherapy and occupational therapy for Lakeside Unit patients View source Failure of nominated officers to review the operation and performance of Service Agreements View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Harry Pryal · 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
Harry Pryal died on 8 January 2015 after an accidental fall, with the inquest recording bronchopneumonia and traumatic spinal cord injury as the medical cause of death. An X-ray identifying a suspected cervical spine fracture was not reported promptly, and the report raised concerns about communication and record-keeping, conflicting interpretations of a radiology service agreement, access to imaging, and the provision of physical healthcare 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 to record advice on medical treatment and care
Wider context from the report “i. 5BP contact WWL for advise in relation to medical treatment for patients at the Lakeside Unit on a regular basis as a matter of protocol. The Doctors in psychiatry at the Lakeside Unit, are dependent upon such advice for the treatment and care of patients.
The evidence identified that there is no note of the advice in the records maintained by WWL, neither to identify the Doctor giving advice nor the content of the advice . Furthermore evidence was given that this was a situation arising on a nationwide scale. The absence of any notes prevents a record of the advice for the purpose of continuity of treatment and any subsequent referrals , particularly in a case when the Doctor giving the advice is no longer available and further advice is requested by the referring Doctor for medical 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 Failure of Lakeside Unit clinical notes to identify actions, times and clinicians
Wider context from the report “v. The evidence at the Inquest revealed that the notes completed by clinicians at the Lakeside Unit, failed to identify the times of actions by them and in one note failed to identify the identity of the clinician making the note . The notes were inadequate , particularly the notes which accompanied Mr Pryal on his transfer from the Lakeside Unit, to RAEI.
The details to be included in a request for x-ray examination and the fact that an urgent x-ray examination required either a telephone call to the Radiologist or a note of priority on the x-ray form did not appear to be understood by clinicians at the Lakeside Unit, and demonstrated a lack of liaison and understanding between the two Trusts, which would be necessary to allow the terms of the Service Agreement to be operated and performed.
” Open source report × Source evidence
How 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 triage procedures for urgent or unexpected significant x-ray findings
Wider context from the report “iii. The evidence given by WWL was that there were no time lines in relation to the reporting of x-ray performed at the Leigh Infirmary, other than national timelines , although it was accepted that the Service Agreement provided that “urgent or unexpected significant clinical findings will be communicated to referring clinicians at the time of the Consultant Radiological reporting”. It was accepted if there was an unexpected significant clinical finding it would be necessary to communicate the finding to the referring clinician without delay.
WWL do not have any triage procedures in relation to x-ray examinations so that any “urgent or unexpected significant clinical finding” would not be reported to the referring clinician for some time after the examination . An early triage of the x-ray examination within a short period of the examination would allow any urgent or unexpected significant clinical finding to be communicated to the referring clinician without delay.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of Lakeside Unit clinicians to understand x-ray request and urgency requirements
Wider context from the report “v. The evidence at the Inquest revealed that the notes completed by clinicians at the Lakeside Unit, failed to identify the times of actions by them and in one note failed to identify the identity of the clinician making the note. The notes were inadequate, particularly the notes which accompanied Mr Pryal on his transfer from the Lakeside Unit, to RAEI.
The details to be included in a request for x-ray examination and the fact that an urgent x-ray examination required either a telephone call to the Radiologist or a note of priority on the x-ray form did not appear to be understood by clinicians at the Lakeside Unit, and demonstrated a lack of liaison and understanding between the two Trusts, which would be necessary to allow the terms of the Service Agreement to be operated and performed.
” Open source report × Source evidence
How 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 5BP and WWL to maintain a shared understanding and interpretation of the Service Agreement
Wider context from the report “ii. The Service Agreement entered into between 5BP and WWL for the period from the 1st April 2014 to the 31st March 2015 was the subject of different interpretations by each Trust. There was confusion in relation to the prioritisation of imaging and there was a fundamental conflict in relation to the interpretation of clause 2.1 .
The Agreement provided for meetings between nominated officers from each trust at intervals not exceeding every 3 months from the effective date of the Agreement to consider any issues arising from the operation and performance of the Agreement, as provided in paragraph 14.1 on page 10 of the Agreement. The evidence of the Inquest confirmed that no meetings had taken place during the concurrence of the Agreement and there was no proactive involvement of the nominated officers to identify any issues arising from the operation and performance of the Agreement. Furthermore evidence was given that there were similar Service Agreements for the period from 1st April 2013 to the 31st March 2014 and from the 1st April 2015 to the 31st March 2016 with similar provisions for meetings during the concurrence of the Agreements but no meetings between nominated officers had ever taken place.
The evidence identified a lack of liaison and understanding between 5BP and WWL in relation to the Agreement and their relationship , even in circumstances where both trusts are operating on the same site at Leigh Infirmary, Leigh.
During the Inquest WWL confirmed that they had similar Service Agreements in relation to the provision of services to health professionals in other areas of treatment and the provisions of all Agreements were similar and the provisions in all Agreements may not be performed in accordance with the requirements of each Agreement.
” Open source report × Source evidence
How 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 electronic access to WWL x-rays for 5BP clinicians
Wider context from the report “iv. 5BP accepted that the Service Agreement provided for web viewing of the x-rays but accepted that the software operated by 5BP does not allow web viewing of x-rays and 5BP did not have network connections to view the x-rays electronically by access to the WWL network . In any event the Consultant Psychiatrist from the Lakeside Unit indicated that the Doctors in her team based at the Lakeside Unit, may not have the expertise to interpret the x-rays on web view and the Doctors would be dependent upon a formal report, either verbal or written, from the Radiologist.
” Open source report × Source evidence
How 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 physiotherapy and occupational therapy for Lakeside Unit patients
Wider context from the report “vi. Evidence was given at the Inquest that there was no physiotherapy or occupational therapy at the Lakeside Unit to deal with the physical health needs of any patients on the Unit . There was no Service Agreement for the provision of physiotherapy and occupational therapy and no understanding as to who would provide such services . The evidence indicated that the Clinical Commissioning Group in Wigan would provide the services and 5BP were not in a position to enter into agreements for the provision of services from elsewhere. Evidence was given by 5BP that the Clinical Commissioning Group in Wigan had not provided services so that the physical health needs of patients in the Lakeside Unit, were not being satisfied in relation to physiotherapy and occupational therapy .
” Open source report × Source evidence
How 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 nominated officers to review the operation and performance of Service Agreements
Wider context from the report “ii. The Service Agreement entered into between 5BP and WWL for the period from the 1st April 2014 to the 31st March 2015 was the subject of different interpretations by each Trust. There was confusion in relation to the prioritisation of imaging and there was a fundamental conflict in relation to the interpretation of clause 2.1.
The Agreement provided for meetings between nominated officers from each trust at intervals not exceeding every 3 months from the effective date of the Agreement to consider any issues arising from the operation and performance of the Agreement, as provided in paragraph 14.1 on page 10 of the Agreement. The evidence of the Inquest confirmed that no meetings had taken place during the concurrence of the Agreement and there was no proactive involvement of the nominated officers to identify any issues arising from the operation and performance of the Agreement . Furthermore evidence was given that there were similar Service Agreements for the period from 1st April 2013 to the 31st March 2014 and from the 1st April 2015 to the 31st March 2016 with similar provisions for meetings during the concurrence of the Agreements but no meetings between nominated officers had ever taken place .
The evidence identified a lack of liaison and understanding between 5BP and WWL in relation to the Agreement and their relationship, even in circumstances where both trusts are operating on the same site at Leigh Infirmary, Leigh.
During the Inquest WWL confirmed that they had similar Service Agreements in relation to the provision of services to health professionals in other areas of treatment and the provisions of all Agreements were similar and the provisions in all Agreements may not be performed in accordance with the requirements of each Agreement.
” Open source report
2 Feb 2015 Kimberley Lauren Lindfield · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 6 Lack of a written protocol defining increased observations and required recording View source Lack of auditing of the appropriateness and timeliness of responses to mental health assessment presentations View source Failure to assign clear responsibility for recording increased observations View source Failure to ensure nursing and clinical staff understand their record-keeping responsibilities View source Lack of written guidance for clinical review and care-plan changes in response to new risks View source Lack of periodic audits of record keeping in similar cases 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
Kimberley Lauren Lindfield · 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
Kimberley Lauren Lindfield, who had a history of mental health problems and self-harm, was admitted to hospital after taking an overdose. While on Ward A10, she was found hanging from a dressing gown cord and died several days later after suffering severe brain damage. The principal concerns were failures to arrange a timely mental health assessment, record and respond to increased self-harm observations and risk information, maintain appropriate clinical management, and ensure staff followed relevant referral policies.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a written protocol defining increased observations and required recording
Wider context from the report “2. Whenever an increased level of observations is initiated pending a mental health assessment because of the concern about a patient’s mental state and/or self harm/suicidal behaviour there should be a clear written policy or protocol setting out what those observations actually involve (e.g. what 1 in every 15 minutes means and precisely what should be recorded) and the recording of them with a clear chain of responsibility with the obligation on one appropriate member of staff to ensure that this is done. I am concerned that at present such does not exist .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of auditing of the appropriateness and timeliness of responses to mental health assessment presentations
Wider context from the report “1. I am told that all patients presenting with symptoms of mental illness/mental disorder and/or after reported self harm/suicidal behaviour will now be automatically referred for a mental health assessment to be conducted as soon as possible whether that referral is from A& E or any ward. Pending that assessment, mental health staff can give advice by phone concerning the patients interim care and management. Both UHSM and MHSC provided evidence about a joint understanding and approach as well as a training and induction of staff. GMW may also be involved in such a case. That was to a very large extent the assurance I was provided after the death of Mr Dean. There were no plans or thoughts to audit whether or not in practice there was an appropriate and timely response to such presentations to ensure that the new system was actually working. In view of the history I am concerned that without such an auditing process failures of care may take place as identified above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to assign clear responsibility for recording increased observations
Wider context from the report “2. Whenever an increased level of observations is initiated pending a mental health assessment because of the concern about a patient’s mental state and/or self harm/suicidal behaviour there should be a clear written policy or protocol setting out what those observations actually involve (e.g. what 1 in every 15 minutes means and precisely what should be recorded) and the recording of them with a clear chain of responsibility with the obligation on one appropriate member of staff to ensure that this is done . I am concerned that at present such does not exist .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure nursing and clinical staff understand their record-keeping responsibilities
Wider context from the report “4. I am concerned that all UHSM Nursing and Clinical staff should be reminded of their responsibilities for good quality record keeping as an essential part of patient care and that there are periodic audits of record keeping in similar cases to ensure that appropriate standards are being met.
” Open source report × Source evidence
How 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 written guidance for clinical review and care-plan changes in response to new risks
Wider context from the report “3. I am concerned that there is currently no written protocol or guidance where there is an appropriate clinical review and there should be a change in the care and management plan in response to new or changed circumstances or new risks .
” Open source report × Source evidence
How 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 periodic audits of record keeping in similar cases
Wider context from the report “4. I am concerned that all UHSM Nursing and Clinical staff should be reminded of their responsibilities for good quality record keeping as an essential part of patient care and that there are periodic audits of record keeping in similar cases to ensure that appropriate standards are being met .
” Open source report
Concerns raised 2 Significant waiting times for access to psychological therapy View source Lack of availability of psychological services within crisis teams View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rowena Kathryn Golton · 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
Rowena Kathryn Golton had a history of recurring depression, suicidal thinking and deteriorating mental illness. On 6 April 2014, after being assessed as low risk of suicide and discharged from A&E with a plan for later crisis-team review, she jumped from a fire escape and died from multiple traumatic injuries. Concerns included limited access to psychologists within crisis teams and significant waiting times for psychological therapy.
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 Significant waiting times for access to psychological therapy
Wider context from the report “- Evidence was given as to the lack of availability of psychological services within the crisis teams. Following her admission as an inpatient she was then under the care of the crisis team. Not all crisis teams have access to a psychologist and the internal admissions recognised that there needed to be a review of the availability of psychological services to ensure adequate provision and access.
- In addition there was recognition that the waiting times for access to psychological therapy are significant and there is a greater need for the service to prioritise cases .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of availability of psychological services within crisis teams
Wider context from the report “- Evidence was given as to the lack of availability of psychological services within the crisis teams . Following her admission as an inpatient she was then under the care of the crisis team. Not all crisis teams have access to a psychologist and the internal admissions recognised that there needed to be a review of the availability of psychological services to ensure adequate provision and access.
- In addition there was recognition that the waiting times for access to psychological therapy are significant and there is a greater need for the service to prioritise cases.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission a diagnostic review of Citywide IAPT services.
Verbatim wording from the response “With regards to Manchester Mental Health and Social Care Trust response indicating that they have reviewed access to clinical psychology services I can confirm that the Citywide Team commissioned a review of psychological therapies (IAPT) with the two providers of this service in Manchester; Manchester Mental Health and Social Care Trust being one of the providers reviewed. I assume that this review is what the Trust response relates to as I am not aware of any separate review of IAPT being undertaken.” Source location 2014-0486-Response-by-North-Central-South-Manchester-Clinical-Commissioning-Groups
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 the Trust to improve data-cleansing and waiting-list management processes.
Verbatim wording from the response “Following the National IAPT team review and the examination of the Psychological Therapies CQIN that is in place relating to waiting times, Commissioners now have a better understanding of how the Trust manages waiting lists. We need to further examine the current waiting list information to verify the actual number of patients waiting to be assured that all possible actions are being taken by the Trust to regularly cleanse and review the number of patients waiting. We are working with the Trust to improve their data cleansing and waiting list management processes as we have concerns regarding the accuracy of the data.” Source location 2014-0486-Response-by-North-Central-South-Manchester-Clinical-Commissioning-Groups
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 information on psychological therapy provision across inpatient and community services.
Verbatim wording from the response “The Trust have indicated areas of significant pressure and that complex cases service are exceeding the available commissioned resource’. Within the block contract in place there is no specific allocation for this service or any other Psychological Therapies, with the exception of IAPT, and so I am unsure what the Trust considers ‘the available commissioned resource’. We have received a request to ████████ (Director of Finance) at the Contracts Meeting with the Trust for information regarding the level of Psychological Therapy input into inpatient and community services to understand which services have input and which do not.” Source location 2014-0486-Response-by-North-Central-South-Manchester-Clinical-Commissioning-Groups
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 care pathways for service users requiring psychological therapies.
Verbatim wording from the response “We have not, as yet, received any information from Manchester Mental Health and Social Care Trust in relation to the lack of availability of psychological therapies in crisis teams. ████████, Head of Mental Health Improvement Programme, is working closely with Trust colleagues to review service provision across all services and to develop care pathways for service users.” Source location 2014-0486-Response-by-North-Central-South-Manchester-Clinical-Commissioning-Groups
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 psychological therapy service provision across services.
Verbatim wording from the response “We have not, as yet, received any information from Manchester Mental Health and Social Care Trust in relation to the lack of availability of psychological therapies in crisis teams. ████████, Head of Mental Health Improvement Programme, is working closely with Trust colleagues to review service provision across all services and to develop care pathways for service users.” Source location 2014-0486-Response-by-North-Central-South-Manchester-Clinical-Commissioning-Groups
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 Further examine waiting-list information to verify patient numbers and actions taken to manage waits.
Verbatim wording from the response “Following the National IAPT team review and the examination of the Psychological Therapies CQIN that is in place relating to waiting times, Commissioners now have a better understanding of how the Trust manages waiting lists. We need to further examine the current waiting list information to verify the actual number of patients waiting to be assured that all possible actions are being taken by the Trust to regularly cleanse and review the number of patients waiting. We are working with the Trust to improve their data cleansing and waiting list management processes as we have concerns regarding the accuracy of the data.” Source location 2014-0486-Response-by-North-Central-South-Manchester-Clinical-Commissioning-Groups
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 providers to implement recommendations from the IAPT diagnostic review.
Verbatim wording from the response “The National IAPT Intensive Support Team was asked to undertake a diagnostic review of the Citywide IAPT services. The review was requested by Commissioners in response to our low performance for the national indictors and the need to achieve 15% access to psychological therapies in line with the IAPT programme and the long waiting lists. An external and expert review was required to help understand why performance is low. The subsequent report offered a number of options to consider to more effectively offer NICE recommended therapies for mild to moderate-severe anxiety and depression, Step 2 and Step 3 psychological therapies (IAPT). As a result both commissioners and providers are working together to implement the recommendations of the report.” Source location 2014-0486-Response-by-North-Central-South-Manchester-Clinical-Commissioning-Groups
Open published response
27 Jun 2014 ASHLEY CORIN DE WINTER PONSONBY · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 3 Lack of staff training in recognising and dealing with physical harm and risks from illicit substance use in wards with dual diagnosis patients View source Lack of a coherent and mutually understood Mental Health Trust and Police policy on involvement in illegal activity View source Failure to use incident reporting and risk-register procedures to identify drug supply or consumption 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
ASHLEY CORIN DE WINTER PONSONBY · 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
Ashley Ponsonby was a detained dual-diagnosis patient who died after injecting illicit drugs on a psychiatric ward. The inquest found amphetamine and paramethoxyamphetamine toxicity as the cause of death, with contributing factors including poor communication, inadequate observations and escalation, failure to recognise toxicity and deterioration, inadequate control of access to illicit drugs, insufficient staff training, and an inadequate emergency response. Concerns included the absence of staff training in managing physical risks from illicit substances, failures to use incident-reporting and risk-register procedures, and the lack of a coherent policy governing cooperation between the Mental Health Trust and police regarding illegal activity.
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 staff training in recognising and dealing with physical harm and risks from illicit substance use in wards with dual diagnosis patients
Wider context from the report “1. It is a matter of concern that any ward could be set up and operated involving the inherent risks of drug misuse by dual diagnosis patients without the staff having any training in recognising and dealing with the physical harm and risks arising from the use of illicit substances . The evidence from the independent psychiatrist was that this was an essential ingredient. Consequently, in rehabilitation wards or those with dual diagnosis patients where there is a risk of continuing drug misuse , the concern which arose was that without this, there was a risk of a future death arising. This has implications locally for the Trust, regionally and on a national basis.
” Open source report × Source evidence
How 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 coherent and mutually understood Mental Health Trust and Police policy on involvement in illegal activity
Wider context from the report “3. There was a concern that a lack of a coherent and mutually understood policy between the Mental Health Trust and the Police as to when they would become involved in illegal activity meant that neither the patients nor the staff had clarity on the position . Just because patients have mental disorder, does not absolve them of all legal responsibilities and indeed understanding and facing possible criminal consequences may be important in their overall clinical management and for the administration of justice. It was suggested that this was being considered by Greater Manchester Police and the local Police and Crime Commissioner, but no policy had yet been finalised . Once again, this has local, regional and national implications, and that the concern is without such policies being formulated and implemented, there is a continuing risk of future deaths which could be prevented.
” Open source report × Source evidence
How 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 use incident reporting and risk-register procedures to identify drug supply or consumption
Wider context from the report “2. There is a concern that the failure to use the Datix and Trust incident reporting policy, as well as the risk register (or other similar procedures available to other Mental Health Trusts), to identify the problem of drug supply and/or consumption , if unremedied may lead to a future death. It is a concern both locally for the Trust, regionally and nationally, that such procedures should be appropriately used so as to prevent a future death.
” Open source report
Concerns raised 9 Failure to make case-specific referrals through the single point of entry process View source Failure to refer patients to psychiatric services for expert diagnosis, opinion, management and treatment planning View source Unnecessarily bureaucratic and deterrent processes for accessing mental health services View source Unavailability of direct referral to in-house community-based psychiatrists for new patients View source Failure to ensure medically qualified practitioner management of single point of entry triage View source Restrictions on cross-Clinical Commissioning Group referrals without special approval View source Failure of contemporaneous record keeping to support clinical recollections View source Failure to use recognised assessment tools in clinical evaluation View source Failure to assess medication appropriateness in light of patients’ mental health history View source See 6 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
David Gary Chatburn · 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 Gary Chatburn had a significant history of mental health problems, including depression, probable bipolar disorder, alcohol misuse and fluctuating mood. He was found hanging from a tree on 18 October 2013, and the inquest concluded that he took his own life while the balance of his mind was disturbed. Concerns included the lack of referral to psychiatric services, the GP-led diagnosis and treatment, medication management, informal follow-up, record keeping and barriers in accessing mental health 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 to make case-specific referrals through the single point of entry process
Wider context from the report “4. That the GP felt it was sufficient for him to simply discuss the deceased’s care with the practice-based community psychiatrist and thus, no need for a referral to the single point of entry process . Such discussions were not necessarily case specific in any event but rather, general in nature .
” Open source report × Source evidence
How 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 to psychiatric services for expert diagnosis, opinion, management and treatment planning
Wider context from the report “1. That there was no referral made by the GP to the Psychiatric services for an expert diagnosis/opinion/management and treatment plan . The GP considered that there was no need, as he felt clinically competent to manage the deceased’s care and in any event, had a special interest in mental health, although he conceded that he was not formally recognised as a GP with a Special Interest (‘GPwSPi’) and whilst confident in his ability to manage the deceased’s care, his area of special interest was in fact the management of addictions.
Irrespective, he felt that he was best placed to assess, diagnose and treat the deceased on the basis that had he referred Mr Chatburn to the single point of entry system, the person ‘triaging’ would not have been medically qualified and would not have known the deceased as well as he felt he did.
” Open source report × Source evidence
How 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 Unnecessarily bureaucratic and deterrent processes for accessing mental health services
Wider context from the report “7. That the processes GPs are expected to use in order to access mental health services for their patients are unnecessarily bureaucratic and deterrent . GPs can no longer simply contact a Consultant Psychiatrist directly for advice. Everything must pass through the single point of entry.
” Open source report × Source evidence
How 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 direct referral to in-house community-based psychiatrists for new patients
Wider context from the report “3. That the GP was unable to refer the deceased, as a new patient, directly to the in-house community based psychiatrist , thus effectively defeating the object.
” Open source report × Source evidence
How 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 medically qualified practitioner management of single point of entry triage
Wider context from the report “8. That the ‘triage’ process used by the single point of entry system is not always managed by a medically qualified practitioner – this being a vital stage in determining diversion/allocation .
” Open source report × Source evidence
How 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 Restrictions on cross-Clinical Commissioning Group referrals without special approval
Wider context from the report “9. That GPs cannot refer patients outside their Clinical Commissioning Group area without special permission/approval by the same . In order to do so, a ‘special case’ must be argued . This potentially limits patient (and practitioner) accessibility and 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 Failure of contemporaneous record keeping to support clinical recollections
Wider context from the report “5. That the GP’s recollection of events was not supported by contemporaneous record keeping , thus calling into question accuracy.
” Open source report × Source evidence
How 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 use recognised assessment tools in clinical evaluation
Wider context from the report “6. That the GP did not use a recognised assessment tool, as an adjunct or otherwise, in his clinical evaluation of the deceased . He felt that they were ineffective and of little, if any, value.
” Open source report × Source evidence
How 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 medication appropriateness in light of patients’ mental health history
Wider context from the report “2. That the GP did not consider the appropriateness of the medication prescribed, particularly in light of the patient’s past mental health history - preferring to rely upon the presumed, anecdotal preferences of the community psychiatrists.
” Open source report
Concerns raised 9 Failure to complete and record patient observations View source Lack of nurse review of recent records during admission or transfer handover View source Delays in admission to an appropriate mental health bed View source Failure to properly clerk in mental health patients View source Failure to implement handover policies in practice View source Lack of clinical supervision and guidance for junior medical staff View source Failure to conduct prompt, thorough and independent investigations of serious patient deaths View source Failure of junior medical staff to review clinical records and history before prescribing medication View source Lack of a reliable method for notifying the responsible Consultant of patient admission View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
STEPHANIE DANIELS · 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
Stephanie Daniels, who had a history of serious mental health problems and repeated self-harm, was admitted to the Safire unit on 22 March 2012 after a delay in securing an inpatient bed. She died there on 24 March 2012 after being found unconscious with a ligature around her neck. The principal concerns included inadequate observation and handover, failure to clerk her in, medication-recording and supervision problems, failures in the emergency response, and deficiencies in the subsequent internal investigation.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and record patient observations
Wider context from the report “8. Performing and recording observations on other patients
I was concerned about the discovery of incomplete written observations for another patient where there are significant gaps in the records and may illustrate a systemic problem because the patient was transferred to a different ward. This was only discovered during the course of the inquest and was brought to the attention of MHSC so that they could carry out their own investigations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of nurse review of recent records during admission or transfer handover
Wider context from the report “2. Handover
All the evidence showed that the handover of information between nursing and clinical colleagues was a vital piece in the jigsaw of care. MHSC have introduced a new policy but I have a concern that simple issues may be overlooked. For new patients being admitted or transferred, there is no requirement for the nurse in charge to review their recent records . MHSC have produced new or updated policies/protocols but experience has shown that what may be delivered on paper is not being done in practice. Consequently, I am concerned that without appropriate audit and clinical/nursing leadership this may prove to be ineffective.
” Open source report × Source evidence
How 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 admission to an appropriate mental health bed
Wider context from the report “3. Bed Availability
MHSC say that following the death of the deceased, a new policy has been introduced so that there is no waiting time at all for the allocation of a bed in the case of a patient who is deemed clinically to require one. A bed will be found somewhere which will be appropriate to their needs. As I understood the evidence from the CCG in the case this should have occurred in any event. However, other NHS Trusts nationwide who do not have such a policy, may have patients whose delayed admission means that they are not having the appropriate nursing and clinical input, as well as medication review . In turn this means their condition may continue to deteriorate and when effective care does start, the patient may well be more ill than they should be. I am concerned that the importance of this is recognised not only by MHSC but nationally for all other NHS mental health 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 properly clerk in mental health patients
Wider context from the report “4. Clerking In
The failure to properly clerk in the patient is a matter of serious concern , especially as many such patients will have physical health problems. MHSC had clear policies requiring the clerking in of a patient, but these were simply not adhered to . It is very common for patients with mental health problems to have associated physical conditions which require appropriate monitoring and treatment. It seems that despite the existence of appropriate policies, in practice these were not being complied with . Whether or not any new or different policy or auditing of compliance is the way to achieve uniformity is a matter for MHSC. I repeat what I have said earlier. MHSC have produced new or updated policies/protocols but experience has shown that what may be delivered on paper is not being done in practice. Consequently, I am concerned that without appropriate audit and clinical/nursing leadership this may prove to be ineffective.
” Open source report × Source evidence
How 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 implement handover policies in practice
Wider context from the report “2. Handover
All the evidence showed that the handover of information between nursing and clinical colleagues was a vital piece in the jigsaw of care. MHSC have introduced a new policy but I have a concern that simple issues may be overlooked. For new patients being admitted or transferred, there is no requirement for the nurse in charge to review their recent records. MHSC have produced new or updated policies/protocols but experience has shown that what may be delivered on paper is not being done in practice . Consequently, I am concerned that without appropriate audit and clinical/nursing leadership this may prove to be ineffective .
” Open source report × Source evidence
How 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 clinical supervision and guidance for junior medical staff
Wider context from the report “5. Supervision of Junior Medical Staff
I am concerned about the lack of appropriate clinical supervision and guidance for junior medical staff . Two junior doctors were asked to attend the ward and made no appropriate clinical records of the reason for their attendance, reviewing the records, seeing the patient and explaining any clinical decision to prescribe medication. It is appreciated that they are busy with a number of duties but it is a matter of concern that they did not undertake basic clinical recording duties for a patient who clearly should have been seen. They did not notice that the patient had not been clerked in. Medication was being prescribed without adequate consideration of the relevant clinical history. They did not notice the named Consultant in charge of the patient was unaware of the admission. Appropriate clinical supervision would be expected to ensure an appropriate standard of performance. I understand that supervision may be delegated by the North West Deanery to the relevant NHS Trust but there has to be some basic accepted levels of interaction, communication and supervision between the junior Doctors and their Consultants to ensure an appropriate standard and continuity of care. This may be a joint responsibility between the Deanery and the NHS trust involved.
” Open source report × Source evidence
How 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 prompt, thorough and independent investigations of serious patient deaths
Wider context from the report “1. Internal NHS SUI Investigation v Independent Investigation
I am concerned that a death such as this of either a detained or voluntary patient (where Article 2 is arguably engaged) requires a prompt, thorough and robust investigation to be completed as soon as possible. Deficiencies in systems, protocols, policies, record keeping and individual actions need to be identified quickly and remedial action taken. This cannot wait for an inquest which may not take place for many months. This was not the first case of a poor or incomplete SUI investigation. The court was aware of and invited submissions about the recent case of R (Antoniou) v Central and North West London NHS Foundation Trust and others [2013] EWHC 3055 (Admin).
In this case there were significant errors and omissions in the SUI investigation . Important witnesses were not interviewed. The delay in finding the deceased a bed was not a central issue and no specific findings were made about it. The medication recording errors had not been noted and had the deceased been injected with PRN Haloperidol for severe agitation, then she should have been subject to physical observations for a continuous period of time immediately afterwards, as well as other steps in compliance with the Trust’s Rapid Tranquilisation Policy. It is accepted that SUI investigations are important and hope to learn lessons quickly to be implemented. Whilst the current law indicated that it is not a requirement for there to be an independent investigation at that stage, it is a matter of concern that very significant failures in the investigative process have occurred. The Trust investigation did not reveal at all the allegation of the commencement of discreet continuous observations on the morning of 24th March.
This is not the first time that the Trust SUI investigations have been found to be flawed and I have experience of other Trusts’ investigations also being significantly flawed. In conclusion in this sort of case I am concerned that without appropriately speedy and thorough independent investigation commissioned by the NHS Trust involved, flawed SUI investigation reports may continue to be produced . This is a policy decision for the NHS but I strongly urge consideration of this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of junior medical staff to review clinical records and history before prescribing medication
Wider context from the report “6. Prescribing of Medication by Junior Medical Staff
I am concerned by the circumstances in this case where medication came to be prescribed. There is an overlap of my concerns about supervision and my observations at paragraph 5 above should be regarded as repeated here. Both junior doctors had no recollection of attending the ward, speaking to the staff or seeing the patient. They simply prescribed the medication. They had no recollection of reviewing the deceased’s records and understood that was essential when considering prescribing any medication, and in particular PRN rapid tranquillisation. In this case, the patient was already taking a number of drugs which had sedative effects. Two further medications were introduced that have similar properties and that also could potentially affect heart function.
” Open source report × Source evidence
How 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 reliable method for notifying the responsible Consultant of patient admission
Wider context from the report “7. Mechanism by which the Consultant in charge of the patient would learn of the patient’s admission
It is of concern that there was apparently no simple method of ensuring that the Consultant in whose name the patient was admitted became aware of the admission and could therefore ensure appropriate clinical leadership and review was undertaken. It would seem that there could be a number of simple solutions for this problem.
” 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 Operate the revised governance process and monthly Citywide Patient Safety Committee to review serious incidents and other patient-safety concerns.
Verbatim wording from the response “A revised governance process has been developed within the Citywide Commissioning, Quality and Safeguarding Team and the Trust now attends an established Citywide Patient Safety Committee. This committee meets monthly and is responsible for the review and monitoring of serious incidents requiring investigation reported at the Trust as well as any other patient safety related issues including those highlighted at inquest via Prevention of Future Death Reports.” Source location 2013-0353-Response-by-Manchester-Clinical-Commissioning-Groups
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and maintain the escalation protocol enabling use of private-sector beds when Trust capacity is unavailable.
Verbatim wording from the response “An escalation protocol was agreed with the Trust in the financial year of 2011/12 which enabled the Trust to utilise private sector beds when it did not have the capacity to accommodate a patient in need of an inpatient bed. This protocol was reviewed following the inquest into the death of patient FK and has been reviewed again in July 2013 to ensure it remains robust. The CCG is confident that the protocol is appropriate and robust.” Source location 2013-0353-Response-by-Manchester-Clinical-Commissioning-Groups
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 Purchase additional inpatient capacity in neighbouring NHS facilities and through the charitable sector.
Verbatim wording from the response “• There are weekly mental health inpatient capacity meetings with representatives from the Trust. Additional capacity has been purchased in neighbouring NHS facilities and via the charitable sector.” Source location 2013-0353-Response-by-Manchester-Clinical-Commissioning-Groups
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 Operate daily bed-management calls, weekly delayed-discharge teleconferences and weekly mental-health inpatient-capacity meetings with relevant partners.
Verbatim wording from the response “As a result of the CCG's concerns relating to out of area placements the following process has been set up and has been operational since August 2013:” Source location 2013-0353-Response-by-Manchester-Clinical-Commissioning-Groups
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 Monitor out-of-area placements and bed availability daily and weekly to support rapid allocation or repatriation and prevent unnecessary waiting.
Verbatim wording from the response “The number of out of area placements utilised by the Trust is significant and the CCG monitors usage on a daily and weekly basis (as above) to ensure that patients are either allocated a bed quickly or are repatriated as quickly as possible when a bed is available within the Trust.” Source location 2013-0353-Response-by-Manchester-Clinical-Commissioning-Groups
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 Scrutinise Trust investigation reports through High Level Investigation Panels and review resulting action plans for SMART actions that reduce recurrence risk.
Verbatim wording from the response “The City Wide Commissioning, Quality and Safeguarding Team are represented at all High Level Investigation Panels (HLIP) held by the Trust. The HLIP’s were established by the Trust in order to allow scrutiny of their investigations and reports. Prior to the HLIP the Trust provides the City Wide Commissioning, Quality and Safeguarding Team with a draft copy of their investigation report. This allows the City Wide Commissioning, Quality and Safeguarding Team representative to review the report and challenge its robustness, contents and findings. Following the HLIP the Trust develops an action plan and the City Wide Commissioning, Quality and Safeguarding Team representative reviews this to ensure that the actions identified are Specific, Measurable, Achievable, Realistic and Time based (SMART) to reduce the likelihood of a recurrence of the incident.” Source location 2013-0353-Response-by-Manchester-Clinical-Commissioning-Groups
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 Scrutinise the Trust’s response to the Prevention of Future Deaths report and seek assurance that proposed actions are appropriate, robust and implemented.
Verbatim wording from the response “The Trust's response to the Prevention of Future Deaths Report in this case will be scrutinised by the CCG and assurances will be sought from the Trust in relation to any actions it proposes to take to ensure that they are appropriate and robust and that they are implemented.” Source location 2013-0353-Response-by-Manchester-Clinical-Commissioning-Groups
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the inpatient capacity management plan to improve patient experience, bed flow and joint working across stakeholder organisations.
Verbatim wording from the response “An inpatient capacity management plan has been developed and implemented by the CCG. The overall aims of this plan are:” Source location 2013-0353-Response-by-Manchester-Clinical-Commissioning-Groups
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 Decisions about admitting and discharging mental health patients rest with the provider NHS Trust, not the commissioning organisation.
Verbatim wording from the response “Concern No 2 - Bed Availability
The commissioning of beds is based on evidence of past need and emerging needs from commissioning intelligence. The CCG does not directly instruct Manchester Mental Health and Social Care Trust, or any other NHS Trust about how its beds should be utilised and although it monitors the Trust's bed utilisation decisions on patient management are solely the responsibility of the Trust as the provider of NHS care.” Source location 2013-0353-Response-by-Manchester-Clinical-Commissioning-Groups
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing escalation, monitoring and capacity-management arrangements are considered appropriate and robust for managing inpatient bed availability and out-of-area placements.
Verbatim wording from the response “The number of out of area placements utilised by the Trust is significant and the CCG monitors usage on a daily and weekly basis (as above) to ensure that patients are either allocated a bed quickly or are repatriated as quickly as possible when a bed is available within the Trust.” Source location 2013-0353-Response-by-Manchester-Clinical-Commissioning-Groups
Open published response
Concerns raised 1 Lack of a proper and efficient system for speedy reassessment and transfer of rapidly deteriorating patients 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
George Renshaw · 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 Renshaw, a resident at Mayfield Care Home, left through a fire door on 17 February 2013, fell down concrete steps, fractured his cervical spine and subsequently developed pneumonia, leading to his death. The report raised concern that there was no proper and efficient system for the speedy reassessment and transfer of care-home residents whose conditions were rapidly deteriorating, despite concerns about his advancing dementia being reported.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Greater Manchester Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a proper and efficient system for speedy reassessment and transfer of rapidly deteriorating patients
Wider context from the report “(1) There is clear evidence given that Mr Brown was placed, properly, at Mayfield Care Home and that Mayfield Care Home were looking after him within the capabilities of that type of establishment. It soon became apparent to the Manager of that Care Home that they were unable to meet the needs of Mr Brown’s advancing dementia and whilst she brought this to the attention of the appropriate authorities nonetheless it took several months to have him moved to a suitable alternative accommodation. There seemed to be no or no proper and efficient system in place for a speedy re-assessment and transfer of patients whose condition is deteriorating rapidly.
” 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