Concerns raised 8 Unavailability of affordable NHS ADHD services View source Failure to communicate effectively with and listen meaningfully to families of patients with mental health difficulties View source Personality disorder provision not yet sufficiently developed as an individual, therapeutic and trauma-informed pathway View source Fragmented connectivity between mental health and physical or neurodivergence services View source Failure to incorporate family concerns and available information into ongoing treatment and clinical assessment View source Failure to brief families on neurodivergent and mental health diagnoses and their potential difficulties View source Failure to provide advice on possible medication withdrawal symptoms View source Lack of a comorbidity policy guiding staff caring for patients with mental health conditions and learning difficulties View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kirsty Clare TAYLOR · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kirsty Clare TAYLOR, aged 33, was found dead in the garage at her family home on 25 June 2022 after taking her own life by hanging in the early hours. The report identified concerns about fragmented mental and physical health services, insufficiently developed personality disorder provision, inadequate communication with and listening to families, and insufficient information and support for families of patients with neurodiversity.
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 Hampshire and Isle of Wight Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of affordable NHS ADHD services
Wider context from the report “1. It was recognised in evidence and in submission to the Court by representatives of the Trust, that there is and remains a fragmented relationship between mental health and physical health services, with little inter-service connectivity. It was recognised that ideally services for those with both mental and physical health diagnoses should be connecting in a seamless, timely and collaborative manner - specifically through the joint commissioning of services, to support patients of all ages.
Nationally it is recognised that co-morbidity, especially with ADHD (as was the case in this death), impacts on both treatment compliance and treatment response. Whilst local initiatives have been explored by SHFT and by the ICB - Project Fusion I understand is such an example - much of the development of such services falls outside of scope and commissioning. Consequently, there is a significant and pressing need for connectivity between mental health services and those services supporting neurodivergent patients.
It was noted in evidence e.g. that SHFT do not currently have a comorbidity policy that would provide guidance to staff regarding patients who have a mental health condition and a learning difficulty. There are no ADHD services within SHFT or other NHS organisations within the Southampton (or in fact the wider Hampshire) area - save for private clinics, which many cannot afford.
The facts in this case have highlighted that progress on initiatives and connectivity between services is still too little and too slow. More needs to be done, and with greater integration, if the needs and support of patients such as Kirsty Taylor are to be sufficiently and appropriately met in the future and similar deaths 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 Hampshire and Isle of Wight Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate effectively with and listen meaningfully to families of patients with mental health difficulties
Wider context from the report “3. I remain concerned (as it is a matter I have raised on many occasions at inquest and again as a result of the experiences of the family in this case), that communication with the families of patients with mental health difficulties is still not being effectively achieved . Nor are such families being sufficiently, effectively and meaningfully listened to or understood when they voice concerns , based on their experience of the patient outside of a treatment or assessment environment. Consequently, I am concerned that such matters are not being reflected sufficiently or frequently enough in the onward treatment of those patients or in the clinical curiosity afforded to their conditions.
There remains an over-focus on patient centric assessments and patient only responses. It is recognised that patients can present quite differently to and in the presence of their families, who know them intimately, to how they may (or may be able to) present to assessing clinicians - with or without the intent to mask their condition.
Whilst consent to share is an understandable barrier in some cases, there should not be a bar to listening to or to actively encouraging feedback and input from families, especially where a family's concerns are heightened by any sudden or marked changes in the behaviours, mood or presentation of their relative outside of the clinical/assessment environment - particularly in the case of neurodiversity.
Unless all concerns are heard and considered and all available information is taken on board, holistically, there is a continuing risk that the masking of mental health conditions and the deterioration of them may occur or that significant red flags are missed. In this case, the family's increasing desperate concerns voiced about their daughter's evident mental health deterioration in her final days went un-responded.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Hampshire and Isle of Wight Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Personality disorder provision not yet sufficiently developed as an individual, therapeutic and trauma-informed pathway
Wider context from the report “2. Evidence before this inquest indicated that SHFT has recognised that the mental health provision for those with personality disorders must move towards an individual, therapeutic and trauma-informed approach , which is both compassionate and recovery focused. It is evident that the 'Personality Disorder Pathway' currently being developed is an important step towards that aim, enabling practitioners and services to take a more holistic and person-centred approach, reducing risk and improving outcomes. I am aware that SHFT have been encouraged to review and further develop the Pathway. I am concerned that that must occur, and at pace .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Hampshire and Isle of Wight Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Fragmented connectivity between mental health and physical or neurodivergence services
Wider context from the report “1. It was recognised in evidence and in submission to the Court by representatives of the Trust, that there is and remains a fragmented relationship between mental health and physical health services, with little inter-service connectivity . It was recognised that ideally services for those with both mental and physical health diagnoses should be connecting in a seamless, timely and collaborative manner - specifically through the joint commissioning of services, to support patients of all ages.
Nationally it is recognised that co-morbidity, especially with ADHD (as was the case in this death), impacts on both treatment compliance and treatment response. Whilst local initiatives have been explored by SHFT and by the ICB - Project Fusion I understand is such an example - much of the development of such services falls outside of scope and commissioning. Consequently, there is a significant and pressing need for connectivity between mental health services and those services supporting neurodivergent patients .
It was noted in evidence e.g. that SHFT do not currently have a comorbidity policy that would provide guidance to staff regarding patients who have a mental health condition and a learning difficulty. There are no ADHD services within SHFT or other NHS organisations within the Southampton (or in fact the wider Hampshire) area - save for private clinics, which many cannot afford.
The facts in this case have highlighted that progress on initiatives and connectivity between services is still too little and too slow . More needs to be done, and with greater integration, if the needs and support of patients such as Kirsty Taylor are to be sufficiently and appropriately met in the future and similar deaths 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 Hampshire and Isle of Wight Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate family concerns and available information into ongoing treatment and clinical assessment
Wider context from the report “3. I remain concerned (as it is a matter I have raised on many occasions at inquest and again as a result of the experiences of the family in this case), that communication with the families of patients with mental health difficulties is still not being effectively achieved. Nor are such families being sufficiently, effectively and meaningfully listened to or understood when they voice concerns, based on their experience of the patient outside of a treatment or assessment environment. Consequently, I am concerned that such matters are not being reflected sufficiently or frequently enough in the onward treatment of those patients or in the clinical curiosity afforded to their conditions .
There remains an over-focus on patient centric assessments and patient only responses. It is recognised that patients can present quite differently to and in the presence of their families, who know them intimately, to how they may (or may be able to) present to assessing clinicians - with or without the intent to mask their condition.
Whilst consent to share is an understandable barrier in some cases, there should not be a bar to listening to or to actively encouraging feedback and input from families, especially where a family's concerns are heightened by any sudden or marked changes in the behaviours, mood or presentation of their relative outside of the clinical/assessment environment - particularly in the case of neurodiversity.
Unless all concerns are heard and considered and all available information is taken on board, holistically , there is a continuing risk that the masking of mental health conditions and the deterioration of them may occur or that significant red flags are missed . In this case, the family's increasing desperate concerns voiced about their daughter's evident mental health deterioration in her final days went un-responded.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Hampshire and Isle of Wight Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to brief families on neurodivergent and mental health diagnoses and their potential difficulties
Wider context from the report “4. Finally, I am concerned that more needs to be done to inform and assist families, particularly in cases of patients with neurodiversity. In this particular case, the evidence found, for example, that the family were never briefed on what EUPD and ADHD really meant or on the difficulties which could present as a result of their daughter’s joint diagnoses . Being unaware as to what they were to expect, they were consequently often at a loss to know how to interact with or to help her. Neither they nor their daughter received advice on possible medication withdrawal symptoms.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Hampshire and Isle of Wight Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide advice on possible medication withdrawal symptoms
Wider context from the report “4. Finally, I am concerned that more needs to be done to inform and assist families, particularly in cases of patients with neurodiversity. In this particular case, the evidence found, for example, that the family were never briefed on what EUPD and ADHD really meant or on the difficulties which could present as a result of their daughter’s joint diagnoses. Being unaware as to what they were to expect, they were consequently often at a loss to know how to interact with or to help her. Neither they nor their daughter received advice on possible medication withdrawal symptoms.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Hampshire and Isle of Wight Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a comorbidity policy guiding staff caring for patients with mental health conditions and learning difficulties
Wider context from the report “1. It was recognised in evidence and in submission to the Court by representatives of the Trust, that there is and remains a fragmented relationship between mental health and physical health services, with little inter-service connectivity. It was recognised that ideally services for those with both mental and physical health diagnoses should be connecting in a seamless, timely and collaborative manner - specifically through the joint commissioning of services, to support patients of all ages.
Nationally it is recognised that co-morbidity, especially with ADHD (as was the case in this death), impacts on both treatment compliance and treatment response. Whilst local initiatives have been explored by SHFT and by the ICB - Project Fusion I understand is such an example - much of the development of such services falls outside of scope and commissioning. Consequently, there is a significant and pressing need for connectivity between mental health services and those services supporting neurodivergent patients.
It was noted in evidence e.g. that SHFT do not currently have a comorbidity policy that would provide guidance to staff regarding patients who have a mental health condition and a learning difficulty . There are no ADHD services within SHFT or other NHS organisations within the Southampton (or in fact the wider Hampshire) area - save for private clinics, which many cannot afford.
The facts in this case have highlighted that progress on initiatives and connectivity between services is still too little and too slow. More needs to be done, and with greater integration, if the needs and support of patients such as Kirsty Taylor are to be sufficiently and appropriately met in the future and similar deaths prevented.
” 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 Recommission autism and ADHD assessment and prescribing pathways to provide a cohesive population-wide service.
Verbatim wording from the response “2. Autistic Spectrum Condition (ASC) and Attention Deficit Hyperactivity Disorder (ADHD) pathway developments” Source location Response from Hampshire and Isle of Wight
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 an ongoing focus on improving engagement with families and carers using learning from this case.
Verbatim wording from the response “Whilst there is more to be done to ensure that feedback from families and carers is heard and acted on and informs the delivery of care and decision-making for those in receipt of services, the trust has demonstrated its commitment to deliver continuous improvements in this area.” Source location Response from Hampshire and Isle of Wight
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 improved personality-disorder provision for mobilisation in 2024/25.
Verbatim wording from the response “The review and development of evidence-based pathway and provision for people with personality disorders is one of five key Mental Health System Transformation priorities in 2023/24 for the Hampshire and the Isle of Wight system. The review is in process and will consider:” Source location Response from Hampshire and Isle of Wight
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the Hampshire and Isle of Wight trauma-informed strategy, allocating resources and providing senior-level support.
Verbatim wording from the response “Mental Wellbeing is a priority set out in the Hampshire and Isle of Wight Forward Plan including working in partnership with the system in developing trauma informed approaches across services to reduce health inequalities and improve emotional wellbeing. The ICB, alongside Southern Health Foundation NHS Trust, is a signatory of the Trauma Informed concordat for Hampshire, the Isle of Wight, Portsmouth and Southampton, committing to the delivery of the Trauma Informed Strategy, allocating resources, and providing support and commitment at a senior level.” Source location Response from Hampshire and Isle of Wight
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate an all-age autism and ADHD improvement group to oversee transformation of the neurodiversity pathway.
Verbatim wording from the response “secondary care provider of mental health services and future ASC/ADHD assessment and prescribing provider(s) to establish much stronger and collaborative working arrangements.” Source location Response from Hampshire and Isle of Wight
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 current and future personality-disorder provision using benchmarking, stakeholder views, projected need, and best practice.
Verbatim wording from the response “Issue - Evidence before this inquest indicated that SHFT has recognised that the mental health provision for those with personality disorders must move towards an individual, therapeutic and trauma-informed approached.” Source location Response from Hampshire and Isle of Wight
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 post-diagnostic support options for neurodiverse people and families.
Verbatim wording from the response “In addition to the re-commissioning of the assessment and prescribing pathways, a HIOW All Age ASC and ADHD Improvement Group is now operational and responsible for overseeing the transformation of the whole neurodiversity pathway, including:” Source location Response from Hampshire and Isle of Wight
Open published response
Concerns raised 6 Risk of using prescribed Propranolol for overdose View source Failure to agree and update a common action plan for revoked s.17 leave View source Failure to collect and return patients to the ward when s.17 leave is revoked View source Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol View source Failure to finalise the formal revocation of s.17 leave View source Lack of shared awareness of powers and responsibilities when s.17 leave is revoked 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
Sasha Sabrina FORSTER · 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
Sasha Sabrina FORSTER, a 20-year-old woman with a lengthy history of mental health disorders, self-harm and overdoses, died by suicide following deliberate ingestion of a fatal overdose of Propranolol tablets. The inquest identified concerns that hospitals and police forces were not always aware of their powers and responsibilities when her section 17 leave was revoked, or had not agreed and updated a common plan, resulting in inconsistent actions and an increased risk to Sasha.
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 Hampshire and Isle of Wight Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Risk of using prescribed Propranolol for overdose
Wider context from the report “Evidence was heard at the inquest that after her treating psychiatrist had stopped prescribing her Propranolol, due to the risk of overdose, Sasha visited two private GPs at a clinic in London, on occasions two weeks apart.
In each consultation Sasha:
- requested Propranolol, on the basis that it was currently being prescribed to her for anxiety;
- revealed a limited history of mental health issues;
- failed to reveal either her extensive overdose history or the fact that her treating psychiatrist had stopped prescribing her Propranolol.
Without details of Sasha’s GP or her treating psychiatrist, or her consent to contact them ( neither of which was given ), neither GP had the means of discovering her worrying psychiatric background. Had they had those means, it is likely that neither GP would have given her a 28 day supply of Propranolol.
Whilst it could not be proven that the Propranolol prescribed by these GPs was the Propranolol used by Sasha for her final, fatal overdose, there remained at the time a considerable risk that she would so use it .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Hampshire and Isle of Wight Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to agree and update a common action plan for revoked s.17 leave
Wider context from the report “Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked, or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances .
As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or not.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Hampshire and Isle of Wight Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to collect and return patients to the ward when s.17 leave is revoked
Wider context from the report “(1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked , was that they did not have the resources to allow them to do this , despite it being their legal responsibility so to do .
(2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked , placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request.
(3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised, Sasha’s mother was given to believe that it would be, and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Hampshire and Isle of Wight Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol
Wider context from the report “Evidence was heard at the inquest that after her treating psychiatrist had stopped prescribing her Propranolol, due to the risk of overdose, Sasha visited two private GPs at a clinic in London, on occasions two weeks apart.
In each consultation Sasha:
- requested Propranolol, on the basis that it was currently being prescribed to her for anxiety;
- revealed a limited history of mental health issues;
- failed to reveal either her extensive overdose history or the fact that her treating psychiatrist had stopped prescribing her Propranolol.
Without details of Sasha’s GP or her treating psychiatrist, or her consent to contact them ( neither of which was given ), neither GP had the means of discovering her worrying psychiatric background. Had they had those means, it is likely that neither GP would have given her a 28 day supply of Propranolol.
Whilst it could not be proven that the Propranolol prescribed by these GPs was the Propranolol used by Sasha for her final, fatal overdose, there remained at the time a considerable risk that she would so use it.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Hampshire and Isle of Wight Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to finalise the formal revocation of s.17 leave
Wider context from the report “(1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked, was that they did not have the resources to allow them to do this, despite it being their legal responsibility so to do.
(2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked, placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request.
(3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised , Sasha’s mother was given to believe that it would be , and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Hampshire and Isle of Wight Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of shared awareness of powers and responsibilities when s.17 leave is revoked
Wider context from the report “Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked , or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances.
As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or not.
” Open source report
Concerns raised 1 Lack of a formal GP surgery policy or protocol for monitoring patients prescribed clozapine antipsychotic medication 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
Megan Nicole JONES · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Megan Nicole JONES, aged 28, was found dead at home after a history of mental health issues and treatment with combined antipsychotic medications. The report states that she was believed to have suffered a fatal cardiac arrhythmia associated with a higher-than-optimal recommended dose of the medications. The principal concern was the absence of a formal policy for regular monitoring, including QTc recording, of patients prescribed Clozapine, particularly when antipsychotic prescribing exceeded 100% of the BNF limit.
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 Hampshire and Isle of Wight Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal GP surgery policy or protocol for monitoring patients prescribed clozapine antipsychotic medication
Wider context from the report “1. It is clear that there is no formal policy or protocol in place for GP’s surgeries with regard to the monitoring of those patients who are prescribed Clozapine antipsychotic medication .
2. It would be relatively simple for the CCG to instigate such a policy or protocol that where a patient is prescribed Clozapine, they must be monitored on a regular basis to ensure that there is some form of QTc recording.
3. This policy/protocol is especially important where the patient is prescribed more than 100% of the BNF limit of antipsychotic medication(s).
” Open source report
Concerns raised 1 Failure to regularly monitor patients prescribed medication that could be dangerous to their welfare 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
Nathan John COOKE · 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
Nathan John COOKE was found dead at home after being prescribed Methadone and Clomipramine and supplementing these with illicit medication. The inquest concluded that the death was drug related, with the medical cause recorded as cardio-respiratory failure, severe central nervous system depression, and Methadone and Clomipramine overdose. A principal concern was that the known risk associated with QTc prolongation was not adequately addressed through clinical monitoring and medication management.
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 Hampshire and Isle of Wight Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to regularly monitor patients prescribed medication that could be dangerous to their welfare
Wider context from the report “1. It was agreed that a more appropriate way to manage and control this situation whereby a patient is prescribed medication which could be dangerous to their welfare without regular monitoring would be for the primary care practice to write to the patient, inviting them to attend for a review, and informing them that if they failed to attend the review by a specified date, their medication would be reduced and eventually stopped. The incentive and responsibility to comply with clinicians is thereby passed to the patient.
” Open source report
1 Aug 2018 Cuthbert Anthony Stanley Hingert · Prevention of Future Deaths report Isle of Wight
View report summary
Concerns raised 7 Lack of training for clinicians in use of the JAC medicines database View source Failure to make immediate DATIX incident reports in accordance with hospital protocol View source Failure to check the medicines database before prescribing duplicate medication doses View source Failure to prevent inappropriate continuing prescriptions of Fondaparinux and Ticagrelor View source Failure to prescribe aspirin at the standard continuing dose View source Failure to ensure safe clinical decision-making when prescribing hypnotics to confused patients View source Delays in documenting verbal prescribing orders 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
Cuthbert Anthony Stanley Hingert · 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
Cuthbert Anthony Stanley Hingert was admitted to hospital with shortness of breath and possible acute coronary syndrome, during which duplicate doses of antiplatelet and anticoagulant medications were given. He later became confused, fell and sustained a subdural haematoma, skull fracture and subarachnoid haemorrhage, dying in hospital on 5 March 2017. Concerns included failures to check the medicines database, inappropriate or potentially inappropriate prescribing, delayed documentation, inadequate staff training and failure to report a medication incident according to protocol.
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 Hampshire and Isle of Wight Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of training for clinicians in use of the JAC medicines database
Wider context from the report “4. There was evidence that at least one of the clinicians treating Mr Hingert had not been trained to use the JAC medicines database .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Hampshire and Isle of Wight Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to make immediate DATIX incident reports in accordance with hospital protocol
Wider context from the report “7. Upon discovering the errors with the medications which are documented above, a nurse did not follow hospital protocol and make a DATIX incident report despite acknowledging that she should have done so immediately .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Hampshire and Isle of Wight Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to check the medicines database before prescribing duplicate medication doses
Wider context from the report “1. The evidence revealed that the Medical Registrar did not check the JAC medicines database to see that Mr Hingert had already been administered a stat dose of antiplatelets and anticoagulant medication before prescribing second dose of these medications .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Hampshire and Isle of Wight Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent inappropriate continuing prescriptions of Fondaparinux and Ticagrelor
Wider context from the report “3. Mr Hingert had already been prescribed continuing doses of Fondaparinux and Ticagrelor , which (fortuitously) were not administered.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Hampshire and Isle of Wight Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to prescribe aspirin at the standard continuing dose
Wider context from the report “2. The Medical Registrar prescribed aspirin to continue at 300mg rather than at the standard dose of 75mg daily .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Hampshire and Isle of Wight Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure safe clinical decision-making when prescribing hypnotics to confused patients
Wider context from the report “6. A decision was made to treat Mr Hingert, who was already confused, with the hypnotic Zopiclone , which may not have been a sound clinical decision .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Hampshire and Isle of Wight Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in documenting verbal prescribing orders
Wider context from the report “5. There was a 2-hour delay in writing up a verbal order with regard to a prescribing decision.
” Open source report
4 Jun 2014 John William Day · Prevention of Future Deaths report Isle of Wight
View report summary
Concerns raised 1 Lack of reliable access to patients’ allergy information by out-of-hours doctors 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 William Day · 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 William Day, who had COPD, heart failure and respiratory difficulties, was found dead on 6 April 2014 while attached to his oxygen supply. An out-of-hours doctor prescribed Co-Amoxiclav after being unable to access Mr Day’s medical records, although he had a known allergy to the drug; the report states that the medication did not cause his death. The principal concern was that out-of-hours doctors could not access patients’ allergy information in every case.
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 Hampshire and Isle of Wight Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of reliable access to patients’ allergy information by out-of-hours doctors
Wider context from the report “(1) During the course of my investigation, I heard live evidence from ████████ who was the out-of-hours doctor who visited Mr Day. He told me that he did not have access to the ████████ medical records and that this was a common situation . He said that he had asked Mr Day if he had any allergies to medication, and Mr Day replied that he did not have any such allergies. Whilst Mr Day appeared to have capacity, the information which he gave to ████████ was incorrect, and as a consequence, ████████ prescribed Co-Amoxiclav to Mr Day.
(2) In this case, the patient did not die as a result of the medication which was prescribed, but if the patient had died, an inquest would have inevitably resulted. Moreover, the patient had capacity to give an (incorrect) answer, but if the patient lacked capacity to do so, I am concerned that the out-of-hours doctor has no way of verifying the appropriateness of the medication which he wishes to prescribe . Accordingly I am concerned that there is not a way in which out-of-hours doctors can access the “Allergies” section of a patient’s medical notes in every case . As I understand it, even if a patient opts out of the NHS Spine, the information about allergies should still be available to any medical personnel who consult the database.
” Open source report
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Addressed to Hampshire and Isle of Wight Partnership of Clinical Commissioning Groups, now represented here by NHS Hampshire and Isle of Wight Integrated Care Board.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations