Concerns raised 20 Failure to grade fatal severe harm correctly View source Failure to examine the Trust's own clinical governance processes View source Unreliability of Trust safety and complaints data View source Failure to ensure midwives complete current mandatory training View source Failure of harm-only reporting to identify underlying safety problems View source Failure to notify external and internal patient-safety bodies of serious incidents View source Lack of a system of remedial training View source Inconsistent categorisation of harm for cooled babies with hypoxic injury View source Lack of document version control and audit View source Failure to learn from identified safety issues and themes View source Lack of a culture of candour View source Lack of assured ongoing funding for MSNI investigations View source Insufficiently skilled and trained clinical governance personnel View source Failure of clinical reporting to provide a holistic and complete account of evidence View source Failure to categorise a death-causing harm event correctly View source Inadequate Trust investigations failing to identify safety issues View source Failure to investigate senior staff roles in disputed safety-report decisions View source Failure to provide relevant information transparently and openly View source Chaotic clinical governance arrangements View source Untrained clinical governance staff View source See 17 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 10
Action
Scrutinise patient-safety investigation reports and monitor PSIRF implementation through safety-panel attendance, supportive challenge and review of patient and family engagement.
Stated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025. View source
Action
Operate maternity governance and reporting forums to review incidents, outcomes, investigations, learning and improvement actions across the system.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2025. View source
Action
Triangulate information and data sources, using soft intelligence and formal scrutiny to validate provider data and identify issues requiring further investigation.
Stated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025. View source
Action
Monitor the impact of clinical-governance recruitment and attend Trust committees to scrutinise and challenge governance practices.
Stated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025. View source
Action
Monitor the Duty of Candour improvement action plan through continued assurance, committee attendance, external challenge and scrutiny.
Stated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025. View source
Action
Maintain contractual oversight and scrutiny of the Trust’s patient-safety-event reporting, challenging unexpected variation.
Stated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025. View source
Action
Obtain the external audit outcome on PSIRF progress and monitor implementation of any resulting action plan.
Stated plannedThe respondent said that this action was planned when they made their response on 26 March 2025. View source
Action
Ensure actions arising from shared-learning discussions are implemented across the system.
Stated plannedThe respondent said that this action was planned when they made their response on 26 March 2025. View source
Action
Seek monthly assurance on mandatory maternity-training compliance, including reasons for non-compliance and actions taken to protect patient safety.
Stated plannedThe respondent said that this action was planned when they made their response on 26 March 2025. View source
Action
Participate actively in developing regional maternity guidance and principles for consistent identification and reporting of incidents.
Stated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025. View source See 7 more actions
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AI-generated summary
Ida Jean Lock · 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
Ida Jean Lock died on 16 November 2019 after suffering a lack of oxygen during delivery on 9 November 2019, resulting in severe hypoxic-ischaemic brain damage. The report describes missed opportunities for enhanced care and obstetric input, delays in responding to fetal distress, and initially ineffective neonatal resuscitation. The principal concerns include the Trust’s alleged lack of candour and transparency, deficient clinical and maternity governance, inadequate investigations, gaps in mandatory and remedial training, and inappropriate grading of the harm suffered.
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 Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to grade fatal severe harm correctly
Wider context from the report “14. The Trust graded Ida’s level of harm as “moderate”, even after her death . This grading should have been adjusted to "severe" by the Trust before Ida was transferred to Royal Preston Hospital as the consultant paediatrician identified that she had sustained a severe hypoxic ischaemic encephalopathy due to fetal bradycardia.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to examine the Trust's own clinical governance processes
Wider context from the report “7. As a result of the Trust's deficient processes, the Trust did not undertake any examination of its own clinical governance processes , which were a principle area of concern and which was identified to the Trust five months before the inquest commenced. The Trust's clinical governance arrangements were extracted piecemeal during the course of the inquest. The deficiencies included lack of version control and audit of documents, untrained staff, chaotic clinical governance arrangements, defensive attitudes and inappropriate self-congratulation. The clinicians' reports to the inquest only answered the questions they were asked rather than trying to assist with a holistic view of the evidence, did not provide relevant information until it was extracted from the witness in testimony, that resulted in rolling disclosure of documents and additional witness evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unreliability of Trust safety and complaints data
Wider context from the report “5. Trust figures to the Board provided in 2025 stated that there were no complaints over 6 months old when the Trust at the time of the inquest have not responded to ████████ and ████████'s 1 June 2020 complaint., Together with the Trust's failure to categorise Ida's death as only "Moderate Harm" (see point 4 above) cause me also to have concern about the reliability of Trust's data .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure midwives complete current mandatory training
Wider context from the report “11. The Band 5 midwife supporting ████████ in Labour had not undertaken her required mandatory training and this fact had not been provided and was only revealed at the inquest as part of the evidence of the Head of Midwifery in March 2025. I was also concerned to learn that in 2025 non-completion of mandatory training was still an issue as ████████ had not completed her mandatory training.
12. It concerns me that the Trust do not have robust systems in place to ensure that any midwife who has not completed her mandatory training is subject to immediate action to ensure that all mandatory training is completed and is in date .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of harm-only reporting to identify underlying safety problems
Wider context from the report “15. The 2024 NHSE Learn from patient safety events (LFPSE) guidance that replaced the National Reporting and Learning System (NRLS) confirms that the recording and analysis of patient safety events that occur in healthcare support the NHS to improve learning from patient safety events to help make care safer. There is a significant risk that if reporting is graded on harm alone , clinical care that resulted in hypoxic brain damage during delivery and which was prevented by therapeutic cooling, will not adequately identify the problems that caused the harm during the delivery .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to notify external and internal patient-safety bodies of serious incidents
Wider context from the report “4. The Trust did not disclose that they had failed to notify the external bodies namely the CQC and the then CCG [ICB] via STEIS and the Trust's internal Serious Incidents Reporting Investigation panel , none of which was noted by the Trust's Patient Safety Summits .The matter was reported to the Coroner a year after Ida's death by the family after the Trust took no action to do so, despite being on notice of failures in treatment from the HSIB report Ida’s harm was at no point categorised by the Trust as a harm event that caused “death”.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a system of remedial training
Wider context from the report “13. There was no remedial training was put in place for either the midwives involved in Ida's delivery and resuscitation or for the paediatric SHO after Ida’s death. This raises a significant concern that the Trust do not operate a system of remedial training when this inquest has identified remedial training was required for ████████, ████████, ████████ and ████████
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inconsistent categorisation of harm for cooled babies with hypoxic injury
Wider context from the report “16. ████████ confirmed that nationally there is inconsistency in categorisation of harm for babies who sustain a hypoxic injury due to fetal bradycardia in labour and who require cooling and clarification and guidance would assist prevent further maternity deaths and ensure full and proper investigation of hypoxic injuries sustained in labour.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of document version control and audit
Wider context from the report “7. As a result of the Trust's deficient processes, the Trust did not undertake any examination of its own clinical governance processes, which were a principle area of concern and which was identified to the Trust five months before the inquest commenced. The Trust's clinical governance arrangements were extracted piecemeal during the course of the inquest. The deficiencies included lack of version control and audit of documents , untrained staff, chaotic clinical governance arrangements, defensive attitudes and inappropriate self-congratulation. The clinicians' reports to the inquest only answered the questions they were asked rather than trying to assist with a holistic view of the evidence, did not provide relevant information until it was extracted from the witness in testimony, that resulted in rolling disclosure of documents and additional witness evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to learn from identified safety issues and themes
Wider context from the report “2. ████████s evidence to the inquest was that a deep-seated and endemic culture within the Trust leads to denial and a failure to learn . ████████'s Investigation report was published in 2015, the Trust is ten years on and still issues and themes identified in 2015 were very much in issue in 2019 and still exist at the Trust as identified by Ida’s inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a culture of candour
Wider context from the report “1. I am concerned that there is not a culture of candour within University Hospitals of Morecambe Bay NHS Foundation Trust (Trust) and the impact that this has on safety, learning and implementing required changes to prevent deaths. Urgent action is required by the Trust to meaningfully embed the Duty of Candour
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of assured ongoing funding for MSNI investigations
Wider context from the report “18. The MSNI is now hosted by the CQC with funding secured for the next two years but no certainty as to ongoing funding after this date . These independent investigations by specialist skilled investigators into the most serious of events is an essential safeguard to the lives of mothers and unborn children.
19. Without an assurance that funding will continue beyond 2027 I am concerned that significant harm events to mothers and babies and deaths such as Ida's will go unrecorded and lessons that should be learned to prevent future maternal and baby deaths will go unnoticed, and there will be a risk of future maternity deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficiently skilled and trained clinical governance personnel
Wider context from the report “6. I consider the clinical governance arrangements at the Trust require urgent review to ensure the appropriate personnel are in place, with the necessary training and skills to deliver robust clinical governance to ensure patient safety in maternity 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 Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of clinical reporting to provide a holistic and complete account of evidence
Wider context from the report “7. As a result of the Trust's deficient processes, the Trust did not undertake any examination of its own clinical governance processes, which were a principle area of concern and which was identified to the Trust five months before the inquest commenced. The Trust's clinical governance arrangements were extracted piecemeal during the course of the inquest. The deficiencies included lack of version control and audit of documents, untrained staff, chaotic clinical governance arrangements, defensive attitudes and inappropriate self-congratulation. The clinicians' reports to the inquest only answered the questions they were asked rather than trying to assist with a holistic view of the evidence , did not provide relevant information until it was extracted from the witness in testimony , that resulted in rolling disclosure of documents and additional witness evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to categorise a death-causing harm event correctly
Wider context from the report “4. The Trust did not disclose that they had failed to notify the external bodies namely the CQC and the then CCG [ICB] via STEIS and the Trust's internal Serious Incidents Reporting Investigation panel, none of which was noted by the Trust's Patient Safety Summits .The matter was reported to the Coroner a year after Ida's death by the family after the Trust took no action to do so, despite being on notice of failures in treatment from the HSIB report Ida’s harm was at no point categorised by the Trust as a harm event that caused “death” .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate Trust investigations failing to identify safety issues
Wider context from the report “9. All investigations conducted by the Trust to date in respect of Ida’s death have been unskilled, superficial, brief, failed to identify issues and left the family without answers and were all features identified by the 2015 Kirkup Report. In view of the continuing culture at the Trust, this cause a significant concern that issues of safety and safeguarding are not properly considered, transparently engaged with and then addressed formally in respect of a child fatality and serious injury by the Trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate senior staff roles in disputed safety-report decisions
Wider context from the report “8. ████████ is now Head of Compliance and Assurance at the Trust but that there has been no investigation into her role in respect of reneging on the Trust's acceptance of the HSIB report at senior management level and with the family as was indicated by her approval of the July 2021 position statement. Similarly, ████████ is now Head of Midwifery at the Trust and there has been no investigation in respect of her disputing the HSIB findings and submission of challenge to the HSIB report in Ida’s case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide relevant information transparently and openly
Wider context from the report “3. The Trust's approach to the inquest has been one of a lack of transparency and openness, failure to provide relevant information and a failure to identify with candour the defective clinical governance processes that have operated at the Trust from 2019 to present day.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Chaotic clinical governance arrangements
Wider context from the report “7. As a result of the Trust's deficient processes, the Trust did not undertake any examination of its own clinical governance processes, which were a principle area of concern and which was identified to the Trust five months before the inquest commenced. The Trust's clinical governance arrangements were extracted piecemeal during the course of the inquest. The deficiencies included lack of version control and audit of documents, untrained staff, chaotic clinical governance arrangements , defensive attitudes and inappropriate self-congratulation. The clinicians' reports to the inquest only answered the questions they were asked rather than trying to assist with a holistic view of the evidence, did not provide relevant information until it was extracted from the witness in testimony, that resulted in rolling disclosure of documents and additional witness evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Untrained clinical governance staff
Wider context from the report “7. As a result of the Trust's deficient processes, the Trust did not undertake any examination of its own clinical governance processes, which were a principle area of concern and which was identified to the Trust five months before the inquest commenced. The Trust's clinical governance arrangements were extracted piecemeal during the course of the inquest. The deficiencies included lack of version control and audit of documents, untrained staff, chaotic clinical governance arrangements , defensive attitudes and inappropriate self-congratulation. The clinicians' reports to the inquest only answered the questions they were asked rather than trying to assist with a holistic view of the evidence, did not provide relevant information until it was extracted from the witness in testimony, that resulted in rolling disclosure of documents and additional witness evidence.
” 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 Scrutinise patient-safety investigation reports and monitor PSIRF implementation through safety-panel attendance, supportive challenge and review of patient and family engagement.
Verbatim wording from the response “As stated earlier in this response the ICB acknowledges that the Trusts journey in implementing and embedding PSIRF, the frameworks principles and the training of investigators in line with national expectations is not as advanced as initially planned or expected. This includes the clear need for compassionate engagement that is timely, open and transparent when care goes wrong. We are re-assured by the Trust that there is a plan in place to address these gaps and will actively and robustly monitor the progress to fully meet the PSIRF expectations using both quantitative and qualitative intelligence sources.” Source location Response from NHS Lancashire and South Cumbria Integrated Care Board
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 maternity governance and reporting forums to review incidents, outcomes, investigations, learning and improvement actions across the system.
Verbatim wording from the response “The LMNS, (the maternity arm of the Integrated Care Board) has established and embedded a governance and reporting structure for all local maternity services. This includes a bi-monthly Quality Assurance Panel and Patient Safety Learning Group (see attached Terms of Reference). U H M B T maternity service are fully engaged and provide regular reporting on maternity and neonatal outcomes and patient safety incidents in order to maximise learning across the Integrated Care System (ICS).” Source location Response from NHS Lancashire and South Cumbria Integrated Care Board
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 Triangulate information and data sources, using soft intelligence and formal scrutiny to validate provider data and identify issues requiring further investigation.
Verbatim wording from the response “The ICB acknowledges the concerns of the coroner in respect of reliability of data. In order to be re-assured on the validity of data either supplied to the ICB or in the public domain, triangulation of hard and soft information is undertaken. This also includes the use of a Soft Intelligence System across Lancashire and South Cumbria; issues can be raised that allow for consideration of further interrogation or collation/theme/trending to build a wider view of a service or provider. This system plus all the other information held gives an ability to validate information/data provided and where necessary provide external scrutiny and challenge through formal contract meetings and Quality Review meetings.” Source location Response from NHS Lancashire and South Cumbria Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor the impact of clinical-governance recruitment and attend Trust committees to scrutinise and challenge governance practices.
Verbatim wording from the response “The ICB is deeply saddened that the family of Ida were unnecessarily exposed to an extended court hearing as a result of poor clinical governance within the Trust; we were very concerned to read the findings from the inquest and do not support poor governance practices. We are aware that there has been staffing vacancies/absences within the clinical governance team which we would partly attribute to the deficiencies identified. The ICB are assured that key governance posts have been recruited to and staff commenced in post (albeit interim in some cases). The ICB will continue to monitor the impact of this recruitment to assure itself that clinical governance practices are improved, embedded and sustained. Additionally, the ICB will attend internal Trust key committee meetings and ensure scrutiny is afforded and challenge given where these practices are seen.” Source location Response from NHS Lancashire and South Cumbria Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor the Duty of Candour improvement action plan through continued assurance, committee attendance, external challenge and scrutiny.
Verbatim wording from the response “The ICB has identified that the Trust is currently showing common cause variation with the lower compliance attributed to staffing capacity. The capacity issue is being addressed through divisional reconfiguration and additional capacity was identified which came into effect on 1 April 2025. An audit has been undertaken and there is an associated action plan in order to improve compliance to ensure every patient/family is served Duty of Candour in a timely and compassionate manner. The ICB are committed to ensuring that compliance improves and will monitor the effectiveness of the action plan through continued mechanisms including attendance at the Trust Quality Assurance Committee providing external challenge and scrutiny.” Source location Response from NHS Lancashire and South Cumbria Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain contractual oversight and scrutiny of the Trust’s patient-safety-event reporting, challenging unexpected variation.
Verbatim wording from the response “In line with contractual and regulatory requirements LSC ICB expects all providers to report all patient safety events onto the Learning From Patient Safety Events (LFPSE) platform (this has replaced the National Reporting Learning System – NRLS). Where appropriate and in line with Trust local and national priorities, patient safety events must also be reported onto StEIS where the ICB is then notified. The ICB is very concerned to note from you findings that the Trust failed to fulfil these contractual and regulatory requirements. Since the inception of the ICB there has been a detailed oversight in the reporting of patient safety events from the Trust against expected reporting, with challenge where there has been unexpected variation. The ICB will continue to seek assurance from the Trust through the contractual route and by the ongoing scrutiny of patient safety events.” Source location Response from NHS Lancashire and South Cumbria Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtain the external audit outcome on PSIRF progress and monitor implementation of any resulting action plan.
Verbatim wording from the response “It is understood by LSC ICB that Mersey Internal Audit Authority (MIAA) as external auditors are scheduled to undertake an audit on the Trust’s PSIRF progress in 2025/26; the ICB will seek a copy of the audit outcome and monitor the implementation of any resulting action plan.” Source location Response from NHS Lancashire and South Cumbria Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure actions arising from shared-learning discussions are implemented across the system.
Verbatim wording from the response “Additionally, the ICB are sighted on the improvements being made to embed the Patient Safety Incident Response Framework (PSIRF) which is focussed on learning and compassionate engagement. We do however acknowledge that progress with PSIRF has been limited which in turn delays learning and improvements. In order to address this deficit the ICB are aware that additional capacity has now been sought to ensure that investigations into patient safety events are conducted in a timely manner, and this is currently being closely monitored with appropriate challenge provided to the Trust at both internal Trust and external assurance meetings. Within the wider organisation the Trust attend and actively participate in the ICS Shared Learning Forum and Patient Safety Specialist meetings. The ICB will ensure that actions taken from these discussions are implemented.” Source location Response from NHS Lancashire and South Cumbria Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Seek monthly assurance on mandatory maternity-training compliance, including reasons for non-compliance and actions taken to protect patient safety.
Verbatim wording from the response “It is acknowledged that whilst the LMNS has oversight and assurance of training in line with Training Needs Analysis (Maternity Incentive scheme safety action 8), this does not include mandatory training. The Director of Midwifery at UHMBT has provided reassurance to the LMNS that further actions are underway to ensure there is monthly reporting on mandatory maternity training with deep dives to understand those staff not compliant and immediate action taken to remedy this position. As an LMNS we will seek assurance through the monthly reporting process that all staff are compliant and where this is not the case the rationale and actions being taken to ensure patient safety.” Source location Response from NHS Lancashire and South Cumbria Integrated Care Board
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 Participate actively in developing regional maternity guidance and principles for consistent identification and reporting of incidents.
Verbatim wording from the response “The North-West Regional Chief Midwife is developing Maternity Guidance and Principles with the aim to ensure there is a consistent approach in the identification and reporting of incidents. The ICB are supportive of this work and are actively engaged with the regional work to reduce this known risk.” Source location Response from NHS Lancashire and South Cumbria Integrated Care Board
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust is best placed to respond to concerns about individual staff members.
Verbatim wording from the response “8. Specific concerns relating to individual members of staff” Source location Response from NHS Lancashire and South Cumbria Integrated Care Board
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 Nationally led MSNI funding prevents assurance about funding continuing beyond 2027.
Verbatim wording from the response “E. Funding for MSNI” Source location Response from NHS Lancashire and South Cumbria Integrated Care Board
Open published response
8 Dec 2023 Claire Nicole Briggs · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Lack of consistent and reliable understanding of respective emergency service roles for suspected drug overdoses View source Lack of a consistent and reliable method for police escalation of suspected drug overdose concerns to the ambulance service View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Claire Nicole Briggs · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Claire Nicole Briggs died at Stepping Hill Hospital on 28 November 2022 after a propranolol overdose. The report identified delays in ambulance response and failures to conduct timely clinical reviews, alongside the absence of a consistent and reliable process for police officers to escalate concerns about suspected drug overdoses to the ambulance service.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent and reliable understanding of respective emergency service roles for suspected drug overdoses
Wider context from the report “The evidence I heard was that a Joint Operating Protocol between the North West Ambulance Service and the five regional police forces designed to address the issues of which emergency service should take responsibility for incidents involving drug overdoses and the method by which the police officers attending such incidents prior to the arrival of the ambulance service can escalate their concerns over a person suspected to have taken a drug overdose, was in an advanced stage of completion, but was stalled in July 2022.
Whilst I heard that discussions have recently recommenced, they now encompass the Right Care, Right Person model, the findings of the Manchester Arena Bombing Enquiry and that additionally, the Fire and Rescue Service and the British Transport Police have now become involved.
Pending agreement of a Joint Operating Protocol, there does not appear to be any consistent and reliable understanding in place across the police forces and the North West Ambulance Service to provide clarity as to the roles of the respective services and the method by which concerns about individual patients can be escalated to the ambulance service by police officers dealing with those who are suspected to have taken drug overdoses.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a consistent and reliable method for police escalation of suspected drug overdose concerns to the ambulance service
Wider context from the report “The evidence I heard was that a Joint Operating Protocol between the North West Ambulance Service and the five regional police forces designed to address the issues of which emergency service should take responsibility for incidents involving drug overdoses and the method by which the police officers attending such incidents prior to the arrival of the ambulance service can escalate their concerns over a person suspected to have taken a drug overdose, was in an advanced stage of completion, but was stalled in July 2022.
Whilst I heard that discussions have recently recommenced, they now encompass the Right Care, Right Person model, the findings of the Manchester Arena Bombing Enquiry and that additionally, the Fire and Rescue Service and the British Transport Police have now become involved.
Pending agreement of a Joint Operating Protocol, there does not appear to be any consistent and reliable understanding in place across the police forces and the North West Ambulance Service to provide clarity as to the roles of the respective services and the method by which concerns about individual patients can be escalated to the ambulance service by police officers dealing with those who are suspected to have taken drug overdoses .
” Open source report
1 Sep 2023 Harold Derek PEDLEY Otherwise known as Derek PEDLEY · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 4 Failure to provide GPs with a realistic picture of hospital waiting times View source Inability of emergency departments to triage patients during OPEL 4 pressures View source Use of hospital pressures as a default explanation for substandard patient care View source Failure to notify receiving doctors when patients arrive at the hospital View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Harold Derek PEDLEY Otherwise known as Derek PEDLEY · 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
Harold Derek Pedley, known as Derek, attended hospital after referral by his GP with abdominal pain and vomiting, but remained in the Emergency Department waiting area for almost two hours without being assessed or spoken to by a medical professional, and died before he was called. The report raised concerns about hospital pressures at OPEL 4, the inability to triage patients and notify expecting doctors, and the risk that patients may arrive expecting prompt assessment when this cannot be provided.
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 Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide GPs with a realistic picture of hospital waiting times
Wider context from the report “• Concern 3 - Finally, it is relevant to point out that Derek had not moved for some time before a medical professional called for Derek. I formed the view that there had been a reluctance on his Friend’s part to request assistance due to the pressures staff were clearly under, but also because he had already handed in Derek’s paperwork and was expecting some assistance imminently which did not arrive. I feel Derek and his Friend thought as they knew doctors had discussed his case with his GP and that his attendance was expected they did not need to raise a concern until it was too late. In actual fact, such are the pressures Emergency Departments are working under, this may not be the case. It is not for me to be prescriptive about what should be done, but unless GPs are provided with a realistic picture about how quickly their patients may be seen once they arrive at hospital (even if they have been in communication with the hospital doctors) their patients may arrive at hospital expecting to be seen quickly, when in reality this may not be the case particularly when the department is under significant pressures .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inability of emergency departments to triage patients during OPEL 4 pressures
Wider context from the report “• Concern 1 – that the medical professionals who work in a hospital emergency department are routinely expected to do so when the OPEL 4 applies, a recognition they are performing their roles when the hospital is “unable to deliver comprehensive care, and patient safety is at risk”. Such pressures may serve to leave the Emergency Department unable to triage patients such as Derek , and have no time to notify the doctors expecting his arrival (in this case doctors on the Surgical Assessment Unit) who are consequently left unaware that a patient has in fact arrived, all of which serves to place vulnerable patients such as Derek Pedley at serious 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 Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Use of hospital pressures as a default explanation for substandard patient care
Wider context from the report “• Concern 2 - that there is a risk that the pressures on hospitals become so significant they are used as a default explanation for levels of patient care that fall below what they would wish to deliver . I found that the hospital Trust did not seek to do so in this case, but it seems to me there is a risk this could happen. The pressures are indeed significant, but ultimately this case involves a 90 year old man with what appears to be an acute medical problem finding himself attending his local emergency department, not being spoken to / triaged by a medical professional for almost two hours, and dying by the time he is called for. There is a clear risk that puts patients at risk and it would be remiss of me not to raise 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 Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to notify receiving doctors when patients arrive at the hospital
Wider context from the report “• Concern 1 – that the medical professionals who work in a hospital emergency department are routinely expected to do so when the OPEL 4 applies, a recognition they are performing their roles when the hospital is “unable to deliver comprehensive care, and patient safety is at risk”. Such pressures may serve to leave the Emergency Department unable to triage patients such as Derek, and have no time to notify the doctors expecting his arrival (in this case doctors on the Surgical Assessment Unit) who are consequently left unaware that a patient has in fact arrived , all of which serves to place vulnerable patients such as Derek Pedley at serious risk.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the Fundamentals of Care Improvement Programme and monitor its impact, outcomes and further learning.
Verbatim wording from the response “From an Emergency Department workforce perspective, the ICB understands that Blackpool Teaching Hospitals is in the process of increasing the number of senior decision makers to enable the timely assessment and treatment of patients attending the Emergency Department, and that the nursing workforce has been increased following a recruitment drive to ensure safe staffing levels in the Emergency Department.
A Fundamentals of Care Improvement Programme was launched in the Trust during August 2023 for which the ICB are receiving regular updates in terms of impact, outcomes and further learning.” Source location Response from Lancashire and South Cumbria Integrated Care Board
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 Ensure GPs receive estimated Emergency Department wait times for direct surgical referrals so they can inform patients before arrival.
Verbatim wording from the response “If there is no bed/space for the patient with the specialty team then the patient will remain in ED until a bed becomes available and the speciality team are required to attend ED and visit the patient and complete any required assessments. The learning will also be cascaded across other Trusts.
With regards to direct referrals from GPs to the surgical team in Blackpool Victoria going forwards the surgical team have provided re-assurance in all instances that the GP will be advised of the estimated wait times within ED so that this can also be relayed to the patient prior to their arrival at ED.” Source location Response from Lancashire and South Cumbria Integrated Care Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase the number of Emergency Department senior decision makers to enable timely patient assessment and treatment.
Verbatim wording from the response “From an Emergency Department workforce perspective, the ICB understands that Blackpool Teaching Hospitals is in the process of increasing the number of senior decision makers to enable the timely assessment and treatment of patients attending the Emergency Department, and that the nursing workforce has been increased following a recruitment drive to ensure safe staffing levels in the Emergency Department.
A Fundamentals of Care Improvement Programme was launched in the Trust during August 2023 for which the ICB are receiving regular updates in terms of impact, outcomes and further learning.” Source location Response from Lancashire and South Cumbria Integrated Care Board
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 Direct referred Emergency Department patients to the admissions area, contact receiving specialty teams, and require specialty assessment when no admission capacity exists.
Verbatim wording from the response “As a result of the learning from this case Blackpool Victoria Hospital have revised their processes now so that if a patient arrives in the Emergency Department and has already been referred for example to the surgical team, then the patient is now directed to the admissions area. If the patient has already been accepted by the specialty, then the reception team at the Fylde Coast Medical Service (FCMS), or the streaming or triage nurse contact the receiving area, and if there is capacity then the patient is transferred to receiving speciality team. If there is no capacity in the admission area, the ED nursing or medical team will communicate directly with the speciality team and inform them of the patient’s arrival.” Source location Response from Lancashire and South Cumbria Integrated Care Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase the Emergency Department nursing workforce to ensure safe staffing levels.
Verbatim wording from the response “From an Emergency Department workforce perspective, the ICB understands that Blackpool Teaching Hospitals is in the process of increasing the number of senior decision makers to enable the timely assessment and treatment of patients attending the Emergency Department, and that the nursing workforce has been increased following a recruitment drive to ensure safe staffing levels in the Emergency Department.
A Fundamentals of Care Improvement Programme was launched in the Trust during August 2023 for which the ICB are receiving regular updates in terms of impact, outcomes and further learning.” Source location Response from Lancashire and South Cumbria Integrated Care Board
Open published response
11 May 2021 Coral Amy O’Donnell · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 7 Limited awareness among medical professionals of PVL-SA infection diagnosis and management guidance View source Insufficient microbiologist staffing capacity View source Lack of clinician awareness of relevant PVL guidance and hospital protocols View source Lack of awareness among primary and secondary care professionals of PVL-SA risk indicators View source Failure of critical care and microbiology teams to communicate relevant patient information View source Lack of clinician awareness and training in relevant internal information systems View source Failure of clinical and microbiology teams to consider PVL Staphylococcus Aureus when Staphylococcus Aureus is identified View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Coral Amy O’Donnell · 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
Coral Amy O’Donnell developed severe pneumonia after presenting with cough and cold-like symptoms and died in hospital on 17 May 2019 after prolonged intensive care. Concerns included failure to consider PVL Staphylococcus aureus promptly, limited awareness of relevant guidance and internal systems, problematic communication between critical care and microbiology teams, and insufficient microbiology staffing.
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 Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Limited awareness among medical professionals of PVL-SA infection diagnosis and management guidance
Wider context from the report “The court was told that there is a Public Health England publication entitled “Guidance on the diagnosis & management of PVL – associated Staphylococcus aureus infections”, but amongst medical professionals any awareness of this guidance appears to be limited .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient microbiologist staffing capacity
Wider context from the report “That the number of microbiologists at the time of Coral’s admission was limited – a senior Microbiologist told the court her team ought to comprise six microbiologists, but were limited to a maximum of four at the time and that remains the case .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of clinician awareness of relevant PVL guidance and hospital protocols
Wider context from the report “That there was a lack of awareness of PVL amongst senior clinicians , despite the fact that a senior Microbiologist from the hospital Trust confirmed that national guidance covering the treatment of such condition was in use at the Trust at the time, but none of the critical care team who gave evidence at the inquest seem to have been aware of that document . Although the court was told this has now been rectified there is a concern that some clinicians are unfamiliar with hospital protocols which may be relevant to their work ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness among primary and secondary care professionals of PVL-SA risk indicators
Wider context from the report “Although Staphylococcus aureus is a common bacterial infection, for the PVL strain of that infection to lead to the lung damage suffered by Coral is very rare. Nevertheless, one of the symptoms which may give medical professionals an indication that a patient may be at risk of PVL – SA is a history of skin infections and in otherwise healthy young people. There is clearly a lack of awareness of this condition in both primary and secondary care and in the absence of efforts to highlight this issue, young people such as Coral may continue to be placed 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 Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of critical care and microbiology teams to communicate relevant patient information
Wider context from the report “That communication between the critical care and microbiology teams was problematic and neither team considered PVL until there was established damage to her lungs identified on a chest x-ray. Senior clinicians had not mentioned a susceptibility to skin infections to the microbiologists which may have resulted in Coral receiving the correct treatment at an early stage of admission. The lack of communication between Microbiology and the clinical team appears to have in part been contributed to by a previous cessation of the thrice weekly joint microbiology and critical care ward rounds, which the court heard have not been re-instated;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of clinician awareness and training in relevant internal information systems
Wider context from the report “That there was a stark lack of awareness, noticeably amongst senior clinicians, about internal systems in place at the hospital Trust . The Cyberlab system, and also a red flag system which the court was told a number of critical care clinicians had previously been unaware of . If clinicians have not received the necessary training in relation to such systems there is a risk they may not recognise potentially relevant information , placing patients at potential 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 Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of clinical and microbiology teams to consider PVL Staphylococcus Aureus when Staphylococcus Aureus is identified
Wider context from the report “That when evidence of Staphylococcus Aureus was identified the clinical and microbiology teams did not consider the possibility of Panton Valentine Leukocidin (PVL) Staphylococcus Aureus , despite Coral’s history of skin infections and the severe pneumonia she presented with on admission in a previously young fit woman.
” 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 Circulate PVL-SA information and Public Health England guidance through the weekly CCG bulletin to GPs and out-of-hours providers.
Verbatim wording from the response “Given the implications this poses to the ongoing treatment of patients across the Fylde coast I have already undertaken the following actions:” Source location 2021-0152-Response-from-Blackpool-Fylde-and-Wyre-Clinical-Commissioning-Groups-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss PVL-SA awareness and guidance at the regular GP teleconference.
Verbatim wording from the response “Given the implications this poses to the ongoing treatment of patients across the Fylde coast I have already undertaken the following actions:” Source location 2021-0152-Response-from-Blackpool-Fylde-and-Wyre-Clinical-Commissioning-Groups-Redacted
Open published response
18 Nov 2020 Michelle Susan Turner · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 1 Potential loss of peer support worker services for people with mental health and/or alcohol or substance misuse problems View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Michelle Susan Turner · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michelle Susan Turner was found unresponsive at home on 1 June 2019 and died after using heroin, cocaine and tramadol. The substantive concern was that funding for peer support workers might be lost, potentially resulting in the loss of a service described as essential for some people with mental health conditions or alcohol and substance misuse problems.
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 Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Potential loss of peer support worker services for people with mental health and/or alcohol or substance misuse problems
Wider context from the report “I heard evidence and found that Michelle Turner had the support of her care coordinator and of her peer support worker and that she appeared to have built very positive relationships with each of them. I also heard evidence that:
• The Clinical Commissioning Group holds the responsibility for the funding of peer support workers;
• Peer support workers provide a variety of forms of support to service users, including assistance with connecting with drug services, support in managing their day, support in leaving the house and support in engaging in activity and that, very significantly, peer support workers have or may have “lived experience” of alcohol and/or substance misuse;
• This is an “invaluable” resource and, despite the circumstances of her death, Michelle Turner had felt inspired by her peer support worker;
• There is a possibility that funding for peer support workers will be lost in March 2021.
The concern that arises in these circumstances is that the service provided by peer support workers, which may be essential to those with mental health conditions and/or with alcohol and/or substance misuse problems and which is provided by those who, amongst service providers, may have the unique perspective of having “lived experience” of such problems, may be lost.
” 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 Extend the peer-support worker provision to maintain continuity until March 2022.
Verbatim wording from the response “Fylde and Wyre CCG commissions peer support workers recurrently from Lancashire and South Cumbria NHS Foundation Trust, who sub-contract to Calico, as the current provider. This sub-contract arrangement was due to end on 31 March 2021; however, an extension has been agreed to ensure continuity of provision until March 2022.” Source location 2020-0240-Response-from-Blackpool-CCG-Redacted.pdf
Open published response
Concerns raised 2 Delays in hospital patient handover causing prolonged ambulance unavailability View source Meal break policy causing crews to become unavailable for call allocation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
William Oliver · 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
William Oliver died at home on 1 November 2018 after becoming acutely unwell and contacting emergency services. The report describes concerns about inappropriate handling and re-triage of subsequent calls, ambulance resource availability affected by meal-break rostering and prolonged hospital turnaround times.
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 Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in hospital patient handover causing prolonged ambulance unavailability
Wider context from the report “2. Turnaround times at Greater Manchester Hospitals
Another contributing factor to the decreased availability of ambulances on the 31st October - 1st November 2018 was the turnaround times from hospitals in the Greater Manchester area. This was greater than anticipated at numerous sites. Whilst all hospitals were busy the turnaround times at Manchester Royal Infirmary, North Manchester hospital, Royal Oldham, Salford Royal and Stepping Hill hospital were all particularly higher than anticipated with numerous ambulances delayed for over one hour. In total from the commencement of the night shift on the 31st October more than 273 hours of ambulance availability were spent at hospital sites handing over patients. The evidence from NWAS did not suggest this was significantly different to other nights or uncommon.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Meal break policy causing crews to become unavailable for call allocation
Wider context from the report “1. Meal Break Policy and Shift Rostering
During the course of the Inquest the Court heard evidence as to the demand placed on NWAS during the night of the 31st October – 1st November. Difficulties in allocating resources within the Manchester area of the North West that night had been escalated to the Regional Control and Command Centre. One of the reasons for difficulties in allocating resources was directly attributed to the Meal Break Policy. In short, the issue being that each crew has to take a 30 minute meal break within their meal break window (this being three hours after their shift starts). If the crews reach the end of their meal break window without having taken a break they are automatically stood down and are unavailable to allocate calls to. The consequences of this policy have also been highlighted in other investigations following a death. In this case there was a significant reduction in the number of vehicles able to be allocated during the time Mr Oliver had contacted NWAS. The Court heard evidence this policy has been under review for sometime and consideration has been given to staggering the shift start times, but as yet no changes have been implemented
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the meal-break policy to ensure it does not compromise workforce profiling and ambulance availability.
Verbatim wording from the response “As part of the NHS Standard Contract 2019/20 Service Development Improvement Plan Blackpool CCG has emphasised the importance of a Roster Review and have included the Roster Review in commissioner requirements to support and gain assurance from NWAS in its implementation. The roster review will use detailed demand profiling data to align the entire workforce to meet the expected service demand and will be reviewed on an annual basis. As part of these changes the meal break policy will be reviewed to ensure that it does not compromise the effectiveness of this workforce profiling. Implementation in Greater Manchester is planned for January 2020.” Source location 2019-0494-Response-by-Blackpool-CCG
Open published response
Concerns raised 2 Delays in obtaining mental health treatment for children and young people in Cumbria View source Underfunding of mental health services for children and young people in Cumbria 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.
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AI-generated summary
Karen Jane Edgar · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Karen Jane Edgar had emotional and behavioural difficulties and was referred to CAMHS in October 2015, aged 15. She received delayed and limited mental health support, including gaps in family therapy, individual therapy, risk reassessment and care planning, before she died after hanging herself on 8 April 2017. The report raised concerns about underfunded child and adolescent mental health services, delays in treatment and inadequate resources and care.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining mental health treatment for children and young people in Cumbria
Wider context from the report “(1) The provision of mental health services for children and young people in Cumbria is underfunded.
(2) There are long delays in getting 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 Lancashire and South Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Underfunding of mental health services for children and young people in Cumbria
Wider context from the report “(1) The provision of mental health services for children and young people in Cumbria is underfunded.
(2) There are long delays in getting treatment.
” Open source report
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Addressed to NHS Blackpool Clinical Commissioning Group, now represented here by NHS Lancashire and South Cumbria Integrated Care Board.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations