Concerns raised 2 Failure to treat raised glucose levels as an ambulance-service emergency before hyperglycaemic collapse View source Lack of standby rapid-acting insulin prescriptions for otherwise stable diabetic patients 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
Colleen Alice FLETCHER · 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
Colleen Fletcher, who was insulin-dependent and cared for in a residential care home, experienced progressively rising blood glucose levels, collapsed into a diabetic coma and died on 29 January 2021. The report raises concerns about the availability of rapid-acting insulin for patients whose glucose levels were previously stable, and the potential delay before increased insulin could be administered or ambulance assistance considered necessary.
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 Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to treat raised glucose levels as an ambulance-service emergency before hyperglycaemic collapse
Wider context from the report “I understand that patients who have volatile glucose levels have the availability of pre-issued prescriptions for rapid acting insulin.
Those patients, like Mrs Fletcher, whose glucose levels are relatively stable don’t have the availability of the same prescription. Should their glucose levels begin to rise they would have to be referred to a GP, reviewed by that GP, possibly asked to monitor further and/or a prescription issued and collected from the surgery/chemist, before increased insulin could be administered. I was told that this could take in excess of a 24 hour period, during which time a patient’s glucose levels could continue to rise. I was told that raised glucose levels in and of themselves would not be considered an emergency for the ambulance service until a patient went into a state of hyperglycaemic collapse , which, as in the case of Mrs Fletcher, was a point of no return.
I understand that discussions are taking place to ensure the availability of fast acting insulin to be prescribed for all patients who are diabetic (regardless of volatility in their blood glucose levels) and that whilst progress has been made for those whose readings are volatile there is still work to be done to have the standby provision of bolus injections available for patients otherwise stable, whose glucose levels could at any point become unstable (by contracting an infection for example).
I consider that this is an essential tool for nurses on the front line to have at their disposal in treating effectively rising glucose levels and preventing hyperglycaemia and subsequent 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 Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of standby rapid-acting insulin prescriptions for otherwise stable diabetic patients
Wider context from the report “I understand that patients who have volatile glucose levels have the availability of pre-issued prescriptions for rapid acting insulin.
Those patients, like Mrs Fletcher, whose glucose levels are relatively stable don’t have the availability of the same prescription. Should their glucose levels begin to rise they would have to be referred to a GP, reviewed by that GP, possibly asked to monitor further and/or a prescription issued and collected from the surgery/chemist, before increased insulin could be administered. I was told that this could take in excess of a 24 hour period, during which time a patient’s glucose levels could continue to rise. I was told that raised glucose levels in and of themselves would not be considered an emergency for the ambulance service until a patient went into a state of hyperglycaemic collapse, which, as in the case of Mrs Fletcher, was a point of no return.
I understand that discussions are taking place to ensure the availability of fast acting insulin to be prescribed for all patients who are diabetic (regardless of volatility in their blood glucose levels) and that whilst progress has been made for those whose readings are volatile there is still work to be done to have the standby provision of bolus injections available for patients otherwise stable, whose glucose levels could at any point become unstable (by contracting an infection for example).
I consider that this is an essential tool for nurses on the front line to have at their disposal in treating effectively rising glucose levels and preventing hyperglycaemia and subsequent death.
” 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 Embed Home First into the revised pathway to support administration of rapid-acting insulin within two hours of referral when clinically necessary.
Verbatim wording from the response “5. Prioritising availability and administration of rapid acting insulin for the patient where it is deemed necessary by linking the pathway to our existing Home First service for a faster response. Home First is our expert rapid response team that are on hand within two hours to help keep older people well at home and avoid hospital admissions, this will ensure that diabetic care home residents who are experiencing an episode of unstable glucose will receive administration of insulin bolus within 2 hours of a referral. | 1st October 2022 | 15th October 2022 | Started and in progress. Home First have agreed to support and will be embedded into the revised pathway.” Source location Response from Leicester, Leicestershire and Rutland
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 Revise insulin authorisation forms, require their use, and include frailty-based dosing guidance and recorded authorisation for ad hoc rapid-acting insulin.
Verbatim wording from the response “4. Review the existing insulin authorisation form and make it mandatory for primary care and hospital clinicians to use Insulin authorisation forms to quality assure safe prescribing of insulin including authorisation for bolus insulin in the community.” Source location Response from Leicester, Leicestershire and Rutland
Open published response
Concerns raised 7 Failure to share complex and high-risk patients between units early in the inpatient stay View source Failure to consider bespoke placements early for complex patients View source Failure to verbally communicate increased suicidal risk to the responsible nurse View source Failure to prioritise timely safer placements for patients at high risk of self-harm View source Failure to base staff handovers on clinical-record examination and update care plans for risk management View source Lack of deadlines for finding alternative placements View source Risk of clinical silos between sections of mental health services 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
Rebecca Jane Hursey · 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
Rebecca Jane Hursey died at St George’s Hospital on 4 May 2018 after taking an aspirin overdose while detained under Section 3 of the Mental Health Act and receiving care on the Avalon Ward. The report identifies concerns about suicidal-risk information not being verbally communicated during handover, observations and searches not mitigating her self-harm risk, and the prolonged failure to find a suitable alternative placement.
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 Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to share complex and high-risk patients between units early in the inpatient stay
Wider context from the report “6. That consideration be given to the “sharing” of such complex and high-risk patients between units early on the in-patient stay to help provide the patient with more suitable care and share the stress of caring for such unwell patients on staff and other patients. One way this could be done would be to consider a network arrangement between different units to avoid the risk of clinical silos between the different sections of the mental health services and encourage a more wholistic approach to service provision.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to consider bespoke placements early for complex patients
Wider context from the report “5. That bespoke placements are considered early in the discharge process for complex patients .
” 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 Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to verbally communicate increased suicidal risk to the responsible nurse
Wider context from the report “2. That practitioners who recognise increase in suicidal risk of a patient should pass this on verbally to the nurse on charge of the ward or the nurse allocated to the patient .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise timely safer placements for patients at high risk of self-harm
Wider context from the report “4. That placements for patients with high risk of self-harm , such as Rebecca are prioritised such that safer placements are found within a timely fashion .
” 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 Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to base staff handovers on clinical-record examination and update care plans for risk management
Wider context from the report “1. That staff handovers be led by examination of the clinical record such that recent progress can be assessed especially in relation to risk management and care plans amended accordingly .
” 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 Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of deadlines for finding alternative placements
Wider context from the report “3. That NHS England consider a system of introducing deadlines for alternative placements to be found for such patients, so that they must be found in a timely fashion .
” 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 Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Risk of clinical silos between sections of mental health services
Wider context from the report “6. That consideration be given to the “sharing” of such complex and high-risk patients between units early on the in-patient stay to help provide the patient with more suitable care and share the stress of caring for such unwell patients on staff and other patients. One way this could be done would be to consider a network arrangement between different units to avoid the risk of clinical silos between the different sections of the mental health services and encourage a more wholistic approach to service provision .
” Open source report
Concerns raised 2 Lack of commissioned services for autism management View source Unavailability of local inpatient mental health provision for people with autism 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
Amanda Jaye Briley · 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
Amanda Jaye Briley, who had Asperger’s and a history of serious self-harm attempts, was found unconscious with trousers around her neck in a psychiatric ward on 26 December 2016 and died in intensive care on 28 December 2016. Her observation level had been reduced for Christmas leave and was not reinstated at the previous level after her return. The report also raised concern about the lack of local inpatient provision and commissioning arrangements for people with autism requiring inpatient mental health treatment.
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 Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of commissioned services for autism management
Wider context from the report “The court was advised that CCG have only commissioned services in respect of the diagnosis of autism and not the management of this condition . There is no local in-patient provision and any patient with this diagnosis who requires in-patient mental health treatment would have to be placed out of area. It is a central tenet to the Winterbourne Report and the Mental Health Act Code of Practice that hospital provision should be as local as possible for individuals to maintain contact with families and communities. I ask that the CCG consider the local provision and given we are geographically so well placed, to consider (if not alone) a collaborative commissioning arrangement based on the Transforming care recommendations.
” 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 Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of local inpatient mental health provision for people with autism
Wider context from the report “The court was advised that CCG have only commissioned services in respect of the diagnosis of autism and not the management of this condition. There is no local in-patient provision and any patient with this diagnosis who requires in-patient mental health treatment would have to be placed out of area . It is a central tenet to the Winterbourne Report and the Mental Health Act Code of Practice that hospital provision should be as local as possible for individuals to maintain contact with families and communities. I ask that the CCG consider the local provision and given we are geographically so well placed, to consider (if not alone) a collaborative commissioning arrangement based on the Transforming care recommendations.
” Open source report
Concerns raised 1 Lack of identifiable beds for mentally disordered patients in cases of special urgency 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
David Reginald Bert Stacey · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Reginald Bert Stacey died after sustaining chest injuries in a road traffic collision on 27 November 2017. Before the collision, he had been assessed under the Mental Health Act and was left alone after the assessment team departed. Concerns included a failure to communicate that a bed was available, the assessment team leaving before safeguards were in place, and the lack of an identifiable facility for cases of special urgency in Leicestershire.
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 Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of identifiable beds for mentally disordered patients in cases of special urgency
Wider context from the report “An expert was instructed to advise on the psychiatric aspect of Mr Stacey’s death. One of the issues he identified was a failure to identify availability of a bed for cases of special urgency . This is a statutory requirement under section 140 of the Mental Health Act 1983 that the relevant health bodies (local Clinical Commissioning Group and Local Health Board) give advice to every social services authorities within the area of arrangements that are in force for the reception of mentally disordered patients in cases of special urgency . The expert was in no doubt that Mr Stacey would have fulfilled the ‘special urgency’ category. It transpires from my further communication with the Leicestershire Partnership Trust that there is no such facility in Leicestershire . It would appear to be a statutory requirement that is currently being ignored and I am concerned that another similar situation might arise when there are no beds available to or identifiable by, the local Trust .
” Open source report
Concerns raised 1 Lack of long-term mental health care for children unable to attend hospital because of anxiety View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Brandon Singh Rayat · 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
Brandon Singh Rayat, aged 15, died in hospital on 10 August 2016 after being discovered hanging at home the previous day. The report identified a concern that there was no provision of long-term mental health care for children in Leicestershire whose anxiety prevented them from attending hospital for treatment.
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 Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of long-term mental health care for children unable to attend hospital because of anxiety
Wider context from the report “That there is no provision of mental health care for children in Leicestershire who due to their anxiety are unable to attend hospital for treatment . There is a CRISIS team for children but I have been told that this cannot fulfil the function of long term treatment .
” 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 Commission and operate outpatient and community mental health care for children and adolescents, including home visits and treatment where appropriate.
Verbatim wording from the response “The Leicester, Leicestershire and Rutland Clinical Commissioning Groups (LLR CCGs) commission a range of Children and Adolescent Mental Health services (CAMHs) to meet different levels of need, which is led by Leicester City CCG, our lead commissioner. These include an outpatient and community service that has been operational for over 6 years and last year, in April 2016, the new Crisis and Home Treatment service was introduced and has been fully operational since April 2017. Both of these services are able to provide home visits and can carry out care and/or treatment which may include welfare visits to families and children, assessment of need and risk and an offer of support and interventions as appropriate.” Source location 2017-0231-Response-by-Leicestershire-and-Rutland-NHS-CCG
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Crisis and Home Treatment service, including a dedicated home treatment team able to visit children and families at home.
Verbatim wording from the response “The Leicester, Leicestershire and Rutland Clinical Commissioning Groups (LLR CCGs) commission a range of Children and Adolescent Mental Health services (CAMHs) to meet different levels of need, which is led by Leicester City CCG, our lead commissioner. These include an outpatient and community service that has been operational for over 6 years and last year, in April 2016, the new Crisis and Home Treatment service was introduced and has been fully operational since April 2017. Both of these services are able to provide home visits and can carry out care and/or treatment which may include welfare visits to families and children, assessment of need and risk and an offer of support and interventions as appropriate.” Source location 2017-0231-Response-by-Leicestershire-and-Rutland-NHS-CCG
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing CAMHS services are considered to provide a full range of care, including home visits, although specifications may be amended after review.
Verbatim wording from the response “The Leicester, Leicestershire and Rutland Clinical Commissioning Groups (LLR CCGs) commission a range of Children and Adolescent Mental Health services (CAMHs) to meet different levels of need, which is led by Leicester City CCG, our lead commissioner. These include an outpatient and community service that has been operational for over 6 years and last year, in April 2016, the new Crisis and Home Treatment service was introduced and has been fully operational since April 2017. Both of these services are able to provide home visits and can carry out care and/or treatment which may include welfare visits to families and children, assessment of need and risk and an offer of support and interventions as appropriate.” Source location 2017-0231-Response-by-Leicestershire-and-Rutland-NHS-CCG
Open published response
Concerns raised 6 Failure of screening committee oversight to ensure referrals are received and actioned View source Failure to direct screening referrals to the vascular screening team View source Uncertainty within general practice about the screening programme and referral criteria View source Absence of a system to direct screening requests to the correct department View source Failure by radiology to appropriately process screening referrals View source Failure to take further action when screening requests are refused 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
Michael John Halfpenny · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael John Halfpenny requested screening for an aortic aneurysm in March 2016 because of a strong family history, but the referral was sent to the wrong department, rejected, and not followed up. He later presented with severe abdominal pain on 9 December 2016, but diagnosis was delayed until he was peri-arrest; he died following emergency surgery for a ruptured abdominal aortic aneurysm. Concerns included inadequate referral and follow-up processes, uncertainty about the screening programme, and failures to ensure screening requests reached the correct team.
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 Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of screening committee oversight to ensure referrals are received and actioned
Wider context from the report “Regarding the General Practice involvement
- The referral should have been made directly to the vascular screening team but was made to the radiology department
- No further action was taken when the screening request was refused
- The court heard that screening has been in place in Leicester since the 1990’s and nationally since 2013, and that the family saw posters advertising the service on display at Leicester Royal Infirmary but not at the GP surgery.
- The GP practice were uncertain of the existing screening programme and on what criteria to refer patients
Regarding the University Hospitals of Leicester NHS Trust
- The referral request was marked by the radiology department that screening was “not offered” and the request was refused
- The vascular team were unaware of the patient and the request and no system was in place to ensure any screening request was directed to the correct department
- The screening committee group set up by UHL were unaware of this matter and therefore had taken no action to ensure referrals were appropriately received and actioned .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to direct screening referrals to the vascular screening team
Wider context from the report “Regarding the General Practice involvement
- The referral should have been made directly to the vascular screening team but was made to the radiology department
- No further action was taken when the screening request was refused
- The court heard that screening has been in place in Leicester since the 1990’s and nationally since 2013, and that the family saw posters advertising the service on display at Leicester Royal Infirmary but not at the GP surgery.
- The GP practice were uncertain of the existing screening programme and on what criteria to refer patients
Regarding the University Hospitals of Leicester NHS Trust
- The referral request was marked by the radiology department that screening was “not offered” and the request was refused
- The vascular team were unaware of the patient and the request and no system was in place to ensure any screening request was directed to the correct department
- The screening committee group set up by UHL were unaware of this matter and therefore had taken no action to ensure referrals were appropriately received and actioned.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Uncertainty within general practice about the screening programme and referral criteria
Wider context from the report “Regarding the General Practice involvement
- The referral should have been made directly to the vascular screening team but was made to the radiology department
- No further action was taken when the screening request was refused
- The court heard that screening has been in place in Leicester since the 1990’s and nationally since 2013, and that the family saw posters advertising the service on display at Leicester Royal Infirmary but not at the GP surgery.
- The GP practice were uncertain of the existing screening programme and on what criteria to refer patients
Regarding the University Hospitals of Leicester NHS Trust
- The referral request was marked by the radiology department that screening was “not offered” and the request was refused
- The vascular team were unaware of the patient and the request and no system was in place to ensure any screening request was directed to the correct department
- The screening committee group set up by UHL were unaware of this matter and therefore had taken no action to ensure referrals were appropriately received and actioned.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Absence of a system to direct screening requests to the correct department
Wider context from the report “Regarding the General Practice involvement
- The referral should have been made directly to the vascular screening team but was made to the radiology department
- No further action was taken when the screening request was refused
- The court heard that screening has been in place in Leicester since the 1990’s and nationally since 2013, and that the family saw posters advertising the service on display at Leicester Royal Infirmary but not at the GP surgery.
- The GP practice were uncertain of the existing screening programme and on what criteria to refer patients
Regarding the University Hospitals of Leicester NHS Trust
- The referral request was marked by the radiology department that screening was “not offered” and the request was refused
- The vascular team were unaware of the patient and the request and no system was in place to ensure any screening request was directed to the correct department
- The screening committee group set up by UHL were unaware of this matter and therefore had taken no action to ensure referrals were appropriately received and actioned.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure by radiology to appropriately process screening referrals
Wider context from the report “Regarding the General Practice involvement
- The referral should have been made directly to the vascular screening team but was made to the radiology department
- No further action was taken when the screening request was refused
- The court heard that screening has been in place in Leicester since the 1990’s and nationally since 2013, and that the family saw posters advertising the service on display at Leicester Royal Infirmary but not at the GP surgery.
- The GP practice were uncertain of the existing screening programme and on what criteria to refer patients
Regarding the University Hospitals of Leicester NHS Trust
- The referral request was marked by the radiology department that screening was “not offered” and the request was refused
- The vascular team were unaware of the patient and the request and no system was in place to ensure any screening request was directed to the correct department
- The screening committee group set up by UHL were unaware of this matter and therefore had taken no action to ensure referrals were appropriately received and actioned.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to take further action when screening requests are refused
Wider context from the report “Regarding the General Practice involvement
- The referral should have been made directly to the vascular screening team but was made to the radiology department
- No further action was taken when the screening request was refused
- The court heard that screening has been in place in Leicester since the 1990’s and nationally since 2013, and that the family saw posters advertising the service on display at Leicester Royal Infirmary but not at the GP surgery.
- The GP practice were uncertain of the existing screening programme and on what criteria to refer patients
Regarding the University Hospitals of Leicester NHS Trust
- The referral request was marked by the radiology department that screening was “not offered” and the request was refused
- The vascular team were unaware of the patient and the request and no system was in place to ensure any screening request was directed to the correct department
- The screening committee group set up by UHL were unaware of this matter and therefore had taken no action to ensure referrals were appropriately received and actioned.
” Open source report
Concerns raised 3 Failure to involve next of kin in significant decisions for a patient with declining cognitive function View source Failure to record the rationale and patient consent for a change of GP View source Failure to record consideration and outcome of the patient's capacity View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Francis James Lea · 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
Francis James Lea, who was living in a care home, was transferred to a new GP without his family being informed. After a hospital admission for a seizure, his prescribed anti-epileptic medication was not continued because the new GP was unaware of the admission and prescription. The report raised concerns about involving next of kin, recording the rationale and consent or capacity assessment for changing GP, and ensuring a safe transfer of care between the care home and GP surgeries.
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 Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to involve next of kin in significant decisions for a patient with declining cognitive function
Wider context from the report “(1) For a patient in a care situation, with declining cognitive function (as set out in his home care plan) it would seem appropriate to consider involving the next of kin in any significant decision such as change of GP . This would have enabled the family (who always ensured they accompanied Mr Lea for any medical care) to pass on the updated information, and this outcome would have been avoided.
” 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 Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to record the rationale and patient consent for a change of GP
Wider context from the report “(2) There appeared to be no notes on the patient's medical record regarding the rationale for this change, or any consent from the patient that he was in agreement that it should take place . There was also no record of whether any consideration of his capacity had been undertaken, and if so what the outcome of that decision was.
” 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 Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to record consideration and outcome of the patient's capacity
Wider context from the report “(2) There appeared to be no notes on the patient's medical record regarding the rationale for this change, or any consent from the patient that he was in agreement that it should take place. There was also no record of whether any consideration of his capacity had been undertaken, and if so what the outcome of that decision was .
” 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 Contact care homes to recommend policies and documentation standards for staff signing on behalf of residents who can consent but cannot physically sign.
Verbatim wording from the response “During the course of the investigation it was established that the care home manager had signed the form on behalf of Mr Lea although this was not made clear to the Practice. Therefore we will be contacting all care homes to recommend:” Source location 2016-0447-Response-by-East-Leicestershire-and-Rutland-Clinical-Commissioning-Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue standard practice application forms to membership practices, including a section for signing on behalf of another person.
Verbatim wording from the response “Since the time of this incident, we have issued standard practice application forms to all of our membership practices. This includes a section for signing on behalf of somebody else.” Source location 2016-0447-Response-by-East-Leicestershire-and-Rutland-Clinical-Commissioning-Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require robust project plans covering stakeholder, family and next-of-kin engagement, responsibilities, and communication of planned changes to care-home and GP-practice staff.
Verbatim wording from the response “During the course of our investigation, we have been informed by the care home manager that Mr Lea did have the capacity to make the decision to change GP practice. If a person has capacity, there is no requirement to inform the next of kin. However, we recognise that engaging with residents and their families is best practice when making changes such as this. Therefore there are a number of actions that will be put in place to ensure families are aware of future changes with which the CCG is involved:” Source location 2016-0447-Response-by-East-Leicestershire-and-Rutland-Clinical-Commissioning-Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require providers to document discussions and information received from residents, record potential changes in care plans and clinical systems, and update records promptly.
Verbatim wording from the response “Residents/patients are assumed to have capacity unless proved otherwise. As part of this project residents were given the choice as to whether to move practice. In future projects of this type, ELR CCG makes the following recommendations:” Source location 2016-0447-Response-by-East-Leicestershire-and-Rutland-Clinical-Commissioning-Group
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 Patients with capacity are not required to have next of kin informed about a change of GP practice.
Verbatim wording from the response “During the course of our investigation, we have been informed by the care home manager that Mr Lea did have the capacity to make the decision to change GP practice. If a person has capacity, there is no requirement to inform the next of kin. However, we recognise that engaging with residents and their families is best practice when making changes such as this. Therefore there are a number of actions that will be put in place to ensure families are aware of future changes with which the CCG is involved:” Source location 2016-0447-Response-by-East-Leicestershire-and-Rutland-Clinical-Commissioning-Group
Open published response
Concerns raised 7 Failure to identify the roles and responsibilities of involved health and social care professionals View source Lack of a local community support network for patients diagnosed with personality disorder View source Failure to review patients after 2 admissions within 6 months View source Lack of local psychiatric intensive care unit beds for female patients View source Lack of effective community psychiatric nurse involvement View source Failure to adhere to the care programme approach View source Unavailability of community support for patients with challenging presentations 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
Victoria Georgia Halliday · 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
Victoria Georgia Halliday’s mental health deteriorated in 2015, with repeated crises, missing-person incidents, suspected psychotic symptoms and discharge back into the community. She was discovered to have taken her own life after a final missing-person search commenced on 29 July. Concerns included inadequate community psychiatric support, lack of local intensive psychiatric beds for female patients, failures in care planning and guideline adherence, and insufficient support networks for people diagnosed with personality disorder.
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 Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to identify the roles and responsibilities of involved health and social care professionals
Wider context from the report “4) The care programme approach (CPA) was not adhered to and NICE guidelines were not followed, specifically in ensuring there was a review after 2 admissions within 6 months, and to ensure the roles and responsibilities of all health and social care professionals involved were identified .
” 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 Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a local community support network for patients diagnosed with personality disorder
Wider context from the report “5) There is no local network for the community support of patients diagnosed with personality disorder , although evidence suggested such networks were effective when adopted elsewhere.
” 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 Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to review patients after 2 admissions within 6 months
Wider context from the report “4) The care programme approach (CPA) was not adhered to and NICE guidelines were not followed, specifically in ensuring there was a review after 2 admissions within 6 months , and to ensure the roles and responsibilities of all health and social care professionals involved were identified.
” 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 Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of local psychiatric intensive care unit beds for female patients
Wider context from the report “1) There are currently no local psychiatric intensive care unit beds for female patients and this means all female patients can only be placed out of area, potentially many miles away from home and local support.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of effective community psychiatric nurse involvement
Wider context from the report “2) There was no, or no effective, community psychiatric nurse involvement and this was a missed opportunity to monitor and assist Victoria when she was in the community.
” 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 Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to adhere to the care programme approach
Wider context from the report “4) The care programme approach (CPA) was not adhered to and NICE guidelines were not followed, specifically in ensuring there was a review after 2 admissions within 6 months, and to ensure the roles and responsibilities of all health and social care professionals involved were identified.
” 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 Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of community support for patients with challenging presentations
Wider context from the report “3) The “community support” referred to by the in-patient clinicians does not exist in reality for patients with this challenging presentation , leaving discharged patients and their families without adequate support.
” 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 Engage potential provider organisations to resolve local female PICU capacity and placement options.
Verbatim wording from the response “East Leicestershire and Rutland CCG, as the lead commissioners for mental health in LLR would prefer, if possible, for this service to be provided within the LLR border. However, we need to take account of demand, patient quality, cost and provider availability. With this in mind, we are unable, at present, to commission a local service that meets all of these requirements.” Source location Response from East Leicestershire and Rutland Clinical Commissioning Group
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 Develop a local support-network model for patients diagnosed with personality disorder.
Verbatim wording from the response “With regard to a local network for the support of patients diagnosed with a personality disorder, this was recently discussed at the Mental Health Clinical Forum which is led by CCG GP and LPT Clinical” Source location Response from East Leicestershire and Rutland Clinical Commissioning Group
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 Submit the local personality-disorder support-network model for consideration.
Verbatim wording from the response “Leads. A suggested model is currently being developed by Clinicians and will be submitted for consideration during the early part of 2017.” Source location Response from East Leicestershire and Rutland Clinical Commissioning Group
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 Work with regional commissioning colleagues to provide a wider range of female PICU placement options.
Verbatim wording from the response “In line with the national picture, there is recognition that the availability of general acute mental health and PICU beds is under pressure. This continues to be the case despite extensive efforts to minimise out of area placements. Since April 2016, there have been 10 female out of area placements made with an average length of stay of 45 days.” Source location Response from East Leicestershire and Rutland Clinical Commissioning Group
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 A local PICU service cannot currently be commissioned because demand, quality, cost and provider availability cannot all be met.
Verbatim wording from the response “East Leicestershire and Rutland CCG, as the lead commissioners for mental health in LLR would prefer, if possible, for this service to be provided within the LLR border. However, we need to take account of demand, patient quality, cost and provider availability. With this in mind, we are unable, at present, to commission a local service that meets all of these requirements.” Source location Response from East Leicestershire and Rutland Clinical Commissioning Group
Open published response
Concerns raised 3 Failure to use a sepsis screening tool in community healthcare View source Failure to recognise or adopt a UK sepsis clinical toolkit View source Failure to recognise repeated attendances as clinically significant 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
Caroline Robey · 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
Caroline Robey was a fit 34-year-old working mother who became unwell and attended community healthcare providers on six occasions over five days. She was initially diagnosed with a viral infection and later diarrhoea and vomiting, before being admitted to hospital with suspected sepsis; despite treatment, she died the following day from Group A streptococcal infection and evolving sepsis. The principal concerns were the absence of sepsis screening by community healthcare providers, failure to adopt available sepsis toolkit resources, and inadequate consideration of her repeated attendances.
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 Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to use a sepsis screening tool in community healthcare
Wider context from the report “1. No sepsis screening tool was being used by the community health care providers , and so opportunities were lost to consider a diagnosis of sepsis and refer as an emergency for hospital admission and treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise or adopt a UK sepsis clinical toolkit
Wider context from the report “2. A patient safety alert issued 2 September 2014 by NHS England clearly sets out resources available in the provision of a UK sepsis clinical tool kit, but this had not been recognised or adopted by the health care providers involved in this 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 Leicester, Leicestershire and Rutland Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise repeated attendances as clinically significant
Wider context from the report “3. Inadequate note was taken of the number of different attendances Mrs Robey had initiated despite previous good health, and there was no suggestion she was a frequent attender or had ever sought medical assistance inappropriately.
” Open source report
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Request correction
Addressed to NHS East Leicestershire and Rutland Clinical Commissioning Group, now represented here by NHS Leicester, Leicestershire and Rutland Integrated Care Board.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations