4 Mar 2026 Mrs Oriel Vasey · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 3 Failure to review and update the form-handling process View source Failure to ensure that financial decision-making forms do not generate incorrect allergy information in clinical records View source Failure to review and update the form 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
Mrs Oriel Vasey · 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
Mrs Oriel Vasey died at Sunderland Royal Hospital on 5 March 2025 after a pressure sore deteriorated and resulted in sepsis. An erroneous penicillin allergy from a funding and placement form was added to her clinical record, leading penicillin to be ruled out on several occasions. The report’s concerns include that the unchanged process could allow the same error to recur and that it is unclear why the funding form required an allergies section.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to review and update the form-handling process
Wider context from the report “1. This form remains in place unchanged, and the process for handling this form, which belongs to the ICB, remains unchanged which means that this same error could occur again .
” 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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that financial decision-making forms do not generate incorrect allergy information in clinical records
Wider context from the report “2. If this form is intended purely for financial decision making, it is unclear why there is a requirement for a specific section on allergies . That has led, in this case, to sub optimal care being provided to Oriel because treating medics had incorrect information on Oriel's clinical record .
” 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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to review and update the form
Wider context from the report “1. This form remains in place unchanged , and the process for handling this form, which belongs to the ICB, remains unchanged which means that this same error could occur again .
” 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 Make the updated form available on the ICB website.
Verbatim wording from the response “• The updated form has been circulated to NENC NHS Trusts and will be available on the ICBs website.” Source location Response from NHS North East and North Cumbria
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 Amend the standard ICB Nursing Needs Assessment form to identify it as ICB-owned and prohibit modification.
Verbatim wording from the response “To future safeguard against this reoccurring the ICB have implemented several actions as follows:” Source location Response from NHS North East and North Cumbria
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 Check panel use of the correct form for adaptations by partner agencies and repeat these checks periodically.
Verbatim wording from the response “• The ICB will check the use of the correct form in all our panels to ensure no other adaptions have been made by partner agencies and will continue to do so periodically.” Source location Response from NHS North East and North Cumbria
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 Circulate the amended form, including version control, to all All Age Continuing Care teams across the ICB.
Verbatim wording from the response “To future safeguard against this reoccurring the ICB have implemented several actions as follows:” Source location Response from NHS North East and North Cumbria
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 Circulate the updated form to NENC NHS Trusts.
Verbatim wording from the response “• The updated form has been circulated to NENC NHS Trusts and will be available on the ICBs website.” Source location Response from NHS North East and North Cumbria
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 ICB form contains no allergy section; the adapted form containing allergy information was created and used by CNTW.
Verbatim wording from the response “Following an internal investigation, I can confirm that the form in question is an 'assessment of nursing needs' proforma, designed by the ICB. The purpose of the form is to bring together the information from a patient's assessment of needs in order to make recommendations regarding eligibility for NHS All Age Continuing Healthcare (AACC) funding. The version of the form held by the ICB does not request any allergy information and there is no section to record allergies.” Source location Response from NHS North East and North Cumbria
Open published response
23 Jun 2025 REDACTED Deceased · Prevention of Future Deaths report Northumberland
View report summary
Concerns raised 10 Failure to escalate care or make onward referral View source Lack of in-person dietetic assessment recording weight and clinical observations View source Insufficient staff understanding of Medical Emergencies in Eating Disorders guidelines View source Confusion and delayed cascading of Consultant-to-Consultant referral guidance View source Lack of physical face-to-face monitoring of weight View source Lack of scrutiny of reluctance to engage and attend appointments View source Lack of one accessible system for weights, heights and BMI View source Lack of clear accountable oversight of outpatient care View source Failure to provide face-to-face or direct contact before CAMHS discharge View source Failure to share clinically significant eating and weight information with an appropriate body View source See 7 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
REDACTED Deceased · 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
The deceased was a 17-year-old girl with autism, anxiety, significant weight loss and extreme malnutrition who died in hospital on 5 May 2024 after cardiac output was lost following vomiting during preparation for insertion of a central venous line. The principal concerns included inadequate monitoring of her weight, lack of face-to-face assessments, failure to refer or escalate care appropriately, discharge from CAMHS without direct assessment, poor communication and unclear oversight of outpatient care.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate care or make onward referral
Wider context from the report “4.There was no in person assessment by dietetics or escalation of care
The deceased was assessed via telephone on all occasions. I am concerned that whilst telephone assessments expedited contact there was no in person face to face assessment to record weight or to take and record clinical observations.
At assessment on 2 January 2024, the deceased was not aware of her current weight. A weight history from the 20 November 2023 and a 2022 weight were noted. Her BMI was calculated as 17.
On 5 March 2024 the deceased was reviewed by a specialist dietitian again by telephone. The deceased self-reported her weight to be 33kg with a calculated BMI of 13.4.
The Medical Emergencies in Eating Disorders (MEED) guidelines are used to identify at the earliest stage possible the appropriate care and treatment to be provided. It identifies BMI calculators in the green, amber and red.
Red or high risk would be a BMI less than 13.
The next specialist dietitian review took place on 26 April 2024, 2 weeks later than planned again by telephone. The self-reported weight was 31.8kg with a calculated BMI of 12.9
I am concerned that there was no escalation of care or onward referral , and I am concerned about staff’s understanding of the Medical Emergencies in Eating Disorders (MEED) guidelines.
” 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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of in-person dietetic assessment recording weight and clinical observations
Wider context from the report “4.There was no in person assessment by dietetics or escalation of care
The deceased was assessed via telephone on all occasions. I am concerned that whilst telephone assessments expedited contact there was no in person face to face assessment to record weight or to take and record clinical observations .
At assessment on 2 January 2024, the deceased was not aware of her current weight. A weight history from the 20 November 2023 and a 2022 weight were noted. Her BMI was calculated as 17.
On 5 March 2024 the deceased was reviewed by a specialist dietitian again by telephone. The deceased self-reported her weight to be 33kg with a calculated BMI of 13.4.
The Medical Emergencies in Eating Disorders (MEED) guidelines are used to identify at the earliest stage possible the appropriate care and treatment to be provided. It identifies BMI calculators in the green, amber and red.
Red or high risk would be a BMI less than 13.
The next specialist dietitian review took place on 26 April 2024, 2 weeks later than planned again by telephone. The self-reported weight was 31.8kg with a calculated BMI of 12.9
I am concerned that there was no escalation of care or onward referral, and I am concerned about staff’s understanding of the Medical Emergencies in Eating Disorders (MEED) guidelines.
” 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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff understanding of Medical Emergencies in Eating Disorders guidelines
Wider context from the report “4.There was no in person assessment by dietetics or escalation of care
The deceased was assessed via telephone on all occasions. I am concerned that whilst telephone assessments expedited contact there was no in person face to face assessment to record weight or to take and record clinical observations.
At assessment on 2 January 2024, the deceased was not aware of her current weight. A weight history from the 20 November 2023 and a 2022 weight were noted. Her BMI was calculated as 17.
On 5 March 2024 the deceased was reviewed by a specialist dietitian again by telephone. The deceased self-reported her weight to be 33kg with a calculated BMI of 13.4.
The Medical Emergencies in Eating Disorders (MEED) guidelines are used to identify at the earliest stage possible the appropriate care and treatment to be provided. It identifies BMI calculators in the green, amber and red.
Red or high risk would be a BMI less than 13.
The next specialist dietitian review took place on 26 April 2024, 2 weeks later than planned again by telephone. The self-reported weight was 31.8kg with a calculated BMI of 12.9
I am concerned that there was no escalation of care or onward referral, and I am concerned about staff’s understanding of the Medical Emergencies in Eating Disorders (MEED) guidelines .
” 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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Confusion and delayed cascading of Consultant-to-Consultant referral guidance
Wider context from the report “2.There was no referral to gastroenterology
I am concerned there is confusion as to the guidance on Consultant-to-Consultant referrals .
The Consultant Physician wrote to the GP saying, "please monitor weight loss and refer into gastroenterology services for further assessment".
The GP was aware of guidance regarding Consultant-to-Consultant Referrals that had been updated in October 2023 so that Consultants could and should be directly referring patients themselves to another speciality if there was a clinical reason to do so, rather than passing that task back to the GP. The Consultant Physician told me the guidance was not cascaded down to trust level until December 2023 after the Consultant Physician saw the deceased and that the final guidance has not yet been received .
” 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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of physical face-to-face monitoring of weight
Wider context from the report “1.The deceased’s weight was not adequately monitored from November 2023.
I am concerned there was no physical or face to face monitoring of the deceased’s weight from November 2023 . I heard about the importance of physical eye to eye contact and examination on a face-to-face basis so that one can see evidence of the skin, properly see the patient’s face and when doing the height and weight asking for the removal some of their clothing to assess muscle mass.
” 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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of scrutiny of reluctance to engage and attend appointments
Wider context from the report “3.The deceased was discharged from CAMHS in December 2023 without being seen in person, spoken to or weighed
The second referral to CAMHs was following the Consultant Physician’s letter dated 20 November 2023. The request was “I would be grateful if you could see this young girl urgently for advice with regards to oral intake. She has lost weight over a number of months and clinical history as outlined above”. The deceased was offered an appointment in keeping with the 4-week national waiting timescale for CYP with an eating disorder.
Contact was made with mum on 24 November and an appointment offered for 13 December 2023. During the call Mum told staff the deceased “hated CAMHS so might kick off and refuse to come”. Mum cancelled the appointment on 11 December 2023.
CAMHS contacted mum by telephone on 12 December 2023. Mum said that the deceased was not aware that she had been referred to CAMHs, was not willing to attend. Again, there was no exploration as to why that was the case and no direct contact with the deceased.
(a) I am concerned the deceased was discharged from CAMHs on 12 December 2023 without being seen face to face or spoken to directly.
(b) I am concerned there was no scrutiny as to why the deceased was reluctant to engage and not attend appointments .
” 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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of one accessible system for weights, heights and BMI
Wider context from the report “6.One records system - weights, heights and Body Mass Index (BMI)
I heard that patient care records are held on different care record systems within the NHS which are not universally accessible to healthcare organisations, healthcare professionals or patients. I heard good examples of accessible records such as the Great North Care Record (GNCR) and SystmOne operated by some in Primary Care.
I am concerned there is not one accessible system for weights, heights and BMI .
” 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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of clear accountable oversight of outpatient care
Wider context from the report “6.Oversight of care in an Outpatient setting
There is a lack of clarity regarding oversight of care in an outpatient setting .
The Patient Safety Incident Investigation report identified that there was a lack of oversight of care . The early help assessment team were stepped down in 2022 and they may have been the appropriate team to maintain oversight of care. The SI report comments that the referrals between services were all appropriate but it was unclear who had oversight of all the care and that the investigation team felt that oversight was unclear and that arrangements around risk assessment escalation safeguarding and GP involvement could have been better through improved communication.
I heard that in an inpatient setting there are key NHS standards set around what was described as “the name at the end of the bed” which healthcare professionals work within.
I am concerned that in an outpatient setting there is no specific guidance regarding oversight of care within the NHS. No one department or clinician has overall responsibility or accountability .
” 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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide face-to-face or direct contact before CAMHS discharge
Wider context from the report “3.The deceased was discharged from CAMHS in December 2023 without being seen in person, spoken to or weighed
The second referral to CAMHs was following the Consultant Physician’s letter dated 20 November 2023. The request was “I would be grateful if you could see this young girl urgently for advice with regards to oral intake. She has lost weight over a number of months and clinical history as outlined above”. The deceased was offered an appointment in keeping with the 4-week national waiting timescale for CYP with an eating disorder.
Contact was made with mum on 24 November and an appointment offered for 13 December 2023. During the call Mum told staff the deceased “hated CAMHS so might kick off and refuse to come”. Mum cancelled the appointment on 11 December 2023.
CAMHS contacted mum by telephone on 12 December 2023. Mum said that the deceased was not aware that she had been referred to CAMHs, was not willing to attend. Again, there was no exploration as to why that was the case and no direct contact with the deceased.
(a) I am concerned the deceased was discharged from CAMHs on 12 December 2023 without being seen face to face or spoken to directly .
(b) I am concerned there was no scrutiny as to why the deceased was reluctant to engage and not attend appointments.
” 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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to share clinically significant eating and weight information with an appropriate body
Wider context from the report “5.The Passage of information/communication
Communication: I heard about the importance of the passage of information. During the course of the inquest a witness was taken to the SEN chronology and an entry dated 1 March 2024 which refers to a conversation with the deceased’s mother on 29 February 2024 where she described the deceased having significant problems with her eating habits, losing weight and refusing to eat foods that would be good for her and put weight on her.
I am concerned that this information was not shared to an appropriate body .
” Open source report
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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 Overall and specialty-specific outpatient care responsibilities rest with GPs, dieticians, named consultants and care teams, with escalation as needed.
Verbatim wording from the response “Based on the timeline detailed in your report, it appears at the time of ████████ death, she was under the care of the dietician. The GP remains responsible for the overall medical care of the patient, whilst the dietician would manage the specific around the patient's weight. If the dietician had concerns it would be expected that these would be escalated to a senior dietician, the GP, or emergency care services, depending on severity.” Source location 2025-0314 - Response from North East and North Cumbria Integrated Care Board
Open published response
28 May 2025 Mr Dean Bradley · Prevention of Future Deaths report Teesside and Hartlepool
View report summary
Concerns raised 2 Failure to provide adequate safeguarding for intoxicated people before mental health assessment View source Insufficient resources for safeguarding people with mental health illnesses whilst intoxicated 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
Mr Dean Bradley · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Dean Bradley was found deceased by hanging in his hostel flat on 15 October 2021, after earlier suicidal behaviour and expressions of paranoid and persecutory beliefs while apparently under the influence of drugs. Concerns included whether current resources adequately safeguard people with mental health concerns while intoxicated, and failures to contact mental health services and to relay the details of his crisis to hostel staff.
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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate safeguarding for intoxicated people before mental health assessment
Wider context from the report “2) I heard evidence that a person who was suicidal, suffering with mental health concerns and was intoxicated could not be adequately safeguarded until he was sufficiently sober to allow a mental health assessment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient resources for safeguarding people with mental health illnesses whilst intoxicated
Wider context from the report “1) Current resources for safeguarding those with mental health illnesses whilst intoxicated may be placing people at risk .
” Open source report
17 Feb 2025 Diana FAIRWEATHER-PURKIS · Prevention of Future Deaths report Teesside and Hartlepool
View report summary
Concerns raised 2 Insufficient ambulance service availability or resources for timely patient attendance View source Delays in ambulance crew release following hospital attendance 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
Diana FAIRWEATHER-PURKIS · 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
Diana Fairweather-Purkis waited 9 hours and 56 minutes for an ambulance after calling the 111 Service, was admitted to hospital, and died on 3 October 2022 due to multi-organ failure secondary to urosepsis. The report identifies insufficient ambulance availability, delays in releasing ambulance crews after hospital attendance because of patient handover delays, and delays in prescribing and administering antibiotics as substantive concerns or contributing factors.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient ambulance service availability or resources for timely patient attendance
Wider context from the report “1. There is insufficient Ambulance Service availability/resource to enable Ambulances to attend to patients in a timely manner and in accordance with relevant target attendance times .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance crew release following hospital attendance
Wider context from the report “2. There are excessive delays in Ambulance crews being released following attendance at hospital , due to delays in patients being handed over to hospital staff .
” 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 Provide over £40 million in additional ambulance-service funding to increase vehicles on the road and strengthen clinical advisory services.
Verbatim wording from the response “Since the creation of the North East and North Cumbria Integrated Care Board (NENC ICB) in July 2022 there has been significant investment of additional resources into ambulances services to increase capacity and availability. Over £40m of additional funding, made up of local ICB investment and a share of nationally funded NHS England growth monies, has been made available to the North East Ambulance Service (NEAS) since 2023/24 to increase the number of vehicles on the road and also strengthen clinical advisory services.” Source location Response from NHS NORTH EAST AND NORTH 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 Establish an integrated urgent-care clinical assessment service providing multidisciplinary telephone triage and onward referral support for 111 and 999 callers.
Verbatim wording from the response “NEAS have established an Integrated Urgent Care Clinical Assessment Service (IUCAS) which includes paramedics, nurses, advanced practitioners, pharmacists, GPs and clinical specialists who provide enhanced clinical support to call handlers and patients ringing 111 and 999. Senior clinical advisors (clinicians) provide additional clinical assessment via telephone triage, improving the journey and experience for our patients by ensuring they can pass through to services quickly and efficiently. The team also promotes self-care, provides advice and support for patients at home, facilitating onward referral where necessary to a range of primary and secondary care services. By being able to increase the number of patients who are treated and discharged in the community, the IUCAS helps to reduce pressures on ambulances, emergency departments, and other NHS services.” Source location Response from NHS NORTH EAST AND NORTH 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 Coordinate multi-agency ambulance-handover improvement and transformation work across the integrated care system.
Verbatim wording from the response “Ambulance handover delays are a priority area of focus for the ICB, NEAS, and acute provider Foundation Trusts across NENC Integrated Care System (ICS). The multi-agency NENC Strategic Urgent & Emergency Care Network and Local A&E Delivery Boards provide leadership and oversight of a range of transformation initiatives that are being taken to improve patient handover times. There has been a significant programme of work taking place in the second half of 2024/25 to bring together colleagues from across the system (ICS, FT, ambulance trust) to look at ambulance handover improvement and transformation. This programme was externally facilitated and has led to a number of revised and standardised policies and procedures being agreed for elements of the ambulance handover process (e.g., immediate release, cohorting, diverts and deflections etc.).” Source location Response from NHS NORTH EAST AND NORTH 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 Continue implementing system-wide improvement programmes with ambulance and acute hospital providers to improve ambulance response times during 2025/26.
Verbatim wording from the response “With regard to ambulance performance and the target response times, NEAS are consistently the highest performing ambulance provider in England across all 4 response time categories and continue to implement system-wide improvement programmes in conjunction with ICB and our acute hospital providers to further improve response times throughout 2025/26 and work towards achieving the NHS constitutional standards.” Source location Response from NHS NORTH EAST AND NORTH 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 Agree revised and standardised policies and procedures for ambulance handover processes, including immediate release, cohorting, diversions and deflections.
Verbatim wording from the response “Ambulance handover delays are a priority area of focus for the ICB, NEAS, and acute provider Foundation Trusts across NENC Integrated Care System (ICS). The multi-agency NENC Strategic Urgent & Emergency Care Network and Local A&E Delivery Boards provide leadership and oversight of a range of transformation initiatives that are being taken to improve patient handover times. There has been a significant programme of work taking place in the second half of 2024/25 to bring together colleagues from across the system (ICS, FT, ambulance trust) to look at ambulance handover improvement and transformation. This programme was externally facilitated and has led to a number of revised and standardised policies and procedures being agreed for elements of the ambulance handover process (e.g., immediate release, cohorting, diverts and deflections etc.).” Source location Response from NHS NORTH EAST AND NORTH CUMBRIA INTEGRATED CARE BOARD
Open published response
1 Aug 2024 Stephen LINDSAY · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 2 Failure to provide mental health support to people with terminal illness View source Lack of clear responsibility for providing mental health treatment to people with terminal illness View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stephen LINDSAY · 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
Stephen Lindsay, who had metastatic oesophageal cancer, pain and concerns about his mental health and suicidal ideation, died by suicide on 28 February 2024. The principal concern was that responsibility for providing his mental health treatment was passed between several teams, creating a risk that people with terminal illness may not receive mental health support during crisis.
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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide mental health support to people with terminal illness
Wider context from the report “(1) I am concerned that providing treatment for Mr Lindsay's mental health was passed between several teams, with none of them being willing to accept that it fell within the ambit of services they had been commissioned to provide. I am concerned that there is a risk that in future cases mental health support will not be provided to those suffering from terminal illness and that this may lead to other patients experiencing crisis and attempting to end their lives. I consider that the lack of clarity as to the responsibility for providing such care may cause further deaths.
(2)
(3)
” 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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of clear responsibility for providing mental health treatment to people with terminal illness
Wider context from the report “(1) I am concerned that providing treatment for Mr Lindsay's mental health was passed between several teams, with none of them being willing to accept that it fell within the ambit of services they had been commissioned to provide . I am concerned that there is a risk that in future cases mental health support will not be provided to those suffering from terminal illness and that this may lead to other patients experiencing crisis and attempting to end their lives. I consider that the lack of clarity as to the responsibility for providing such care may cause further deaths.
(2)
(3)
” 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 Hold a reflective learning event with those involved in Mr Lindsay’s care to identify opportunities to improve seamless, responsive and supportive terminal-illness care.
Verbatim wording from the response “To further address your concern, the ICB will also be holding a reflective learning event with those involved in Mr Lindsay's care and treatment. This will enable the teams to reflect, identify and explore further opportunities to improve patients experience of care and to ensure that there are no unforeseen barriers in ensuring that any patient suffering a terminal illness receives seamless, responsive and supportive care. We would be happy to share the outcome of this event with Mr Lindsay's family and yourself.” Source location Response from NENC ICB
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review Mr Lindsay’s patient journey from before diagnosis through his death to identify care and treatment issues.
Verbatim wording from the response “The ICB have undertaken a review of Mr Lindsay's patient journey from the months prior to his diagnosis with metastatic Oesophageal Cancer up until his date of death.” Source location Response from NENC ICB
Open published response
Concerns raised 2 Delays in private ambulance attendance to transport patients after MHA assessments View source Failure to provide timely access to second (s.12) doctors out of office hours for MHA assessments 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
Dean Ryan CROSSMAN · 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
On 18 June 2019, Dean Ryan Crossman was found hanging after contact with emergency and crisis mental health services following suicidal behaviour the previous evening. The report identifies ongoing concerns about out-of-hours access to second doctors for Mental Health Act assessments and delays in securing private ambulance attendance.
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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in private ambulance attendance to transport patients after MHA assessments
Wider context from the report “1. Evidence was given at the inquest that at the time of Dean’s passing, there were issues accessing second (s.12) doctors out of office hours for the purpose of carrying out a MHA assessment, resulting in delays to MHA assessments being carried out. The EDT explained that since Dean’s passing, a “s.12 Solutions” App has been introduced, and although this had made a significant improvement, issues still exist trying to access a second doctor out of hours, as the EDT is still wholly reliant on second doctors making themselves available after midnight (with no fixed rota).
2. Evidence was given at the inquest that at the time of Dean’s passing, there were issues securing the timely attendance of the private ambulance service (ERS Medical) to transport patients after a MHA assessment had taken place , potentially resulting in an increased risk to both the AMHP and the patient for MHA assessments in the community. The EDT advised that since Dean’s passing, despite spot purchasing of private ambulances being introduced, issues still exist trying to get the private ambulance to attend a MHA assessment in a timely manner .
3. Evidence was given at the inquest that both of the above matters of concern are on-going national issues .
” 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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely access to second (s.12) doctors out of office hours for MHA assessments
Wider context from the report “1. Evidence was given at the inquest that at the time of Dean’s passing, there were issues accessing second (s.12) doctors out of office hours for the purpose of carrying out a MHA assessment, resulting in delays to MHA assessments being carried out . The EDT explained that since Dean’s passing, a “s.12 Solutions” App has been introduced, and although this had made a significant improvement, issues still exist trying to access a second doctor out of hours, as the EDT is still wholly reliant on second doctors making themselves available after midnight (with no fixed rota) .
2. Evidence was given at the inquest that at the time of Dean’s passing, there were issues securing the timely attendance of the private ambulance service (ERS Medical) to transport patients after a MHA assessment had taken place, potentially resulting in an increased risk to both the AMHP and the patient for MHA assessments in the community. The EDT advised that since Dean’s passing, despite spot purchasing of private ambulances being introduced, issues still exist trying to get the private ambulance to attend a MHA assessment in a timely manner.
3. Evidence was given at the inquest that both of the above matters of concern are on-going national issues .
” Open source report
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.
×
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 North East and North 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 North East and North 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
Concerns raised 2 Lack of assured paramedic crew availability during meal breaks after 10.00 p.m. in Berwick-upon-Tweed View source Insufficient local ambulance crew availability when the single Berwick crew is deployed out of area after 10.00 p.m. 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
Kyle William Lowes · 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
Kyle William Lowes, aged 16, died after his motor scooter collided with a car in Berwick-upon-Tweed on 30 January 2015. Emergency response was delayed because the nearby Berwick ambulance crew was on a meal break, requiring a paramedic to travel from Wooler; the report raised concerns about delayed responses to life-threatening incidents in Berwick-upon-Tweed when only one crew is available or is outside the area.
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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of assured paramedic crew availability during meal breaks after 10.00 p.m. in Berwick-upon-Tweed
Wider context from the report “The new Northumbria Specialist Emergency Care Hospital now make better provision for the County of Northumberland as a whole, but extends still further the long journey times for emergency care from Berwick-upon-Tweed, a sizeable border town, with a population which trebles throughout the tourist season because of its location as a holiday destination. By having only one paramedic crew after 10.00 p.m., if that crew is on a meal break , or as they regularly need to do, attend duties in another part of the County, risk is created to the population of Berwick-upon-Tweed by significant delays in attending life threatening incidents after 10.00 p.m., as there was in Kyle’s case.
I was informed at the Inquest that NEAS are introducing a scheme whereby paramedic crews will be asked at the start of each shift whether they are willing to be contacted for emergency calls during their meal breaks, which might go some way towards helping to resolve the concerns but does not provide any certainty while resting only on the goodwill and agreement of ambulance personnel . This proposal for response to emergency calls during meal breaks would also not address the risk of delayed response times when the single Berwick ambulance crew after 10.00 p.m. is called upon for duties out of the area.
” 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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient local ambulance crew availability when the single Berwick crew is deployed out of area after 10.00 p.m.
Wider context from the report “The new Northumbria Specialist Emergency Care Hospital now make better provision for the County of Northumberland as a whole, but extends still further the long journey times for emergency care from Berwick-upon-Tweed, a sizeable border town, with a population which trebles throughout the tourist season because of its location as a holiday destination. By having only one paramedic crew after 10.00 p.m., if that crew is on a meal break, or as they regularly need to do, attend duties in another part of the County , risk is created to the population of Berwick-upon-Tweed by significant delays in attending life threatening incidents after 10.00 p.m., as there was in Kyle’s case.
I was informed at the Inquest that NEAS are introducing a scheme whereby paramedic crews will be asked at the start of each shift whether they are willing to be contacted for emergency calls during their meal breaks, which might go some way towards helping to resolve the concerns but does not provide any certainty while resting only on the goodwill and agreement of ambulance personnel. This proposal for response to emergency calls during meal breaks would also not address the risk of delayed response times when the single Berwick ambulance crew after 10.00 p.m. is called upon for duties out of the area .
” Open source report
Concerns raised 9 Failure to provide longitudinal management of recurring asthma exacerbations View source Failure to recognise deterioration in respiratory condition View source Failure to enable appropriate referrals to the tertiary paediatric service View source Failure to ensure understanding of the purpose and limits of asthma plans View source Lack of a long-term management plan for chronic asthma View source Lack of effective communication between primary and secondary care services View source Lack of a coordinating record of recurrent asthma presentations View source Failure to assign overall clinical management responsibility View source Failure to refer paediatric asthma patients to tertiary respiratory specialists View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Tamara Mills · 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
Tamara Mills, who had longstanding asthma and repeated acute exacerbations, developed breathing difficulties during the night of 10th/11th April 2015 and died after paramedics were called. The principal concerns were fragmented care, inadequate coordination and communication, insufficient recognition of her deteriorating chronic respiratory condition, and the absence of a long-term management plan.
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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide longitudinal management of recurring asthma exacerbations
Wider context from the report “1. The care management and treatment of this child on the innumerable occasions she presented with an exacerbation of asthma, was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family .
2. There was :-
i) No co-ordinating record of these occasions
ii) No analysis of the frequency or circumstances of the events
iii) No analysis of the medication or level of medication prescribed
iv) No determination of its effectiveness the frequency or regularity of its use
v) No appreciation of the deteriorating nature of her respiratory condition
” 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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise deterioration in respiratory condition
Wider context from the report “1. The care management and treatment of this child on the innumerable occasions she presented with an exacerbation of asthma, was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family.
2. There was :-
i) No co-ordinating record of these occasions
ii) No analysis of the frequency or circumstances of the events
iii) No analysis of the medication or level of medication prescribed
iv) No determination of its effectiveness the frequency or regularity of its use
v) No appreciation of the deteriorating nature of her respiratory condition
” 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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to enable appropriate referrals to the tertiary paediatric service
Wider context from the report “8. Two further areas of concern presented, inter related but independently significant and critical in this matter :
A) Tamara’s mother readily presented her child for care in an out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment.
B) Evidence was also received of the development of a Tertiary service designed to improve medical care in the area of paediatrics.
i) There was a singular lack of understanding by practitioners of how referrals to the service were to be made and once made an anxiety that the receiving trust not be seen to be acquiring a patient at the expense of the referring trust . The net result of this inhibition a further fragmentation in the care and management of the patient.
ii) Within this service there were and indeed are specialist Respiratory Physicians who because of their level of expertise could and did demonstrate their ability to make a difference if they had been permitted in one instance to assume long term management of the child’s care
and
iii) More tragically in another because she was referred to the hospital but not to the service and therefore not to the Tertiary Specialists, managed only as an acute presentation
9. Tamara was never formally referred to this level of service.
” 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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure understanding of the purpose and limits of asthma plans
Wider context from the report “3. Despite the presence of a significant number of health care professional involved in her care and some frequently, no single individual assumed management for her care overall
4. In the absence of no one individual assuming responsibility for her care, there was no plan directed towards her long term management and care identifying the chronic nature of her condition, seeking a sustained and balanced level of treatment, control and resolution of the recurring episodes.
5. Insofar as planning occurred it was in the last six months of her life and was in the form of an emergency plan directed towards the next and apparently accepted inevitable acute event, but not as a part of the necessary strategy to control and avoid such events.
6. Not only did those advised of such a plan fail to understand its limited objective they misinterpreted its purpose and consoled themselves in the false belief there was a purposeful strategy designed to protect this child in the long term.
” 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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a long-term management plan for chronic asthma
Wider context from the report “3. Despite the presence of a significant number of health care professional involved in her care and some frequently, no single individual assumed management for her care overall
4. In the absence of no one individual assuming responsibility for her care, there was no plan directed towards her long term management and care identifying the chronic nature of her condition, seeking a sustained and balanced level of treatment, control and resolution of the recurring episodes .
5. Insofar as planning occurred it was in the last six months of her life and was in the form of an emergency plan directed towards the next and apparently accepted inevitable acute event, but not as a part of the necessary strategy to control and avoid such events.
6. Not only did those advised of such a plan fail to understand its limited objective they misinterpreted its purpose and consoled themselves in the false belief there was a purposeful strategy designed to protect this child in the long term.
” 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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of effective communication between primary and secondary care services
Wider context from the report “8. Two further areas of concern presented, inter related but independently significant and critical in this matter :
A) Tamara’s mother readily presented her child for care in an out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment .
B) Evidence was also received of the development of a Tertiary service designed to improve medical care in the area of paediatrics.
i) There was a singular lack of understanding by practitioners of how referrals to the service were to be made and once made an anxiety that the receiving trust not be seen to be acquiring a patient at the expense of the referring trust. The net result of this inhibition a further fragmentation in the care and management of the patient.
ii) Within this service there were and indeed are specialist Respiratory Physicians who because of their level of expertise could and did demonstrate their ability to make a difference if they had been permitted in one instance to assume long term management of the child’s care
and
iii) More tragically in another because she was referred to the hospital but not to the service and therefore not to the Tertiary Specialists, managed only as an acute presentation
9. Tamara was never formally referred to this level of service.
” 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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a coordinating record of recurrent asthma presentations
Wider context from the report “1. The care management and treatment of this child on the innumerable occasions she presented with an exacerbation of asthma, was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family.
2. There was :-
i) No co-ordinating record of these occasions
ii) No analysis of the frequency or circumstances of the events
iii) No analysis of the medication or level of medication prescribed
iv) No determination of its effectiveness the frequency or regularity of its use
v) No appreciation of the deteriorating nature of her respiratory condition
” 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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to assign overall clinical management responsibility
Wider context from the report “3. Despite the presence of a significant number of health care professional involved in her care and some frequently, no single individual assumed management for her care overall
4. In the absence of no one individual assuming responsibility for her care, there was no plan directed towards her long term management and care identifying the chronic nature of her condition, seeking a sustained and balanced level of treatment, control and resolution of the recurring episodes.
5. Insofar as planning occurred it was in the last six months of her life and was in the form of an emergency plan directed towards the next and apparently accepted inevitable acute event, but not as a part of the necessary strategy to control and avoid such events.
6. Not only did those advised of such a plan fail to understand its limited objective they misinterpreted its purpose and consoled themselves in the false belief there was a purposeful strategy designed to protect this child in the long term.
” 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 North East and North Cumbria Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to refer paediatric asthma patients to tertiary respiratory specialists
Wider context from the report “8. Two further areas of concern presented, inter related but independently significant and critical in this matter :
A) Tamara’s mother readily presented her child for care in an out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment.
B) Evidence was also received of the development of a Tertiary service designed to improve medical care in the area of paediatrics.
i) There was a singular lack of understanding by practitioners of how referrals to the service were to be made and once made an anxiety that the receiving trust not be seen to be acquiring a patient at the expense of the referring trust. The net result of this inhibition a further fragmentation in the care and management of the patient.
ii) Within this service there were and indeed are specialist Respiratory Physicians who because of their level of expertise could and did demonstrate their ability to make a difference if they had been permitted in one instance to assume long term management of the child’s care
and
iii) More tragically in another because she was referred to the hospital but not to the service and therefore not to the Tertiary Specialists, managed only as an acute presentation
9. Tamara was never formally referred to this level of service .
” Open source report
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Addressed to NHS Tees Valley Clinical Commissioning Group, now represented here by NHS North East and North Cumbria Integrated Care Board.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations