Recipient

NHS North West London Integrated Care Board

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First report 29 Jul 2022•Latest report 29 Jul 2022

Recipient record

Reports, concerns and published responses

Health and care · Integrated care board. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from NHS North West London Integrated Care Board linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. West London

    AI-generated summary

    Asher William Robert Sinclair · 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

    Asher William Robert Sinclair was a ventilator-dependent child who died in hospital on 8 October 2019 after life support was withdrawn, following a displaced tracheal tube and a prolonged loss of oxygen. The report identified concerns about inadequate staffing, training, planning, oversight, review and escalation within his complex care package, including that he was left in the care of a sole nurse who did not follow the emergency procedure.

    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 West London Integrated Care Board; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to conduct mandatory care-package quality checks and reviews

    Wider context from the report

    “The care package, despite being described as one of the most complex and most expensive was not appropriately reviewed and there was no mandatory system of quality checks or formal review when there was a significant change in family circumstances. Quarterly reviews were not carried out without explanation. ”
    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 West London Integrated Care Board; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to escalate and follow up concerns raised about the care package

    Wider context from the report

    “The primary responsibility fell upon the family members, namely Asher’s parents, who were also responsible for other children in the family and employed as teachers. Concerns raised by the parents were not taken for discussion to case conference or professional’s meetings and essentially not followed up at all, leaving the situation in the house dangerous with an ultimately calamitous outcome. ”
    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 West London Integrated Care Board; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate training for staff involved in the care package

    Wider context from the report

    “Training for the staff involved was unclear to the court and seemingly not in place or inadequate. A high turnover of staff was cited as one of the reasons, but this should have highlighted a need for increased training and scrutiny. ”
    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 West London Integrated Care Board; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of scrutiny and reconciliation of the care package

    Wider context from the report

    “There was a lack of scrutiny or reconciliation of Asher’s care package, which could have identified gaps that needed to be addressed. ”
    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 West London Integrated Care Board; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide prescribed 2:1 care

    Wider context from the report

    “Asher was entirely dependent upon a complex package of care as a highly vulnerable ventilator dependent child. Evidence at inquest was that on numerous occasions he was not provided with the prescribed 2:1 care. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026