Recipient

NHS Northamptonshire Integrated Care Board

First report 12 Jan 2024•Latest report 22 Dec 2025

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: 4
Published responses: 50%
Concerns addressed: 2
Stated actions: 5

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.

50%published responses found

5stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

22 Dec2025
Northamptonshire
Concerns raised3
1. Failure to communicate medication changes between private and NHS psychiatric providers
2. Failure of notification pathways to identify patients receiving private and NHS psychiatry
3. Lack of a consistent protocol for patients receiving private and NHS psychiatry
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

Wendy Siobhan EYLES · 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

Wendy Siobhan Eyles died aged 55 on 31 October 2024 after being struck by a train at Kettering Station; the inquest concluded that appropriate mental health support and intervention had not been provided. Concerns included the absence of a protocol for patients receiving both private and NHS psychiatric care, risks from poor communication about medication changes, and possible lack of NHS awareness of private psychiatric 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 Northamptonshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate medication changes between private and NHS psychiatric providers
Wider context from the report
“One of the findings of the Patient Safety Incident Investigation (PSII) was that ".. there is no protocol for patients open to private and NHS psychiatry at Northamptonshire Healthcare Foundation Trust. The Psychiatrist’s role in patient care is to review and recommend appropriate medication and it is problematic if two Consultants are overseeing this at the same time. It can cause confusion and detriment to the patient if medication changes are not communicated between parties and represents a risk to patient safety... It is notable that CMHT operational managers from across the service differ in their views on the appropriateness of a patient being open to NHS and private services at the same time...". It also emerged at Inquest that a NHS Consultant may not be aware that the patient is also receiving private psychiatry. Where the GP is notified of private psychiatry, it does not trigger a notification to NHS mental health services. Notification of the dual treatment may then be entirely dependent upon the information being shared by 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 Northamptonshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Failure of notification pathways to identify patients receiving private and NHS psychiatry
Wider context from the report
“One of the findings of the Patient Safety Incident Investigation (PSII) was that ".. there is no protocol for patients open to private and NHS psychiatry at Northamptonshire Healthcare Foundation Trust. The Psychiatrist’s role in patient care is to review and recommend appropriate medication and it is problematic if two Consultants are overseeing this at the same time. It can cause confusion and detriment to the patient if medication changes are not communicated between parties and represents a risk to patient safety... It is notable that CMHT operational managers from across the service differ in their views on the appropriateness of a patient being open to NHS and private services at the same time...". It also emerged at Inquest that a NHS Consultant may not be aware that the patient is also receiving private psychiatry. Where the GP is notified of private psychiatry, it does not trigger a notification to NHS mental health services. Notification of the dual treatment may then be entirely dependent upon the information being shared by 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 Northamptonshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Lack of a consistent protocol for patients receiving private and NHS psychiatry
Wider context from the report
“One of the findings of the Patient Safety Incident Investigation (PSII) was that ".. there is no protocol for patients open to private and NHS psychiatry at Northamptonshire Healthcare Foundation Trust. The Psychiatrist’s role in patient care is to review and recommend appropriate medication and it is problematic if two Consultants are overseeing this at the same time. It can cause confusion and detriment to the patient if medication changes are not communicated between parties and represents a risk to patient safety... It is notable that CMHT operational managers from across the service differ in their views on the appropriateness of a patient being open to NHS and private services at the same time...". It also emerged at Inquest that a NHS Consultant may not be aware that the patient is also receiving private psychiatry. Where the GP is notified of private psychiatry, it does not trigger a notification to NHS mental health services. Notification of the dual treatment may then be entirely dependent upon the information being shared by the patient. ”
Open source report
22 Dec2025
Northamptonshire
Concerns raised3
1. Failure of notification pathways to ensure NHS mental health services are aware of private psychiatric treatment
2. Lack of a protocol for patients receiving concurrent private and NHS psychiatry
3. Failure to communicate medication changes between private and NHS psychiatric providers
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

Wendy Siobhan EYLES · 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

Wendy Siobhan Eyles died on 31 October 2024 after being struck by a train at Kettering Station having climbed down from the platform. The report identified concerns about the lack of a protocol for patients receiving both private and NHS psychiatric care, including risks that medication changes and treatment arrangements may not be communicated between services.

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 Northamptonshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Failure of notification pathways to ensure NHS mental health services are aware of private psychiatric treatment
Wider context from the report
“One of the findings of the Patient Safety Incident Investigation (PSII) was that “.. there is no protocol for patients open to private and NHS psychiatry at Northamptonshire Healthcare Foundation Trust. The Psychiatrist’s role in patient care is to review and recommend appropriate medication and it is problematic if two Consultants are overseeing this at the same time. It can cause confusion and detriment to the patient if medication changes are not communicated between parties and represents a risk to patient safety... It is notable that CMHT operational managers from across the service differ in their views on the appropriateness of a patient being open to NHS and private services at the same time..”. It also emerged at Inquest that a NHS Consultant may not be aware that the patient is also receiving private psychiatry. Where the GP is notified of private psychiatry, it does not trigger a notification to NHS mental health services. Notification of the dual treatment may then be entirely dependent upon the information being shared by 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 Northamptonshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Lack of a protocol for patients receiving concurrent private and NHS psychiatry
Wider context from the report
“One of the findings of the Patient Safety Incident Investigation (PSII) was that “.. there is no protocol for patients open to private and NHS psychiatry at Northamptonshire Healthcare Foundation Trust. The Psychiatrist’s role in patient care is to review and recommend appropriate medication and it is problematic if two Consultants are overseeing this at the same time. It can cause confusion and detriment to the patient if medication changes are not communicated between parties and represents a risk to patient safety... It is notable that CMHT operational managers from across the service differ in their views on the appropriateness of a patient being open to NHS and private services at the same time..”. It also emerged at Inquest that a NHS Consultant may not be aware that the patient is also receiving private psychiatry. Where the GP is notified of private psychiatry, it does not trigger a notification to NHS mental health services. Notification of the dual treatment may then be entirely dependent upon the information being shared by 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 Northamptonshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate medication changes between private and NHS psychiatric providers
Wider context from the report
“One of the findings of the Patient Safety Incident Investigation (PSII) was that “.. there is no protocol for patients open to private and NHS psychiatry at Northamptonshire Healthcare Foundation Trust. The Psychiatrist’s role in patient care is to review and recommend appropriate medication and it is problematic if two Consultants are overseeing this at the same time. It can cause confusion and detriment to the patient if medication changes are not communicated between parties and represents a risk to patient safety... It is notable that CMHT operational managers from across the service differ in their views on the appropriateness of a patient being open to NHS and private services at the same time..”. It also emerged at Inquest that a NHS Consultant may not be aware that the patient is also receiving private psychiatry. Where the GP is notified of private psychiatry, it does not trigger a notification to NHS mental health services. Notification of the dual treatment may then be entirely dependent upon the information being shared by the patient. ”
Open source report
24 Jun2024
Northamptonshire
Concerns raised1
1. Failure to provide EOC mental health professionals with access to relevant community mental health records
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Explore how to share complete patient records, including mental health data, with EMAS throughout the patient journey.
  Stated in progress
2. Action
  Review whether accessing mental health records through SystmOne is the appropriate approach, considering clinician and patient-care implications.
  Stated completed
Respondent positions 2
1. Position
  Accessing regional mental health records was not pursued further because system complexity, clinical risks, licensing, access and training created time and resource constraints.
  Unable to act
1. Position
  Existing NHFT response work and 24/7 mental health clinicians in the emergency operations centre should mitigate risks while a regional records-access solution is explored.
  Existing arrangements considered sufficient
AI-generated summary

Liam Paul McCarlie · 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

Liam Paul McCarlie died by suicide after being found suspended by a ligature on 1 April 2023; death was confirmed shortly after midnight on 2 April 2023. The inquest identified a significant delay in ambulance attendance, which contributed to his death, and an insufficiently clear mental-health support plan while he awaited assessment for the Structured Clinical Management programme. A further concern was that mental-health professionals in the ambulance service’s emergency operations centre did not have access to relevant community mental-health records.

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 Northamptonshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide EOC mental health professionals with access to relevant community mental health records
Wider context from the report
“I was told that there was no technical reason why EMAS staff (especially the mental health nurse located in the EOS) could not access a patient’s mental health records if held on SystmOne. There are such technical reasons why EMAS staff do not have access to RiO (an entirely different database). A data sharing agreement is likely to be needed as may a particular patient’s consent. I am concerned that notwithstanding the recognition of the desirability for specialist mental health input, those mental health professionals within the EOC do not presently have access to records which may have been produced by the community mental health team. That is notwithstanding that the principal database used by the provider of community mental health treatment in Northamptonshire (the Northamptonshire Healthcare NHS Foundation Trust) is one to which EMAS does presently have access. Such information may be relevant to, for example, whether the patient has a history of suicidal ideation or attempts. That information may in turn be material to the triage and dispatch of ambulance resources. ”
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
Explore how to share complete patient records, including mental health data, with EMAS throughout the patient journey.

Verbatim wording from the response
“The ICB has been working closely with EMAS and NHFT to explore how best to share the entire patient record, including mental health data, with the ambulance service at every stage of the patient journey from initial call to attendance on-scene.”

Source location
Joint Response from EMAS and Northamptonshire ICB
Page 2 · response
Published 27 June 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review whether accessing mental health records through SystmOne is the appropriate approach, considering clinician and patient-care implications.

Verbatim wording from the response
“In July 2024 the National Ambulance Mental Health Group met, where it was identified that there would be varying risks in relation to regional providers undertaking a multi system approach. This was escalated to the National Ambulance Service Medical Directors Group as an area of concern. In the interim, whilst it has been explored and discussed, the possibility of access to mental health records via SystmOne for EMAS, the implications on the clinicians within EOC and the potential impact on patient care have led us to review whether this is the correct direction of travel. We are keen to implement a regional response to accessing mental health records within EOC to ensure consistency across the East Midlands. In the meantime, the response work from NHFT and the 24/7 mental health clinicians within EOC should mitigate against any risk in relation to correct response.”

Source location
Joint Response from EMAS and Northamptonshire ICB
Page 2 · response
Published 27 June 2024
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
Accessing regional mental health records was not pursued further because system complexity, clinical risks, licensing, access and training created time and resource constraints.

Verbatim wording from the response
“EMAS have in the past attempted to deploy access to mental health records via other regional mental health Trusts who work off varying systems. This has proved complex with challenges identifying which systems to access dependent on the patient’s location within the region, and highlighted risks relating to multi system use within the Emergency Operations Centre (EOC). This has also proved challenging to enact in terms of time and resource to undertake licensing agreements, access, and training. As a result, access to these systems was not pursued further. EMAS are committed to working with the ICB and NHFT to identify the correct solution at pace, notwithstanding National work being undertaken in relation to alignment of systems that can be accessed by all.”

Source location
Joint Response from EMAS and Northamptonshire ICB
Page 2 · response
Published 27 June 2024
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 NHFT response work and 24/7 mental health clinicians in the emergency operations centre should mitigate risks while a regional records-access solution is explored.

Verbatim wording from the response
“In July 2024 the National Ambulance Mental Health Group met, where it was identified that there would be varying risks in relation to regional providers undertaking a multi system approach. This was escalated to the National Ambulance Service Medical Directors Group as an area of concern. In the interim, whilst it has been explored and discussed, the possibility of access to mental health records via SystmOne for EMAS, the implications on the clinicians within EOC and the potential impact on patient care have led us to review whether this is the correct direction of travel. We are keen to implement a regional response to accessing mental health records within EOC to ensure consistency across the East Midlands. In the meantime, the response work from NHFT and the 24/7 mental health clinicians within EOC should mitigate against any risk in relation to correct response.”

Source location
Joint Response from EMAS and Northamptonshire ICB
Page 2 · response
Published 27 June 2024
Open published response
12 Jan2024
Northamptonshire
Concerns raised1
1. Unavailability of immediate paediatric chest ultrasound assessment
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Work with acute and partner organisations to consider and support safe pathways for patients needing paediatric radiology outside normal working hours.
  Stated in progress
AI-generated summary

Iona Grace Buckingham · 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

Iona Grace Buckingham was admitted to Northampton General Hospital with bronchiolitis and later developed pneumonia, pleural effusion and worsening respiratory distress. She died on 4 December 2022 during an accidental extubation and cardiac arrest, despite attempts at resuscitation. The principal concern was that a very unwell child requiring a chest ultrasound may face a substantial delay because paediatric radiology services were not routinely available outside limited hours, potentially for up to 48 hours over a weekend.

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 Northamptonshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of immediate paediatric chest ultrasound assessment
Wider context from the report
“The recommendation made by the investigation panel was that children with pneumonia who are not improving after forty-eight hours of treatment or deteriorate at a later point should get “an immediate x-ray and chest ultrasound”. However, the evidence I heard suggests this is not possible. I heard from the Clinical Director that as a district general hospital, Northampton General Hospital does not have access to a paediatric radiologist outside of 9am-5pm on Mondays and Fridays when such a specialist is either on duty or on-call. I heard evidence that in Iona’s case, a Consultant in ITU and Anaesthesia was able to perform an ultrasound scan at around 2pm on 4th December 2022 however this is not a facility that would routinely be available to the Trust and was not, in any event, part of that clinician’s core duties. I am concerned that a very unwell child who may require a chest ultrasound may not receive one ‘immediately’ and in fact may have to wait for a considerable period of time. For example, if the need arose over a weekend, that child may not receive an ultrasound scan for up to 48 hours. ”
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
Work with acute and partner organisations to consider and support safe pathways for patients needing paediatric radiology outside normal working hours.

Verbatim wording from the response
“Following your letter, the ICB has been working closely with University Hospitals of Northamptonshire, NHSE Midlands, and Leicester, Leicestershire, and Rutland ICB to consider and support the pathways available for patients who need access to paediatric radiology outside of normal working hours. We understand that UHN is considering the possibility of joint recruitment of a radiologist with a paediatric sub specialism working between Northampton General Hospital NHS Trust and University of Leicester NHS Trust. We also understand that a paediatric consultant is being trained in Point of Care Ultrasound (POCUS) and there are charitable funds requested for the purchase of a POCUS ultrasound machine for the department.”

Source location
Response from Northamtonshire Integrated Care Board
Page 1 · response
Published 19 January 2024
Open published response

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

Reports, concerns and published responses

Reports over time

Concerns raised3

Failure to communicate medication changes between private and NHS psychiatric providers

Failure of notification pathways to identify patients receiving private and NHS psychiatry

Lack of a consistent protocol for patients receiving private and NHS psychiatry

Concerns raised3

Failure of notification pathways to ensure NHS mental health services are aware of private psychiatric treatment

Lack of a protocol for patients receiving concurrent private and NHS psychiatry

Failure to communicate medication changes between private and NHS psychiatric providers

Concerns raised1

Failure to provide EOC mental health professionals with access to relevant community mental health records

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2

Concerns raised1

Unavailability of immediate paediatric chest ultrasound assessment

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.1

Actions described in response 2

Respondent positions 2

Actions described in response 1