Concerns raised 5 Failure to quarantine relevant medical equipment promptly after clinical events View source Failure to download accurate clinical data from medical devices promptly View source Failure to retain relevant clinical material after clinical events View source Absence of a penicillin allergy de-labelling pathway at NUH View source Failure to complete Datix reports promptly after clinical events View source See 2 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
Jennifer Susan BIRCH · 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
Jennifer Susan Birch died on 11 April 2025 after suffering anaphylaxis to teicoplanin during the peri-operative period of an elective procedure, resulting in hypoxic brain injury. Concerns included failure to make a 2222 call during the anaesthetic emergency, failures to promptly record and retain evidence after the event, and the absence of a penicillin allergy de-labelling pathway at the Trust.
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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to quarantine relevant medical equipment promptly after clinical events
Wider context from the report “1. (NUH) Failure to ensure an “inquiring mind” in satisfying the duty of candour
The Trust can only seek to learn lessons from events if it has, at every level, an inquiring mind that seeks to capture all relevant evidence at the earliest opportunity following clinical events.
My investigation, and that of the PSII, was hampered by the failure of staff to complete a Datix report on the day of the event. This led to a failure to quarantine the medical equipment used in theatre (which was suspected of potential malfunction), a failure to download all accurate clinical data from the machines, and a failure to retain the second, retrospectively completed, anaesthetic chart.
This is not an isolated incident, nor one that is unique to this Department. This is a Trust wide issue. Coronial investigations over recent years have been hampered in establishing the truth because of a failure by the Trust to retain relevant material post clinical events (placentas disposed of following neonatal harm – PFD report issued 2021, lost CTG traces, cardiology medical devices not being retained/quarantined/inspected in a timely fashion leading to relevant data being overwritten or devices destroyed – informal letter sent 2026).
The Trust must ensure a culture that promotes a forensic inquiring mind, supported by robust systems to promptly identify and retain evidence, especially as a number of the medical devices used across the Trust are not networked or cloud based, meaning data can be lost when the device is switched off or memory is overwritten when the device is next used.
” 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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to download accurate clinical data from medical devices promptly
Wider context from the report “1. (NUH) Failure to ensure an “inquiring mind” in satisfying the duty of candour
The Trust can only seek to learn lessons from events if it has, at every level, an inquiring mind that seeks to capture all relevant evidence at the earliest opportunity following clinical events.
My investigation, and that of the PSII, was hampered by the failure of staff to complete a Datix report on the day of the event. This led to a failure to quarantine the medical equipment used in theatre (which was suspected of potential malfunction), a failure to download all accurate clinical data from the machines , and a failure to retain the second, retrospectively completed, anaesthetic chart.
This is not an isolated incident, nor one that is unique to this Department. This is a Trust wide issue. Coronial investigations over recent years have been hampered in establishing the truth because of a failure by the Trust to retain relevant material post clinical events (placentas disposed of following neonatal harm – PFD report issued 2021, lost CTG traces, cardiology medical devices not being retained/quarantined/inspected in a timely fashion leading to relevant data being overwritten or devices destroyed – informal letter sent 2026).
The Trust must ensure a culture that promotes a forensic inquiring mind, supported by robust systems to promptly identify and retain evidence, especially as a number of the medical devices used across the Trust are not networked or cloud based, meaning data can be lost when the device is switched off or memory is overwritten when the device is next used .
” 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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to retain relevant clinical material after clinical events
Wider context from the report “1. (NUH) Failure to ensure an “inquiring mind” in satisfying the duty of candour
The Trust can only seek to learn lessons from events if it has, at every level, an inquiring mind that seeks to capture all relevant evidence at the earliest opportunity following clinical events.
My investigation, and that of the PSII, was hampered by the failure of staff to complete a Datix report on the day of the event. This led to a failure to quarantine the medical equipment used in theatre (which was suspected of potential malfunction), a failure to download all accurate clinical data from the machines, and a failure to retain the second, retrospectively completed, anaesthetic chart .
This is not an isolated incident, nor one that is unique to this Department. This is a Trust wide issue. Coronial investigations over recent years have been hampered in establishing the truth because of a failure by the Trust to retain relevant material post clinical events (placentas disposed of following neonatal harm – PFD report issued 2021, lost CTG traces , cardiology medical devices not being retained /quarantined/inspected in a timely fashion leading to relevant data being overwritten or devices destroyed – informal letter sent 2026).
The Trust must ensure a culture that promotes a forensic inquiring mind, supported by robust systems to promptly identify and retain evidence, especially as a number of the medical devices used across the Trust are not networked or cloud based, meaning data can be lost when the device is switched off or memory is overwritten when the device is next used.
” 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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Absence of a penicillin allergy de-labelling pathway at NUH
Wider context from the report “2. (ICB) Roll out of the Penicillin Allergy De-Labelling Pathway
Teicoplanin carries a rare but recognised risk of severe anaphylaxis and reaction occurring in an estimated 0.1-1% of cases. Teicoplanin is often used as an alternative to penicillin for patients who report penicillin allergy. The risk of serious complications is greater in teicoplanin than many other forms of antibiotic (NAP6). It has been described as “an emerging problem in the anaesthetic allergy clinic” (British Journal of Anaesthesia, 2015).
Jen was administered teicoplanin in the peri-operative period because the recommended antibiotic for her elective procedure, Flucloxacillin, is from the same antibiotic family as penicillin, and Jen’s medical records reported an allergy to penicillin in the form of a rash as a baby.
The use of teicoplanin in this case was entirely appropriate given Jen’s allergy warning, but it did expose her to a risk of severe anaphylaxis, which materialised and caused her death. In the months following Jen’s death, some Trusts have rolled out an inpatient initiative to seek to de-label penicillin allergy from patient medical records where risk stratification determines that the patient does not have a true allergy to penicillin. The SPACE study established that up to 10% of the population carries documented penicillin allergy but over 90% of these are inaccurate . False labels have been shown to increase antibiotic resistance, higher surgical site infections, longer hospital stays, as well as exposing patients to unnecessary complications associated with second-line antibiotics.
One local Trust, Doncaster and Bassetlaw NHS Trust, has already rolled out an inpatient PADL pathway. The SPACE study proved it is clinically safe and effective for non-allergy healthcare professionals to use approved risk stratification and direct oral penicillin challenges for low-risk patients, ensuring the burden for this pathway does not impact on the often-small secondary care allergy service.
Does the ICB plan to commission this pathway across all local Trusts? At present, NUH does not offer this pathway.
” 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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to complete Datix reports promptly after clinical events
Wider context from the report “1. (NUH) Failure to ensure an “inquiring mind” in satisfying the duty of candour
The Trust can only seek to learn lessons from events if it has, at every level, an inquiring mind that seeks to capture all relevant evidence at the earliest opportunity following clinical events.
My investigation, and that of the PSII, was hampered by the failure of staff to complete a Datix report on the day of the event . This led to a failure to quarantine the medical equipment used in theatre (which was suspected of potential malfunction), a failure to download all accurate clinical data from the machines, and a failure to retain the second, retrospectively completed, anaesthetic chart.
This is not an isolated incident, nor one that is unique to this Department. This is a Trust wide issue. Coronial investigations over recent years have been hampered in establishing the truth because of a failure by the Trust to retain relevant material post clinical events (placentas disposed of following neonatal harm – PFD report issued 2021, lost CTG traces, cardiology medical devices not being retained/quarantined/inspected in a timely fashion leading to relevant data being overwritten or devices destroyed – informal letter sent 2026).
The Trust must ensure a culture that promotes a forensic inquiring mind, supported by robust systems to promptly identify and retain evidence, especially as a number of the medical devices used across the Trust are not networked or cloud based, meaning data can be lost when the device is switched off or memory is overwritten when the device is next used.
” Open source report
6 Jan 2026 Adam Ali Hussain · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Failure of the urgent care pathway to adequately serve patients with serious, non-immediately-life-threatening systemic illness requiring a Category 3 ambulance response View source Insufficient skills among non-clinicians to safely transfer Category 3 calls to NEMS View source Lack of agreed and unambiguous criteria for transferring Category 3 calls to NEMS View source Failure to inform waiting families when an ambulance will not be sent View source Failure of EMAS staff to reliably read and consider transferred Computer Aided Dispatch information View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Adam Ali Hussain · 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
Adam Ali Hussain died on 16 May 2025 at Queens Medical Centre, Nottingham, from complicated appendicitis with perforation, peritonitis, severe intra-abdominal sepsis and multiple organ failure. The report identifies missed opportunities to recognise worsening illness and sepsis and to arrange face-to-face assessment, particularly on 14 May 2025. Concerns include unreliable handling and transfer of clinical information, unclear Category 3 ambulance-call criteria, and inadequate communication with families.
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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of the urgent care pathway to adequately serve patients with serious, non-immediately-life-threatening systemic illness requiring a Category 3 ambulance response
Wider context from the report “1. The urgent care pathway across Nottinghamshire, whilst working well for most patients, poorly serves patients with systemic illness that is serious, but not immediately life threatening, (such as is seen in sepsis), and where clinical assessment disposition reached is for a Category 3 ambulance response
” 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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient skills among non-clinicians to safely transfer Category 3 calls to NEMS
Wider context from the report “4. Category 3 calls are viewed by non- clinicians at the EMAS Emergency Operations Centre, who do not have sufficient skills to safely transfer calls to NEMS , as the inclusion/exclusion criteria are open to interpretation
5. There is no agreement between EMAS and NEMS as to the criteria for transfer of a category 3 call, including whether or not a previous clinical validation would preclude transfer to NEMS
” 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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of agreed and unambiguous criteria for transferring Category 3 calls to NEMS
Wider context from the report “4. Category 3 calls are viewed by non- clinicians at the EMAS Emergency Operations Centre, who do not have sufficient skills to safely transfer calls to NEMS, as the inclusion/exclusion criteria are open to interpretation
5. There is no agreement between EMAS and NEMS as to the criteria for transfer of a category 3 call, including whether or not a previous clinical validation would preclude transfer to NEMS
” 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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to inform waiting families when an ambulance will not be sent
Wider context from the report “3. Families, waiting for an ambulance response, following a clinical assessment by a 111 clinical adviser are not told by EMAS that an ambulance will not be sent
” 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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of EMAS staff to reliably read and consider transferred Computer Aided Dispatch information
Wider context from the report “2. There remains detailed information in the EMAS Computer Aided Dispatch (CAD) transferred from the 111 service that is not reliably read or considered by EMAS staff , when cancelling a requested ambulance response and referring a case on to the Clinical Assessment Service provided by NEMS.
” 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 Review transferred call codes with comparable East Midlands services to assess whether wider removal is appropriate.
Verbatim wording from the response “We have ensured the manual push remains paused and there are no plans for reinstatement of this pathway at this point in time, as not all actions agreed have been completed. Several codes that were being automatically transferred to NEMS by EMAS have also ceased since December 2025 and we are in the process of reviewing these with other similar services across the East Midlands to assess whether they should be removed on a larger scale.” Source location Response from Nottingham and Nottinghamshire Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop joined-up analytics to understand patient journeys and outcomes across the pathway from March 2026.
Verbatim wording from the response “Our analytics team have recently developed the ability to join up multiple data sets that will from March 2026 allow us to understand the patient journey and outcomes across this entire pathway. This will support us to review and refine the journey for our patients, enhancing our ability to evaluate and adjust accordingly the service offer.” Source location Response from Nottingham and Nottinghamshire Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and redefine the UCCH service specification to incorporate learning from the report.
Verbatim wording from the response “As the commissioner of the UCCH we have also reviewed and redefined the existing service specification that is included in the contract we have with NEMS, ensuring that all learning has been included.” Source location Response from Nottingham and Nottinghamshire Integrated Care Board
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 The manual push pathway will remain paused, with no reinstatement planned while agreed safety actions remain incomplete.
Verbatim wording from the response “We have ensured the manual push remains paused and there are no plans for reinstatement of this pathway at this point in time, as not all actions agreed have been completed. Several codes that were being automatically transferred to NEMS by EMAS have also ceased since December 2025 and we are in the process of reviewing these with other similar services across the East Midlands to assess whether they should be removed on a larger scale.” Source location Response from Nottingham and Nottinghamshire Integrated Care Board
Open published response
5 Jan 2026 Jake Kieran Hartwright · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 6 Insufficient skills among non-clinicians to safely transfer Category 3 calls to NEMS View source Inclusion and exclusion criteria for transferring Category 3 calls open to interpretation View source Lack of agreed criteria between EMAS and NEMS for transfer of Category 3 calls View source Failure of the urgent care pathway to safely serve patients with serious, non-immediately-life-threatening systemic illness requiring a Category 3 ambulance response View source Failure to inform waiting families that an ambulance will be sent View source Failure of EMAS staff to reliably read and consider transferred CAD information when cancelling ambulance responses and referring cases to the Clinical Assessment Service View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jake Kieran Hartwright · 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
Jake Kieran Hartwright developed severe illness associated with bowel ischaemia and had a cardiac arrest at home on 16 January 2025. He died at Queens Medical Centre in the early hours of 17 January 2025 from multiple organ failure secondary to extensive bowel ischaemia. The report identified serious issues in the urgent care pathway, including missed opportunities to arrange a Category 2 ambulance and problems with clinical information transfer and management of Category 3 calls.
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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient skills among non-clinicians to safely transfer Category 3 calls to NEMS
Wider context from the report “4. Category 3 calls are viewed by non- clinicians at the EMAS Emergency Operations Centre, who do not have sufficient skills to safely transfer calls to NEMS , as the inclusion/exclusion criteria are open to interpretation
” 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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inclusion and exclusion criteria for transferring Category 3 calls open to interpretation
Wider context from the report “4. Category 3 calls are viewed by non- clinicians at the EMAS Emergency Operations Centre, who do not have sufficient skills to safely transfer calls to NEMS, as the inclusion/exclusion criteria are open to interpretation
” 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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of agreed criteria between EMAS and NEMS for transfer of Category 3 calls
Wider context from the report “5. There is no agreement between EMAS and NEMS as to the criteria for transfer of a category 3 call , including whether or not a previous clinical validation would preclude transfer to NEMS
” 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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of the urgent care pathway to safely serve patients with serious, non-immediately-life-threatening systemic illness requiring a Category 3 ambulance response
Wider context from the report “1. The urgent care pathway across Nottinghamshire, whilst working well for most patients, poorly serves patients with systemic illness that is serious, but not immediately life threatening, (such as is seen in sepsis), and where clinical assessment disposition is reached is for a Category 3 ambulance response
” 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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to inform waiting families that an ambulance will be sent
Wider context from the report “3. Families, waiting for an ambulance response , following a clinical assessment by a 111 clinical adviser are not told by EMAS that an ambulance will be sent
” 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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of EMAS staff to reliably read and consider transferred CAD information when cancelling ambulance responses and referring cases to the Clinical Assessment Service
Wider context from the report “2. There remains detailed information in the EMAS CAD transferred from the 111 service that is not reliably read or considered by EMAS staff , when cancelling a requested ambulance response and referring a case on to the Clinical Assessment Service provided by NEMS .
” 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 Join the clinical governance meeting established between NEMS and EMAS to support their continuing joint work.
Verbatim wording from the response “We have also offered and committed to joining the clinical governance meeting set up between NEMS and EMAS to support the continued work between the two organisations.” Source location Response from Nottingham and Nottinghamshire Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review automatic transfer codes with comparable East Midlands services to assess whether wider removal is appropriate.
Verbatim wording from the response “We have ensured the manual push remains paused and there are no plans for reinstatement of this pathway at this point in time, as not all actions agreed have been completed. Several codes that were being automatically transferred to NEMS by EMAS have also ceased since December 2025 and we are in the process of reviewing these with other similar services across the East Midlands to assess whether they should be removed on a larger scale.” Source location Response from Nottingham and Nottinghamshire Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Keep the manual push pathway paused pending completion of all agreed safety actions.
Verbatim wording from the response “We have ensured the manual push remains paused and there are no plans for reinstatement of this pathway at this point in time, as not all actions agreed have been completed. Several codes that were being automatically transferred to NEMS by EMAS have also ceased since December 2025 and we are in the process of reviewing these with other similar services across the East Midlands to assess whether they should be removed on a larger scale.” Source location Response from Nottingham and Nottinghamshire Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop joined-up analytics capability to assess patient journeys and outcomes across the entire pathway.
Verbatim wording from the response “Our analytics team have recently developed the ability to join up multiple data sets that will from March 2026 allow us to understand the patient journey and outcomes across this entire pathway. This will support us to review and refine the journey for our patients, enhancing our ability to evaluate and adjust accordingly the service offer.” Source location Response from Nottingham and Nottinghamshire Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and redefine the UCCH service specification in the NEMS contract to incorporate learning from the report.
Verbatim wording from the response “As the commissioner of the UCCH we have also reviewed and redefined the existing service specification that is included in the contract we have with NEMS, ensuring that all learning has been included.” Source location Response from Nottingham and Nottinghamshire Integrated Care Board
Open published response
4 Apr 2023 Thomas Jayamaha · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Failure to have necessary actions in place to address issues identified through the Serious Incident Investigation process View source Delayed progress of the Autism Strategy work View source Insufficient progress with complex case management 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
Thomas Jayamaha · 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
Thomas Jayamaha died by suicide after taking Pentobarbital ordered from a website abroad. He had Autism Spectrum Disorder, longstanding mental health difficulties, suicidal ideation and previous self-harm or suicide attempts, alongside other reported vulnerabilities. The principal concerns were delayed progress on the Trust’s Autism Strategy, insufficient progress with complex case management, and the Serious Incident Investigation process.
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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to have necessary actions in place to address issues identified through the Serious Incident Investigation process
Wider context from the report “3. The Serious Incident Investigation process
I am not reassured that necessary actions to address these serious issues identified are in place .
” 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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delayed progress of the Autism Strategy work
Wider context from the report “1. Delayed progress of the Autism Strategy work across the Trust. I ask that the Nottingham and Nottinghamshire Integrated Care Board provide a joint response with the Trust to address this concern, as I accept progress with the Autism work will depend upon resources and the agreed Com-missioning of specific services
” 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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient progress with complex case management
Wider context from the report “2. Insufficient progress with Complex case management
” Open source report
Concerns raised 3 Failure to review the electronic Patient Report Form during emergency department handover View source Failure to resolve electronic Patient Report Form access problems View source Limited availability of 24/7 mechanical thrombectomy for acute ischaemic stroke 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
Morris REDDINGTON · 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
Morris Reddington died from a rare stroke involving basilar artery thrombosis, likely caused by dissection of the right vertebral artery. The report identified delays in diagnosis and concerns that electronic ambulance handover records were not routinely reviewed, as well as limited out-of-hours access to mechanical thrombectomy. It also raised concerns about the risk of future deaths from failures in patient-information handover and geographical disparities in access to thrombectomy.
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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to review the electronic Patient Report Form during emergency department handover
Wider context from the report “The electronic Patient Report Form (‘ePRF’) is an important template which records all of the pre-hospital interaction with the patient. It forms a crucial part of the professional-to-professional handover of care, and is an adjunct to the concise verbal handover that takes place in the Emergency Department.
The Ambulance Service told me they expect the ePRF to be reviewed by ED staff, rather than staff simply relying on the verbal handover, which can be challenging in the context of a busy hospital environment.
At the point of roll out of the new electronic system, Ambulance Service personnel attended the local Emergency Departments to install software that allowed ED staff to access the electronic Patient Report Form hub from their hospital computers. Further to installing software, the Ambulance Service had also provided ED staff with personalised login details and training to ensure they knew how to access the patient information.
I heard evidence from ED staff that despite having logins and having received training, they did not routinely access the system to review the electronic patient report form . The rationale for this omission, was that the software was “clunky” to use and in some cases it could take up 5 minutes to isolate the correct form; time that busy ED staff do not have. Both Trusts accepted that it had become practise not to review the ePRF instead to rely upon the verbal handover alone .
In this case, had ED staff reviewed the ePRF early in the admission, they would have appreciated from that documentation that Mr Reddington had been suspected of having a stroke, rather than a simple a head injury. His care would then have been provided in accordance with the stroke pathway much earlier in the evening.
I am concerned that ignoring a written handover from a fellow medical professional is not a safe or proportionate solution to the difficulties faced of accessing the electronic system.
I am further concerned that this practise of ignoring the written handover appears to have persisted for a long time without the organisations reaching a sensible solution.
While the Ambulance Service are taking steps to upgrade the system at another local hospital, I heard evidence that there was no agreed plan or date for seeking to resolve the system issues at Kingsmill or Queens Medical Centre.
Whilst ever this problem persists without resolution, there is a risk of future deaths due to failures in the handover of patient information at the point of transfer of care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to resolve electronic Patient Report Form access problems
Wider context from the report “The electronic Patient Report Form (‘ePRF’) is an important template which records all of the pre-hospital interaction with the patient. It forms a crucial part of the professional-to-professional handover of care, and is an adjunct to the concise verbal handover that takes place in the Emergency Department.
The Ambulance Service told me they expect the ePRF to be reviewed by ED staff, rather than staff simply relying on the verbal handover, which can be challenging in the context of a busy hospital environment.
At the point of roll out of the new electronic system, Ambulance Service personnel attended the local Emergency Departments to install software that allowed ED staff to access the electronic Patient Report Form hub from their hospital computers. Further to installing software, the Ambulance Service had also provided ED staff with personalised login details and training to ensure they knew how to access the patient information.
I heard evidence from ED staff that despite having logins and having received training, they did not routinely access the system to review the electronic patient report form. The rationale for this omission, was that the software was “clunky” to use and in some cases it could take up 5 minutes to isolate the correct form; time that busy ED staff do not have. Both Trusts accepted that it had become practise not to review the ePRF instead to rely upon the verbal handover alone.
In this case, had ED staff reviewed the ePRF early in the admission, they would have appreciated from that documentation that Mr Reddington had been suspected of having a stroke, rather than a simple a head injury. His care would then have been provided in accordance with the stroke pathway much earlier in the evening.
I am concerned that ignoring a written handover from a fellow medical professional is not a safe or proportionate solution to the difficulties faced of accessing the electronic system.
I am further concerned that this practise of ignoring the written handover appears to have persisted for a long time without the organisations reaching a sensible solution .
While the Ambulance Service are taking steps to upgrade the system at another local hospital, I heard evidence that there was no agreed plan or date for seeking to resolve the system issues at Kingsmill or Queens Medical Centre .
Whilst ever this problem persists without resolution , there is a risk of future deaths due to failures in the handover of patient information at the point of transfer of care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Limited availability of 24/7 mechanical thrombectomy for acute ischaemic stroke
Wider context from the report “In January 2018, NHS England published its Clinical Commissioning Policy on the use of Mechanical Thrombectomy as treatment for acute ischaemic stroke (all ages).
The aim of the Policy reports to be two-fold; to improve outcomes for adults with stroke, and to improve access to mechanical thrombectomy as soon as possible after the onset of stroke symptoms.
Despite the publication of the policy some 3 years ago, there remains very limited access to 24/7 mechanical thrombectomy . Save for two Trusts in London, and the West Midlands Network, I am not aware of others providing a 24/7 service. There certainly is no such service in the East Midlands .
There is clear geographical disparity in the access to this vital, life-saving service .
Mechanical thrombectomy would likely have avoided Mr Reddington’s death. Instead, because Mr Reddington was unfortunate enough to suffer a stroke outside of the service’s operational hours (Monday to Friday 8am to 4pm), his family were left to watch his deterioration, knowing that a treatment had the potential to save his life, but that such treatment simply was not offered after 4pm .
This is a situation that no family ought to be placed in.
” Open source report
Concerns raised 2 Failure of existing service eligibility pathways to provide support for ASD-related diet concerns View source Lack of commissioned specialist long-term dietetic support for ASD patients with ARFID symptoms View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Owen Joseph HINDS · 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
Owen Joseph Hinds, a young man with autism and a restricted diet, died from an overwhelming chest infection on 28 February 2020. The report states that chronic liver disease and heart failure probably contributed to his death and that these conditions were not detected during his life. The principal concern was the absence of a specialist service providing long-term dietetic support for autistic people with ARFID symptoms, leaving Owen unable to access the sustained support required.
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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of existing service eligibility pathways to provide support for ASD-related diet concerns
Wider context from the report “1. There is no specialist service commissioned to provide ASD patients with long term dietetic support for ARFID symptoms, despite the increasingly prevalence of ARFID diagnosis.
At the time of the inquest, I was informed that Owen did not meet the criteria for support from any of the Dietetic services.
The Nottingham City Autism Service (NCAS) went above and beyond their remit in co-ordinating support from his GP. The service is commissioned to provide diagnostic and short term post-diagnostic intervention, yet they worked with Owen (as they do with many other patients) for years in order to bridge the gap in service provision. However, they could not provide the sustained ARFID support that Owen required.
Owen did not meet the criteria for support from the Eating Disorder Service or Dietetic Services (on account of his diet concerns being linked to his ASD) or Primary Care Learning Disability Nurse (as Owen did not have an intellectual impairment).
” 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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of commissioned specialist long-term dietetic support for ASD patients with ARFID symptoms
Wider context from the report “1. There is no specialist service commissioned to provide ASD patients with long term dietetic support for ARFID symptoms , despite the increasingly prevalence of ARFID diagnosis.
At the time of the inquest, I was informed that Owen did not meet the criteria for support from any of the Dietetic services.
The Nottingham City Autism Service (NCAS) went above and beyond their remit in co-ordinating support from his GP. The service is commissioned to provide diagnostic and short term post-diagnostic intervention, yet they worked with Owen (as they do with many other patients) for years in order to bridge the gap in service provision. However, they could not provide the sustained ARFID support that Owen required.
Owen did not meet the criteria for support from the Eating Disorder Service or Dietetic Services (on account of his diet concerns being linked to his ASD) or Primary Care Learning Disability Nurse (as Owen did not have an intellectual impairment).
” 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 Explore development of expanded ARFID-related roles within primary care.
Verbatim wording from the response “Develop workforce capability across the All Ages ARFID pathway and relevant support services” Source location 2021-0391-Response-from-Nottingham-and-Nottinghamshire-CCG_Published
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 current ARFID service provision.
Verbatim wording from the response “Develop All Ages ARFID Pathway” Source location 2021-0391-Response-from-Nottingham-and-Nottinghamshire-CCG_Published
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 Develop a preferred all-ages ARFID pathway with service-delivery recommendations.
Verbatim wording from the response “As a system we have developed an overarching action plan which describes our intention to develop an all-age pathway for individuals who are affected by ARFID. This pathway will ensure we are able to meet the needs of ARFID patients who are neurotypical and those who are autistic or who have other comorbidities.” Source location 2021-0391-Response-from-Nottingham-and-Nottinghamshire-CCG_Published
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 Explore workforce competencies around ARFID with Health Education England.
Verbatim wording from the response “Develop workforce capability across the All Ages ARFID pathway and relevant support services” Source location 2021-0391-Response-from-Nottingham-and-Nottinghamshire-CCG_Published
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 clinical cases to identify current ARFID provision and service gaps.
Verbatim wording from the response “Develop All Ages ARFID Pathway” Source location 2021-0391-Response-from-Nottingham-and-Nottinghamshire-CCG_Published
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 Undertake a skills audit and training-needs analysis across specialist and non-specialist services.
Verbatim wording from the response “Develop workforce capability across the All Ages ARFID pathway and relevant support services” Source location 2021-0391-Response-from-Nottingham-and-Nottinghamshire-CCG_Published
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 Implement the agreed all-ages ARFID pathway.
Verbatim wording from the response “As a system we have developed an overarching action plan which describes our intention to develop an all-age pathway for individuals who are affected by ARFID. This pathway will ensure we are able to meet the needs of ARFID patients who are neurotypical and those who are autistic or who have other comorbidities.” Source location 2021-0391-Response-from-Nottingham-and-Nottinghamshire-CCG_Published
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 Obtain approval for the preferred ARFID pathway and required resources.
Verbatim wording from the response “Develop preferred pathway with recommendations for service delivery | Jun ’22 | All Ages ARFID Task and Finish Group” Source location 2021-0391-Response-from-Nottingham-and-Nottinghamshire-CCG_Published
Open published response
Concerns raised 1 Insufficient clinical psychology staffing and access within Community Mental Health Teams View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Patricia Ferguson · 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
Patricia Ferguson had significant mental ill health and received secondary mental health services before her death by suicide. Clinicians considered that direct work with a clinical psychologist would benefit her, but no clinical psychologist was available; the report identified limited clinical psychology provision in community mental health teams as an ongoing risk of preventable future deaths.
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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient clinical psychology staffing and access within Community Mental Health Teams
Wider context from the report “(1) The Joint Commissioning Panel for Mental Health’s Guidance for Commissioners of Community Specialist Mental Health Services expresses an expectation there would be more than one clinical psychologist for each Community Mental Health Team , given that clinical psychologists are referred to in the plural within discussions of an appropriate staff team for CMHTs whereas, for example, consultant psychiatrists are referred to in the singular.
(2) CMHTs in Nottingham and Nottinghamshire have a commissioned establishment of, at most, one clinical psychologist per team , with some teams having only a part time clinical psychologist post . This inevitably results in some patients, as here, having no access to clinical psychology when this is clinically indicated , creating an ongoing risk of preventable future deaths .
” 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 planned annual investment to increase clinical psychology provision across Nottinghamshire Healthcare NHS Trust services.
Verbatim wording from the response “The LTP has a strong emphasis throughout on ensuring the provision of high quality, evidence-based mental health services which includes increased access to psychological therapies within the community based offer, as well as an increased focus on psychologically formed therapeutic interventions and care plan formulation through multi-disciplinary team approaches. There is planned investment each year to deliver the LTP ambitions, which includes increased Clinical Psychology provision across a range of services provided by NHT. The delivery of services is monitored by the BCCG and the Transformation plan is reviewed by NHS England on a monthly basis. BCCG have planned monthly transformation meetings with NHT commencing which were due to commence in March 2020. However, this has recently been impacted by the COVID-19 pandemic and has commenced week of 1st June 2020.” Source location 2020-0155-Response-from-Bassetlaw-Clinical-Commissioning-Group_Redacted.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with Nottinghamshire Healthcare NHS Trust on a five-year community mental health transformation programme, including monthly transformation meetings.
Verbatim wording from the response “The BCCG is working in partnership with Nottinghamshire Healthcare NHS Trust (NHT) on a programme of transformation to meet the requirements of the NHS Long Term Plan (LTP) over the next 5 years.” Source location 2020-0155-Response-from-Bassetlaw-Clinical-Commissioning-Group_Redacted.pdf
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 Fund additional clinical psychology posts and other staff capacity to strengthen community mental health team delivery.
Verbatim wording from the response “The national requirement in 2019/20 and 2020/21 is to ‘stabilise and bolster’ core community mental health teams, increasing team capacity and appointment availability. In 2019/20 this included funding for additional Clinical Psychology posts alongside other posts (i.e. pharmacy technicians and administrative support) to support testing new delivery models.” Source location 2020-0155-Response-from-Bassetlaw-Clinical-Commissioning-Group_Redacted.pdf
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 Invest in increased clinical psychology provision across Nottinghamshire Healthcare NHS Trust services to deliver Long Term Plan ambitions.
Verbatim wording from the response “The LTP has a strong emphasis throughout on ensuring the provision of high quality, evidence-based mental health services which includes increased access to psychological therapies within the community based offer, as well as an increased focus on psychologically formed therapeutic interventions and care plan formulation through multi-disciplinary team approaches. There is planned investment ████████ to deliver the LTP ambitions, which includes increased Clinical Psychology provision across a range of services provided by NHT. The delivery of services is monitored by the CCG and the Transformation plan is reviewed by NHS England on a monthly basis. A Steering Group meets on a monthly basis to oversee the transformation of the Adult and Older Adult Community model. However, this has recently been impacted by the COVID-19 pandemic and will recommence in due course.” Source location 2020-0155-Response-from-Nottingham-and-Nottinghamshire-CCG_Redacted.pdf
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 Fund additional clinical psychology posts, alongside other posts, to increase community mental health team capacity and test new delivery models.
Verbatim wording from the response “The national requirement in 2019/20 and 2020/21 is to ‘stabilise and bolster’ core community mental health teams, increasing team capacity and appointment availability. In 2019/20 this included funding for additional Clinical Psychology posts alongside other posts (i.e. pharmacy technicians and administrative support) to support test new delivery models. The LTP is explicit on how community mental health teams need to be developed, with delivery milestones from 2019/20 to 2023/24 (appendix 1).” Source location 2020-0155-Response-from-Nottingham-and-Nottinghamshire-CCG_Redacted.pdf
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 healthcare trust determines the exact community mental health team staffing resource required under the agreed service specification.
Verbatim wording from the response “Currently, there is an agreed specification for community mental health teams which Healthcare NHS Trust use clinical judgement to determine the exact level of staffing resource required to deliver the aims, objectives and outcomes stipulated within the service specification.” Source location 2020-0155-Response-from-Bassetlaw-Clinical-Commissioning-Group_Redacted.pdf
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 agreed community mental health team specification and ongoing transformation programme are considered sufficient to address concerns about clinical psychology provision.
Verbatim wording from the response “The national requirement in 2019/20 and 2020/21 is to ‘stabilise and bolster’ core community mental health teams, increasing team capacity and appointment availability. In 2019/20 this included funding for additional Clinical Psychology posts alongside other posts (i.e. pharmacy technicians and administrative support) to support test new delivery models. The LTP is explicit on how community mental health teams need to be developed, with delivery milestones from 2019/20 to 2023/24 (appendix 1).” Source location 2020-0155-Response-from-Nottingham-and-Nottinghamshire-CCG_Redacted.pdf
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 Nottinghamshire Healthcare NHS Trust determines the staffing resource required to deliver the community mental health team specification.
Verbatim wording from the response “Currently, there is an agreed specification for community mental health teams which outlines the aims, objectives and outcomes for the service. Nottinghamshire Healthcare NHS Trust use clinical judgement to determine the exact level of staffing resource required to deliver the aims, objectives and outcomes stipulated within the service specification.” Source location 2020-0155-Response-from-Nottingham-and-Nottinghamshire-CCG_Redacted.pdf
Open published response
Concerns raised 5 Failure of the Paediatric team to recognise and act on sepsis red flag signs View source Failure to ensure Consultant Paediatrician involvement in Emergency Department disposition decisions for critically ill children View source Failure to support frank discussion and staff speaking up about deteriorating children View source Insufficient Paediatric staffing at Bassetlaw Hospital View source Lack of a face-to-face medical handover protocol View source See 2 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
James David Allbones · 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
James David Allbones, aged five, died from sepsis caused by Influenza B virus infection at Bassetlaw Hospital on 2 March 2016, after being admitted within 12 hours and having been unwell with cough and breathlessness. The report identified concerns that the seriousness of his condition and red-flag signs of sepsis were not recognised, sepsis fluid management was not given, Consultant management and review were limited, and he was not considered early for transfer to a hospital providing Paediatric Intensive Care. Further concerns included paediatric staffing, handover arrangements, and communication about deteriorating children.
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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of the Paediatric team to recognise and act on sepsis red flag signs
Wider context from the report “That the ‘red flag signs’ of sepsis will not be recognised and acted upon by the Paediatric team unless there is further training and awareness raising. I suggest The Paediatric Consultant team access external training and mentoring by senior colleagues ideally within their Critical Care network.
” 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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure Consultant Paediatrician involvement in Emergency Department disposition decisions for critically ill children
Wider context from the report “That a child as ill as James will again be moved from the Emergency Department to the ward or Assessment Unit at the Hospital, rather than being transferred out for ongoing care – there is no reassurance that a sick child will be seen by a Consultant Paediatrician in the Emergency Department to assist with this decision
” 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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to support frank discussion and staff speaking up about deteriorating children
Wider context from the report “that the Consultant team have rejected a model of care that encourages frank discussion with nursing and other staff on the ward , aimed at helping all staff speak up when worried about a deterioration child (the RCPCH SAFE model)
” 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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient Paediatric staffing at Bassetlaw Hospital
Wider context from the report “the level of Paediatric staffing at Bassetlaw Hospital . I understand there is often only one junior doctor available , and that the middle grade doctor is on duty for 24 hours .
” 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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a face-to-face medical handover protocol
Wider context from the report “that there is still no protocol for face to face medical handover
” Open source report
Concerns raised 1 Insufficient medical staffing for EIP patient access 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
Kate Dolby · 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
Kate Dolby was found dead at home on 9 October 2016, with the cause of death recorded as Propranolol toxicity; the inquest concluded that her death was suicide. The report identified delays and communication breakdowns in accessing Early Intervention in Psychosis services, with workload, waiting lists and insufficient medical staffing identified as substantive concerns.
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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient medical staffing for EIP patient access
Wider context from the report “At present, it is somewhat reassuring that most patients are being reviewed by care coordinators from an early stage, but it would appear there is an ongoing problem with having enough doctors to see these patients . The system appears to rely currently on care coordinators identifying those in urgent need and trying to arrange appointments for them, sometimes outside of usual clinical hours. This seems a somewhat precarious system, which relies to some extent on the goodwill of the clinicians themselves. The evidence I heard was that an independently commissioned report concluded that the service requires another full-time consultant in the EIP team . I am aware that recruitment in mental health services is often difficult and time-consuming, and therefore consider that the process for this should be considered without delay.
I was told that the CCG was to make a decision about a request for further funding shortly after the conclusion of the inquest. The trust requested funding for 6 more nurses and 1 full-time consultant.
It is clear that there is an ongoing need for more staff to deal with patients requiring the services of the EIP team. I asked the trust to advise me on the outcome of their funding request, and was subsequently advised ( by email from their legal advisor on 24.4.17) that, at present, funding has been agreed for 3 care-coordinators, an administrator, and 0.4 medic to support EIP access .
On the basis of this information, I remain concerned, particularly about funding for further medics, in this team , and have elected to formalise these concerns in a Regulation 28 Report.
There were undoubtedly failings and communication breakdowns contributing to the delay in Kate’s case. However I find that the most significant factor in the delay was the workload and waiting list . This was the key cause, certainly from 3 June 2016 onwards, which is very much the bigger part of the delay in this case. The trust has addressed most of these issues and I therefore see no benefit in addressing this report to Nottinghamshire Healthcare NHS Foundation Trust as well. The key area of outstanding concern relates to funding.
” Open source report
Concerns raised 4 Lack of a reliable system to identify children de-registered from a General Practice View source Lack of a legal requirement to register or re-register children with a General Practitioner View source Failure to ensure a new General Practitioner is identified and notified before a child is de-registered View source Failure to directly inform paediatric and physiotherapy services of a child's de-registration View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Harry George Mellor · 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
Harry George Mellor, a child with chronic health needs, collapsed unexpectedly on 28 October 2014 and died shortly after arriving at the emergency department. The inquest recorded that he had died from pyelonephritis. Concerns included the lack of a reliable system to identify when a child was de-registered from a GP, potential safeguarding risks when no new GP had been identified, and the paediatric and physiotherapy teams not being informed of the de-registration.
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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a reliable system to identify children de-registered from a General Practice
Wider context from the report “2. There is no reliable system in place to identify when a child has been de-registered from a General Practice
” 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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a legal requirement to register or re-register children with a General Practitioner
Wider context from the report “1. There is no legal requirement to register or re-register a child with a General Practitioner
” 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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure a new General Practitioner is identified and notified before a child is de-registered
Wider context from the report “3. There are potential safeguarding concerns if a General Practitioner can de-register a child , particularly a child with chronic health needs, before a new General Practitioner has been identified and notified of the proposed de-registration
” 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 Nottingham and Nottinghamshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to directly inform paediatric and physiotherapy services of a child's de-registration
Wider context from the report “4. The paediatric team and physiotherapy services were not directly informed that Harry was going to be de-registered or had been de-registered
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission an independent review of GP involvement and the circumstances of GP deregistration in the case.
Verbatim wording from the response “The CCG is aware of this case through representation on the Nottinghamshire Safeguarding Children Board (NSCB) Serious Incident Review Panel which is currently considering this case as part of a multi-agency serious case review. As commissioners of health services we will be appointing an independent author to undertake a review into the GP involvement in the case to ensure that any resulting lessons learned for health organisations arising from this review are implemented.” Source location CCG-Response
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 Request that GP registration and deregistration issues are included in the serious case review terms of reference.
Verbatim wording from the response “1. There is no legal requirement to register or re-register a child with a General Practitioner
The legislative framework is outside the remit of the CCG but we support your request to the Secretary of State regarding this matter. The principle of Parental Responsibility requires parents to make decisions in the best interests of children. In this case, this principle did not result in the best outcome for the child. We will request that this aspect is considered as part of the terms of reference for the NSCB serious case review” Source location CCG-Response
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 legislative framework governing child GP registration is outside the CCG’s remit.
Verbatim wording from the response “1. There is no legal requirement to register or re-register a child with a General Practitioner
The legislative framework is outside the remit of the CCG but we support your request to the Secretary of State regarding this matter. The principle of Parental Responsibility requires parents to make decisions in the best interests of children. In this case, this principle did not result in the best outcome for the child. We will request that this aspect is considered as part of the terms of reference for the NSCB serious case review” Source location CCG-Response
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 Existing attendance checks and revised paediatric pathways locally mitigate the risk of children lacking appropriate primary care.
Verbatim wording from the response “In the meantime this risk is mitigated locally by the following arrangements: -” Source location CCG-Response
Open published response
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Request correction
Addressed to NHS Nottingham and Nottinghamshire Clinical Commissioning Group, now represented here by NHS Nottingham and Nottinghamshire Integrated Care Board.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations