NHS South East London Integrated Care Board

Health and care · Integrated care board

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First report 23 Aug 2013•Latest report 18 Sep 2025

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
6

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

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

  1. East London

    AI-generated summary

    Kwabena Amoateng · 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

    Kwabena Amoateng, a 17-year-old boy with congenital central hypoventilation syndrome, became ill on 16 September 2024 and died in hospital on 23 September 2024 after developing severe respiratory complications. A Paediatric Respiratory Action Plan for his condition was mislabelled and misfiled, so it was unavailable to emergency healthcare professionals assessing him. The report identified the absence of a coordinated process for producing and storing such documents in online clinical records as a substantive concern.

    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 South East London Integrated Care Board; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure prominent and accurate filing of critical respiratory action plans in online clinical records

    Wider context from the report

    “1. The inquest found that a critically important document had been produced by his specialist respiratory doctors to assist emergency healthcare professionals in understanding his rare and potentially dangerous condition - CCHS. The document, A Paediatric Respiratory Action Plan (‘PRAP’) set out the necessary steps to be considered should Kwabena fall ill. 2. During Kwabena’s final illness, those assessing him from 16ᵗʰ-21ˢᵗ September 2024 were unaware of this vital document as it had been mislabelled and misfiled within the online records available to them. 3. Had the PRAP been more prominently filed it is likely that those assessing Kwabena would have escalated his treatment to admission to hospital far earlier, which may have resulted in Kwabena’s life being saved. 4. An investigation into why the PRAP was not visible to emergency services in this case has highlighted that there is no coordinated process to ensure a consistent approach in producing and storing such documents in online clinical records. ”
    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 South East London Integrated Care Board; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a coordinated process for producing and storing critical respiratory action plans in online clinical records

    Wider context from the report

    “1. The inquest found that a critically important document had been produced by his specialist respiratory doctors to assist emergency healthcare professionals in understanding his rare and potentially dangerous condition - CCHS. The document, A Paediatric Respiratory Action Plan (‘PRAP’) set out the necessary steps to be considered should Kwabena fall ill. 2. During Kwabena’s final illness, those assessing him from 16ᵗʰ-21ˢᵗ September 2024 were unaware of this vital document as it had been mislabelled and misfiled within the online records available to them. 3. Had the PRAP been more prominently filed it is likely that those assessing Kwabena would have escalated his treatment to admission to hospital far earlier, which may have resulted in Kwabena’s life being saved. 4. An investigation into why the PRAP was not visible to emergency services in this case has highlighted that there is no coordinated process to ensure a consistent approach in producing and storing such documents in online clinical records. ”
    Open source report

  2. Outer South London

    AI-generated summary

    Emily Rose Collishaw · 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

    Emily Rose Collishaw, who was aged 35, was found dead in her flat on 6 September 2023 in non-suspicious circumstances. She had alcohol dependency and had been receiving mental health and substance misuse support, but was awaiting an inpatient rehabilitation placement. Concerns included delays and insufficient coordination and support, particularly the prolonged wait for residential rehabilitation and the associated risks to patients.

    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 South East London Integrated Care Board; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in organizations agreeing their roles

    Wider context from the report

    “1. Emily’s mother reported that it took some time for the organizations working with her daughter to agree their roles and that the degree of support was insufficient to maintain her physical health or promote abstinence over such a long period of six months before she died. The family felt that the referral for residential care should have been made earlier, especially as her housing situation was a risk to her health. It was accepted that Emily did not engage consistently but did reduce intake on a number of occasions, only to relapse. 2. The inquest heard from professionals that the period of waiting for a residential rehabilitation placement was about three months, but could be as long as seven months. Evidence was heard from the manager of the Pier Project that the delay in accessing residential care had been progressively getting longer over the last 10 years, which posed risks such as sudden death to patients. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS South East London Integrated Care Board; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient support to maintain physical health and promote abstinence

    Wider context from the report

    “1. Emily’s mother reported that it took some time for the organizations working with her daughter to agree their roles and that the degree of support was insufficient to maintain her physical health or promote abstinence over such a long period of six months before she died. The family felt that the referral for residential care should have been made earlier, especially as her housing situation was a risk to her health. It was accepted that Emily did not engage consistently but did reduce intake on a number of occasions, only to relapse. 2. The inquest heard from professionals that the period of waiting for a residential rehabilitation placement was about three months, but could be as long as seven months. Evidence was heard from the manager of the Pier Project that the delay in accessing residential care had been progressively getting longer over the last 10 years, which posed risks such as sudden death to patients. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS South East London Integrated Care Board; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in accessing residential rehabilitation care

    Wider context from the report

    “1. Emily’s mother reported that it took some time for the organizations working with her daughter to agree their roles and that the degree of support was insufficient to maintain her physical health or promote abstinence over such a long period of six months before she died. The family felt that the referral for residential care should have been made earlier, especially as her housing situation was a risk to her health. It was accepted that Emily did not engage consistently but did reduce intake on a number of occasions, only to relapse. 2. The inquest heard from professionals that the period of waiting for a residential rehabilitation placement was about three months, but could be as long as seven months. Evidence was heard from the manager of the Pier Project that the delay in accessing residential care had been progressively getting longer over the last 10 years, which posed risks such as sudden death to patients. ”
    Open source report

  3. Addressed to NHS Bromley Clinical Commissioning Group, now represented here by NHS South East London Integrated Care Board.

    South London

    AI-generated summary

    Francesca Margaux Sio · 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

    Francesca Margaux Sio died from a massive pulmonary tumour embolism caused by a previously undiagnosed sacro-coccygeal yolk sac tumour. Three days before her death, she waited nearly four hours for a doctor at an urgent care centre before being referred to the paediatric accident and emergency department. Expert evidence raised concern that mixing adult and child patients in urgent care centres risked children deteriorating unnoticed.

    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 South East London Integrated Care Board; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to separate adult and child patients in urgent care centres

    Wider context from the report

    “Three days before she died, Francesca attended the urgent care centre in the grounds of Princess Royal University Hospital run by Greenbrook Healthcare. She waited nearly 4 hours to be assessed by a doctor and was then referred appropriately to the paediatric accident emergency department in the hospital. I heard unchallenged expert evidence during the hearing that mixing adult and child patients in urgent care centres risked children quietly deteriorating unnoticed. ”
    Open source report

  4. Addressed to NHS Lewisham Clinical Commissioning Group, now represented here by NHS South East London Integrated Care Board.

    London Inner (South)

    AI-generated summary

    DAPHNE MCCORKLE · 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

    Daphne McCorkle was discharged from hospital with a Grade 2 pressure sore, which deteriorated while she was receiving community care. She died in hospital on 20 November 2014 from sepsis caused by the infected pressure sore. Concerns included the frequency and quality of District Nurse visits and assessments, inadequate care-plan reviews and documentation, delayed referral to a Tissue Viability Nurse, lack of advice about night-time turning, and a gap in night-time care provision.

    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 South East London Integrated Care Board; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of nighttime care provision for patients requiring regular turning

    Wider context from the report

    “(1) On the expert evidence, there will be cases where a patient should be turned every 2/3 hours, even at night, to ensure that the risk of pressure sores being caused or worsened is properly managed. (2) In some cases where this level of turning is required, family members will not be able to perform that task. (3) However I was informed during the inquest that Lewisham District Nurses (for whom I understand the NHS Lewisham Clinical Commissioning Group is responsible) will not visit patients at home at night. (4) I was also informed that agency carers (whose care I understand is commissioned by the London Borough of Lewisham, Adult Social Care Department) will not visit at night either. (5) This leaves a gap in provision for some patients and is a concern. ”
    Open source report

  5. Addressed to NHS Bromley Clinical Commissioning Group, now represented here by NHS South East London Integrated Care Board.

    Inner South London

    AI-generated summary

    Jacqueline Allwood · 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

    Jacqueline Allwood attended a GP with several days of calf pain and concern about a family history of thrombosis. She was not referred to hospital to exclude DVT and later died from pulmonary thromboembolism secondary to DVT. Concerns included whether registration, assessment and referral processes supported early diagnosis and referral, and whether the consulting GP understood and followed appropriate standards for history-taking and examination.

    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 South East London Integrated Care Board; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of registration, assessment and referral documentation and consultation records to facilitate early diagnosis of DVT and low-threshold referral to A&E

    Wider context from the report

    “(1) The registration, assessment and referral forms and consultation records of and between the Urgent Care Centre and Cator Medical Practice may not facilitate the early diagnosis of DVT and the need for a low threshold of referral to A&E. ”
    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 South East London Integrated Care Board; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to make changes to reduce risks of harm to patients

    Wider context from the report

    “(2). Taking as a whole the evidence of the consulting GP, Dr Adlakha, it cannot be said that the public can be assured that he understands and accepts normative standards of practice with respect to history and examination and that he has made or will make changes in order to reduce risks of harm to patients. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS South East London Integrated Care Board; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of assurance that the consulting GP understands and accepts normative standards of practice for history and examination

    Wider context from the report

    “(2). Taking as a whole the evidence of the consulting GP, Dr Adlakha, it cannot be said that the public can be assured that he understands and accepts normative standards of practice with respect to history and examination and that he has made or will make changes in order to reduce risks of harm to patients. ”
    Open source report

  6. Addressed to NHS Lewisham Clinical Commissioning Group, now represented here by NHS South East London Integrated Care Board.

    Inner South London

    AI-generated summary

    Luna Lesko · 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

    Baby Luna Lesko died after being found collapsed with no respirations following an airway occlusion, inadequate required observations and a prolonged period of hypoxia, despite resuscitation and intensive care. The report raised concerns about delays in cardiotocograph monitoring and delivery by caesarean section, including insufficient out-of-hours theatre capacity and a potential risk to future babies.

    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 South East London Integrated Care Board; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient out-of-hours obstetric theatre capacity

    Wider context from the report

    “(2) LSCS was required for the baby, due to lack of progression despite augmentation, adverse position and prolonged rupture of membranes with meconium. The decision was taken at 20.00 hours, but delivery was not possible until 21.40 hours, as theatres were busy. This delay of 1 hour 40 minutes for a category 2 section was 40 minutes outside the Trust’s own guidelines. (3) The consultant obstetrician reported that this delay, which occurred out of hours, in a unit with over 4000 births per year was unacceptable. It worsens the potential impact, carrying a higher risk of brain damage or death of babies, if there were several emergencies at one time. Staff were reluctant to use the second out of hours (non obstetric) theatre as they cannot then respond to a category 1 emergency. My expert obstetric witness, ████████ of Kings College Hospital, gave an opinion that the out of hours theatre access created a real risk of preventable death, especially with the increasing rate of performing LSCS. He advised me that I should be concerned and bring the matter to the attention of the Trust. (4) Whilst the Head of Midwifery reported management changes and compliance with CNST assessment, she did not provide assurance that the theatre capacity had been increased out of hours. Furthermore it was reported that the Trust is shortly to be disbanded and a new Trust is being formed by merger with another. This may lead to service configuration changes. She reported that the future obstetric services were under review. (5) I concluded that a real risk existed that I should report to the Trust and the commissioning body, to ensure that it was fully appreciated and given appropriate priority in the service reconfiguration planning. ”
    Open source report
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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