8 May 2026 Jake Daniel Taylor · Prevention of Future Deaths report West London
View report summary
Concerns raised 6 Lack of airway equipment View source Lack of airway training for staff View source Unavailability of a defibrillator on site View source Lack of individual emergency planning for service users with high-tier needs and life-threatening risk profiles View source Staff misunderstanding of defibrillator function View source Inadequate staff training to conduct CPR unless a contrary decision exists View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jake Daniel Taylor · 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 Daniel Taylor, aged 19, suffered a cardiac arrest at his care home on 16 January 2025 and died in Kingston hospital on 20 January 2025. The report identified delays in first aid and concerns about the lack of individual emergency planning, staff training, immediately available equipment, and airway training and equipment.
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 West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of airway equipment
Wider context from the report “No planning for this foreseeable emergency.
Inadequate staff training (to always conduct CPR if no decision to the contrary)
No defibrillator on site and staff misunderstanding of the function of a defibrillator.
No airway training and equipment although Registered Nursing staff have this within their competencies .
I consider that individual emergency planning for those service users with recognised high tier needs and life-threatening risk profiles is essential to ensure best possible outcomes and care tailored to their needs. Medical emergencies in this cohort of patients are predictable but are likely to happen suddenly and unexpectedly. In this case the staff were not able to respond and their evidence to the court demonstrated that they felt unprepared and uncertain about what to do.
This is a situation that could be replicated throughout the services that care for individuals such as Jake. Those commissioning the services should consider if the individual emergency care planning is comprehensive and complete and reviewed where appropriate.
” 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 West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of airway training for staff
Wider context from the report “No planning for this foreseeable emergency.
Inadequate staff training (to always conduct CPR if no decision to the contrary)
No defibrillator on site and staff misunderstanding of the function of a defibrillator.
No airway training and equipment although Registered Nursing staff have this within their competencies.
I consider that individual emergency planning for those service users with recognised high tier needs and life-threatening risk profiles is essential to ensure best possible outcomes and care tailored to their needs. Medical emergencies in this cohort of patients are predictable but are likely to happen suddenly and unexpectedly. In this case the staff were not able to respond and their evidence to the court demonstrated that they felt unprepared and uncertain about what to do.
This is a situation that could be replicated throughout the services that care for individuals such as Jake. Those commissioning the services should consider if the individual emergency care planning is comprehensive and complete and reviewed where appropriate.
” 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 West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a defibrillator on site
Wider context from the report “No planning for this foreseeable emergency.
Inadequate staff training (to always conduct CPR if no decision to the contrary)
No defibrillator on site and staff misunderstanding of the function of a defibrillator.
No airway training and equipment although Registered Nursing staff have this within their competencies.
I consider that individual emergency planning for those service users with recognised high tier needs and life-threatening risk profiles is essential to ensure best possible outcomes and care tailored to their needs. Medical emergencies in this cohort of patients are predictable but are likely to happen suddenly and unexpectedly. In this case the staff were not able to respond and their evidence to the court demonstrated that they felt unprepared and uncertain about what to do.
This is a situation that could be replicated throughout the services that care for individuals such as Jake. Those commissioning the services should consider if the individual emergency care planning is comprehensive and complete and reviewed where appropriate.
” 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 West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of individual emergency planning for service users with high-tier needs and life-threatening risk profiles
Wider context from the report “No planning for this foreseeable emergency.
Inadequate staff training (to always conduct CPR if no decision to the contrary)
No defibrillator on site and staff misunderstanding of the function of a defibrillator.
No airway training and equipment although Registered Nursing staff have this within their competencies.
I consider that individual emergency planning for those service users with recognised high tier needs and life-threatening risk profiles is essential to ensure best possible outcomes and care tailored to their needs. Medical emergencies in this cohort of patients are predictable but are likely to happen suddenly and unexpectedly. In this case the staff were not able to respond and their evidence to the court demonstrated that they felt unprepared and uncertain about what to do.
This is a situation that could be replicated throughout the services that care for individuals such as Jake. Those commissioning the services should consider if the individual emergency care planning is comprehensive and complete and reviewed where appropriate .
” 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 West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Staff misunderstanding of defibrillator function
Wider context from the report “No planning for this foreseeable emergency.
Inadequate staff training (to always conduct CPR if no decision to the contrary)
No defibrillator on site and staff misunderstanding of the function of a defibrillator .
No airway training and equipment although Registered Nursing staff have this within their competencies.
I consider that individual emergency planning for those service users with recognised high tier needs and life-threatening risk profiles is essential to ensure best possible outcomes and care tailored to their needs. Medical emergencies in this cohort of patients are predictable but are likely to happen suddenly and unexpectedly. In this case the staff were not able to respond and their evidence to the court demonstrated that they felt unprepared and uncertain about what to do.
This is a situation that could be replicated throughout the services that care for individuals such as Jake. Those commissioning the services should consider if the individual emergency care planning is comprehensive and complete and reviewed where appropriate.
” 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 West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate staff training to conduct CPR unless a contrary decision exists
Wider context from the report “No planning for this foreseeable emergency.
Inadequate staff training (to always conduct CPR if no decision to the contrary)
No defibrillator on site and staff misunderstanding of the function of a defibrillator.
No airway training and equipment although Registered Nursing staff have this within their competencies.
I consider that individual emergency planning for those service users with recognised high tier needs and life-threatening risk profiles is essential to ensure best possible outcomes and care tailored to their needs. Medical emergencies in this cohort of patients are predictable but are likely to happen suddenly and unexpectedly. In this case the staff were not able to respond and their evidence to the court demonstrated that they felt unprepared and uncertain about what to do.
This is a situation that could be replicated throughout the services that care for individuals such as Jake. Those commissioning the services should consider if the individual emergency care planning is comprehensive and complete and reviewed where appropriate.
” 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 Create and distribute an additional assurance checklist to identified commissioned providers.
Verbatim wording from the response “▪ Created the following additional assurance checklist to be shared with identified providers as a priority (this is still ongoing)” Source location Response from NHS South West London ICB
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require providers to strengthen life-support training, resuscitation knowledge, competency assessment and auditable compliance records.
Verbatim wording from the response “b. Resuscitation Training and Understanding of CPR Requirements
All commissioned providers will be required to:” Source location Response from NHS South West London ICB
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require providers to review airway needs, maintain appropriate nursing competencies, and provide airway equipment and training where clinically indicated.
Verbatim wording from the response “d. Airway Management Training and Equipment
All commissioned providers to:” Source location Response from NHS South West London ICB
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtain provider assurance on emergency preparedness, equipment availability and staff training.
Verbatim wording from the response “Following Jake’s tragic death and receipt of your report, the ICB took immediate action, including obtaining comprehensive assurance from the provider regarding emergency preparedness arrangements, the availability of emergency equipment, and staff training. A summary of the assurance received from the provider is set out in Section A of Appendix 1.” Source location Response from NHS South West London ICB
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require providers to review emergency preparedness and implement individualised, current emergency response plans for high-risk service users.
Verbatim wording from the response “All commissioned providers supporting individuals with identified high-risk health conditions to undertake a review of their emergency preparedness arrangements. This will include:” Source location Response from NHS South West London ICB
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require providers to assess AED need and provide, maintain and govern AED equipment with appropriate staff training.
Verbatim wording from the response “c. Availability and Use of Defibrillators
All commissioned providers will be required to:” Source location Response from NHS South West London ICB
Open published response
4 Aug 2025 Tracey Ostler · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 13 Unclear legal authority for preventing psychiatric patients leaving the emergency department View source Unavailability of appropriately trained mental health nurses for acute psychiatric patients View source Unclear ultimate clinical responsibility for psychiatric patients in the emergency department View source Compromised emergency department capacity to meet physically ill patients' needs View source Failure to provide appropriate multidisciplinary psychiatric ward-based care View source Lack of psychiatric hospital beds resulting in prolonged emergency department detention View source Failure to undertake thorough mental capacity assessments for life-threatening treatment decisions View source Failure to provide lawful Mental Health Act detention safeguards and Responsible Clinician oversight View source Inadequate paramedic training for mental capacity assessments View source Inadequate and unavailable protocol for capacity assessments in life-threatening circumstances View source Lack of a system for joint ambulance and mental health emergency plans View source Failure to provide frontline paramedics with vital mental health risk and capacity information View source Unsuitable emergency department environment for psychiatric patients View source See 10 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.
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AI-generated summary
Tracey Ostler · 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
Tracey Ostler, who had severe Emotionally Unstable Personality Disorder and a history of self-harm and overdoses, took an overdose and cut her wrists on 12 June 2023. After paramedics attended her home on 16 June following a further overdose, they left her there after deciding she had capacity to refuse hospital treatment; she was later found unconscious and died in hospital on 18 June 2023. The principal concerns were inadequate capacity assessment and clinical consultation, failures to share information and coordinate mental-health and ambulance care, the absence of multi-agency safety planning, and insufficient psychiatric hospital beds.
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 West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unclear legal authority for preventing psychiatric patients leaving the emergency department
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS South West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of appropriately trained mental health nurses for acute psychiatric patients
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them . This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients .
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS South West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unclear ultimate clinical responsibility for psychiatric patients in the emergency department
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS South West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Compromised emergency department capacity to meet physically ill patients' needs
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS South West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate multidisciplinary psychiatric ward-based care
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team .
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS South West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of psychiatric hospital beds resulting in prolonged emergency department detention
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds . The longest wait by such a patient in these circumstances has been 6 weeks . There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed .
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS South West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake thorough mental capacity assessments for life-threatening treatment decisions
Wider context from the report “Training for Paramedics to undertake Capacity Assessments.
Addressed to the Health and Care Professionals Council and South East Coast Ambulance Service
3. I found that the paramedics who attended Ms Ostler on the 16th June 2023, and assessed her capacity to refuse lifesaving treatment after taking a serious paracetamol overdose, failed to undertake a thorough capacity assessment . In particular, they failed to assess adequately whether she had the ability to weigh up the information being given to her .
4. Ms Ostler was recorded in written evidence provided by the more senior attending paramedic who attended as saying that she would not discuss why she wanted to die. A more senior paramedic, who reviewed that evidence for the purposes of the inquest, regarded the written evidence as demonstrating that the capacity assessment had been undertaken appropriately.
5. Neither the attending paramedic nor the reviewing paramedic appreciated that unless the patient was able to tell them why she had decided that she wanted to die, that she had not demonstrated to them how she had weighed up the information available to her. Therefore, a full capacity assessment could not be completed.
6. I am concerned that the training they had received, both whilst students and subsequently, had not been adequate to equip them to undertake adequate capacity assessments.
” 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 West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide lawful Mental Health Act detention safeguards and Responsible Clinician oversight
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department . There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983 . In addition, they do not have a Responsible Clinician .
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS South West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate paramedic training for mental capacity assessments
Wider context from the report “Training for Paramedics to undertake Capacity Assessments.
Addressed to the Health and Care Professionals Council and South East Coast Ambulance Service
3. I found that the paramedics who attended Ms Ostler on the 16th June 2023, and assessed her capacity to refuse lifesaving treatment after taking a serious paracetamol overdose, failed to undertake a thorough capacity assessment. In particular, they failed to assess adequately whether she had the ability to weigh up the information being given to her.
4. Ms Ostler was recorded in written evidence provided by the more senior attending paramedic who attended as saying that she would not discuss why she wanted to die. A more senior paramedic, who reviewed that evidence for the purposes of the inquest, regarded the written evidence as demonstrating that the capacity assessment had been undertaken appropriately.
5. Neither the attending paramedic nor the reviewing paramedic appreciated that unless the patient was able to tell them why she had decided that she wanted to die, that she had not demonstrated to them how she had weighed up the information available to her. Therefore, a full capacity assessment could not be completed.
6. I am concerned that the training they had received, both whilst students and subsequently, had not been adequate to equip them to undertake adequate capacity assessments.
” 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 West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate and unavailable protocol for capacity assessments in life-threatening circumstances
Wider context from the report “South East Coast Ambulance Service’s protocol on undertaking capacity assessments in relation to life threatening decisions.
Addressed to the South East Coast Ambulance Service
7. The Trusts policy on Mental Capacity is being reviewed to improve articulation of how to assess mental capacity in life threatening circumstances. It is not yet available . I regarded the current policy as inadequate and remain concerned about this because I have not been able to review the revised document.
” 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 West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for joint ambulance and mental health emergency plans
Wider context from the report “Multi Agency Safeguarding Plans
Addressed to the Surrey and Borders Partnership Trust and South East Coast Ambulance Service
8. Ms Ostler suffered from a severe Emotionally Unstable Personality Disorder, this was a longstanding diagnosis, and the effects were well known to her mental health team. She was placed in the community on a Positive Risk Taking Plan. She presented a continuous and serious risk to herself in the community and was prone to impulsive acts of self harm. Ambulances were frequently required to attend her home after such acts. The disorder impacted her ability to make capacious decisions about her own care.
9. The independent expert consultant psychiatrist called at the inquest regarded it as good practice in these circumstances to have a joint plan in place, including liaison between the ambulance service and mental health teams, for dealing with emergencies .
10. No system currently exists in Surrey to create such plans.
11. The paramedics who attended Ms Ostler on the 16th June 2023 did not know she had a diagnosis of Emotionally Unstable Personality Disorder, nor that this such a diagnosis would be likely to affect her decision-making capacity because it made her more prone to be volatile and impulsive.
12. The psychiatric evidence was that she would be likely to lack capacity.
13. Paramedics assessing her lacked this vital information. In consequence, she was left at home to die.
14. I have not been provided with any Protocol between the services to ensure safety planning in these circumstances that would ensure that front line paramedics are made aware that they are dealing with a seriously unwell mental health patients who is at high risk living in the community.
15. I therefore remain concerned that such a death could occur again.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS South West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide frontline paramedics with vital mental health risk and capacity information
Wider context from the report “Multi Agency Safeguarding Plans
Addressed to the Surrey and Borders Partnership Trust and South East Coast Ambulance Service
8. Ms Ostler suffered from a severe Emotionally Unstable Personality Disorder, this was a longstanding diagnosis, and the effects were well known to her mental health team. She was placed in the community on a Positive Risk Taking Plan. She presented a continuous and serious risk to herself in the community and was prone to impulsive acts of self harm. Ambulances were frequently required to attend her home after such acts. The disorder impacted her ability to make capacious decisions about her own care.
9. The independent expert consultant psychiatrist called at the inquest regarded it as good practice in these circumstances to have a joint plan in place, including liaison between the ambulance service and mental health teams, for dealing with emergencies.
10. No system currently exists in Surrey to create such plans.
11. The paramedics who attended Ms Ostler on the 16th June 2023 did not know she had a diagnosis of Emotionally Unstable Personality Disorder , nor that this such a diagnosis would be likely to affect her decision-making capacity because it made her more prone to be volatile and impulsive.
12. The psychiatric evidence was that she would be likely to lack capacity.
13. Paramedics assessing her lacked this vital information. In consequence, she was left at home to die.
14. I have not been provided with any Protocol between the services to ensure safety planning in these circumstances that would ensure that front line paramedics are made aware that they are dealing with a seriously unwell mental health patients who is at high risk living in the community.
15. I therefore remain concerned that such a death could occur again.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS South West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unsuitable emergency department environment for psychiatric patients
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” Open source report
11 Jun 2024 Juan David Martin · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 1 Inadequate mental health bed capacity in London View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Juan David Martin · 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
Juan David Martin, who had been detained under the Mental Health Act and was awaiting an appropriate mental health bed, was evacuated from a hospital assessment suite during a fire alarm and ran away. He was later witnessed allowing himself to fall from height and was confirmed deceased on 13 April 2022. The principal concern was that inadequate mental health bed capacity in London created a genuine risk of 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 South West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate mental health bed capacity in London
Wider context from the report “(1) Juan Martin was held informally on 7 April 2022 and following a mental health assessment on 11 April subsequently became liable for detention. He therefore spent 6 days in the Lotus Assessment Suite. Witnesses confirmed that no suitable bed was identified until approximately after 15:00 on 12 April 2022, which then became unavailable.
(2) The Matron in Acute and Urgent Care confirmed bed capacity remains an ongoing problem and has not been resolved . The Matron provided one recent example where a patient waited for 7 days in the Accident and Emergency Department for a mental health bed .
(3) The Matron added there was an exceptional process which required a considered decision at a high level to make a bed available through identifying someone currently occupying a bed space to be discharged and that the ‘flow’ of patients being discharged or moving to another setting amplified the bed capacity issue.
Based on the evidence heard, my principal concern is that bed capacity in London remains inadequate . Whilst some action may have been taken by the Trust to better triage the need for beds it is insufficient to resolve the problem . It follows there is a genuine risk of future deaths directly connected to a shortage of mental health bed spaces in London unless further action is taken.
” 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 Invest in commissioning additional private-sector mental-health beds to mitigate current bed pressures while longer-term patient-flow work continues.
Verbatim wording from the response “The ICB is working with SWLSTG and other healthcare providers in South West London to address situations where patients experience delay in all parts of the care pathway. This includes work focused on reducing length of stay and minimising the use of out of area placements. As part of the 2024/25 planning process, ongoing investment was made into commissioning additional beds in the private sector to mitigate the current bed pressures while longer term work on improved patient flow continues.” Source location Response from SW London ICB
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed a clinical prioritisation tool in acute-flow management to prioritise patient safety when allocating limited beds.
Verbatim wording from the response “- Revised and strengthened our Bed Management Policy, including additional actions at higher levels of escalation, and moved to real-time electronic bed status and waiting list management.
- Embedded a clinical prioritisation tool into our acute flow management process to ensure that patient safety and risk is foremost in allocating limited bed capacity. This tool has subsequently formed the basis of a London-wide prioritisation scoring tool commissioned by NHSE London and to be adopted by all mental health trusts in 2024.
- Commissioned additional, unfunded private sector acute mental health beds from a local provider, and stepdown hostel beds to support flow.
- Invested significantly into community and crisis prevention services to support patients to remain well in the community and avoid the need for an acute admission, thus helping to also provide more available beds.” Source location Response from SW London ICB
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 Implement discharge-planning best practices, including the 100-day challenge, high-impact interventions and ward workflow improvements.
Verbatim wording from the response “As part of our integrated transformation programme, we have implemented a range of projects aimed to improve acute mental health patient flow and bed access, including:” Source location Response from SW London ICB
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 Conduct collaborative discharge and patient-flow work with local-authority partners through the Strategic Operational Interface Programme.
Verbatim wording from the response “As part of our integrated transformation programme, we have implemented a range of projects aimed to improve acute mental health patient flow and bed access, including:” Source location Response from SW London ICB
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 Invest in community and crisis-prevention services to help patients remain well and avoid acute admission.
Verbatim wording from the response “- Revised and strengthened our Bed Management Policy, including additional actions at higher levels of escalation, and moved to real-time electronic bed status and waiting list management.
- Embedded a clinical prioritisation tool into our acute flow management process to ensure that patient safety and risk is foremost in allocating limited bed capacity. This tool has subsequently formed the basis of a London-wide prioritisation scoring tool commissioned by NHSE London and to be adopted by all mental health trusts in 2024.
- Commissioned additional, unfunded private sector acute mental health beds from a local provider, and stepdown hostel beds to support flow.
- Invested significantly into community and crisis prevention services to support patients to remain well in the community and avoid the need for an acute admission, thus helping to also provide more available beds.” Source location Response from SW London ICB
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 Provide intensive support to acute ward teams to identify flow barriers and improve safe, timely discharge practices.
Verbatim wording from the response “Despite this, we appreciate there is still a risk around patients awaiting admission due to the lack of beds and we are undertaking further work in the following areas:” Source location Response from SW London ICB
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 Commission additional private-sector acute mental-health beds from a local provider.
Verbatim wording from the response “- Revised and strengthened our Bed Management Policy, including additional actions at higher levels of escalation, and moved to real-time electronic bed status and waiting list management.
- Embedded a clinical prioritisation tool into our acute flow management process to ensure that patient safety and risk is foremost in allocating limited bed capacity. This tool has subsequently formed the basis of a London-wide prioritisation scoring tool commissioned by NHSE London and to be adopted by all mental health trusts in 2024.
- Commissioned additional, unfunded private sector acute mental health beds from a local provider, and stepdown hostel beds to support flow.
- Invested significantly into community and crisis prevention services to support patients to remain well in the community and avoid the need for an acute admission, thus helping to also provide more available beds.” Source location Response from SW London ICB
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 Strengthen the Bed Management Policy and implement real-time electronic bed-status and waiting-list management.
Verbatim wording from the response “- Revised and strengthened our Bed Management Policy, including additional actions at higher levels of escalation, and moved to real-time electronic bed status and waiting list management.
- Embedded a clinical prioritisation tool into our acute flow management process to ensure that patient safety and risk is foremost in allocating limited bed capacity. This tool has subsequently formed the basis of a London-wide prioritisation scoring tool commissioned by NHSE London and to be adopted by all mental health trusts in 2024.
- Commissioned additional, unfunded private sector acute mental health beds from a local provider, and stepdown hostel beds to support flow.
- Invested significantly into community and crisis prevention services to support patients to remain well in the community and avoid the need for an acute admission, thus helping to also provide more available beds.” Source location Response from SW London ICB
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 Work with healthcare providers to reduce care-pathway delays, shorten stays and minimise out-of-area placements.
Verbatim wording from the response “The ICB is working with SWLSTG and other healthcare providers in South West London to address situations where patients experience delay in all parts of the care pathway. This includes work focused on reducing length of stay and minimising the use of out of area placements. As part of the 2024/25 planning process, ongoing investment was made into commissioning additional beds in the private sector to mitigate the current bed pressures while longer term work on improved patient flow continues.” Source location Response from SW London ICB
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 Transform the mental-health crisis offer by developing triage and rapid-access services for local emergency departments.
Verbatim wording from the response “Despite this, we appreciate there is still a risk around patients awaiting admission due to the lack of beds and we are undertaking further work in the following areas:” Source location Response from SW London ICB
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 rehabilitation and supported-living settings with partners to improve access to onward care.
Verbatim wording from the response “Despite this, we appreciate there is still a risk around patients awaiting admission due to the lack of beds and we are undertaking further work in the following areas:” Source location Response from SW London ICB
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 Commission stepdown hostel beds to support patient flow.
Verbatim wording from the response “- Revised and strengthened our Bed Management Policy, including additional actions at higher levels of escalation, and moved to real-time electronic bed status and waiting list management.
- Embedded a clinical prioritisation tool into our acute flow management process to ensure that patient safety and risk is foremost in allocating limited bed capacity. This tool has subsequently formed the basis of a London-wide prioritisation scoring tool commissioned by NHSE London and to be adopted by all mental health trusts in 2024.
- Commissioned additional, unfunded private sector acute mental health beds from a local provider, and stepdown hostel beds to support flow.
- Invested significantly into community and crisis prevention services to support patients to remain well in the community and avoid the need for an acute admission, thus helping to also provide more available beds.” Source location Response from SW London ICB
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 Full resolution of London’s acute mental health bed shortage is constrained by rising demand and limitations in funding and resources.
Verbatim wording from the response “SWLStG recognises this as a key risk to patient safety, which is fully captured and articulated within our Board Assurance Framework, and we are working to mitigate the risk as far as possible. We note, as has the Coroner, that this is not fully within our control due to the increasing complexity and level of demand for acute mental health services and the constraints on funding and resources to provide acute mental health beds. Where appropriate and available, we seek acute mental health beds in the private sector, but with a recognition that this is not always in the best interest of the patient as these admissions can be remote from a patient’s local support networks and disconnected from their broader NHS care.” Source location Response from SW London ICB
Open published response
26 Apr 2023 Mrs Elsie Leaver · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 5 Failure by SGH doctors to take a reasonable psychiatric history during clerking View source Lack of formal psychiatric liaison cover at QMH View source Omission of pertinent psychiatric history from GP summaries View source Insufficient SGH doctor training on HIE information and access View source Unsafe access pathway requiring physically frail QMH patients to travel by LAS ambulance to SGH A&E for psychiatric advice 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
Mrs Elsie Leaver · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Elsie Leaver died on 23 August 2020, aged 89, from multiple organ failure following a mixed drug overdose. The report raised concerns about missing psychiatric history, inadequate psychiatric assessment and risk assessment, failure to access available health information, and the lack of formal psychiatric liaison cover at QMH.
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 West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure by SGH doctors to take a reasonable psychiatric history during clerking
Wider context from the report “2. That doctors at SGH do not take a reasonable psychiatric history as part of their clerking and thus fail to make a proper holistic assessment of the patient and potentially miss the opportunity to manage risks such as those in this case which may lead to death.
” 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 West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of formal psychiatric liaison cover at QMH
Wider context from the report “4. That NHS South West London Integrated Care Board has made no formal provision for psychiatric liaison cover at QMH , despite there being such a clear clinical need for this that the team from psychiatric liaison have felt compelled to provide informal telephone advice for the last 10 years.
” 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 West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Omission of pertinent psychiatric history from GP summaries
Wider context from the report “1. That the GP summary did not contain pertinent psychiatric history that would have assisted the hospital clinicians to identify Mrs Leaver’s depression and specifically her suicidality.
” 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 West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient SGH doctor training on HIE information and access
Wider context from the report “3. That doctors at SGH need training on the information available on HIE and how to access it .
” 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 West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unsafe access pathway requiring physically frail QMH patients to travel by LAS ambulance to SGH A&E for psychiatric advice
Wider context from the report “5. That the lack of formal psychiatric advice availability at QMH puts vulnerable patients at increased risk, since the only way to properly access such advice is for them to be sent by LAS ambulance to A&E at SGH , when they are physically frail , given that QMH is a rehabilitation unit .
” Open source report
Concerns raised 1 Lack of inpatient facilities for admitting patients with addiction for care and supervision during crisis 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
Jaroslaw Rogala (otherwise known as Jarek) · 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
Jaroslaw Rogala, also known as Jarek, was found deceased by hanging in his bedroom on 3 September 2016 after experiencing suicidal ideation while intoxicated with alcohol. The report raised concern that patients with addiction at risk of suicide may have no inpatient facility available for care and supervision during a crisis.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS South West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of inpatient facilities for admitting patients with addiction for care and supervision during crisis
Wider context from the report “That those patients with addiction are risk of suicide as there are no in-patient facilities to admit them for care and supervision when in crisis in circumstances as described in this case.
” Open source report
Concerns raised 2 Failure to assess emergency department patients consistently regardless of mode of transport View source Insufficient qualification for assessment of urgent care patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Madhumita Mandal · 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
Madhumita Mandal became unwell and attended Croydon University Hospital on 7 September 2013, where the inquest recorded multiple organ failure due to sepsis associated with a ruptured endometriotic ovarian cyst. The principal concerns were delays in assessment and treatment, including initial streaming by a receptionist without medical training, and failures in clinical supervision. The report also raised concerns about differing assessment based on whether patients arrived by ambulance.
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 West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to assess emergency department patients consistently regardless of mode of transport
Wider context from the report “Mrs Mandal’s death also raises questions about the use of ambulance services. A difference in assessment of patients based upon their mode of transport to the emergency department may encourage patients to err on the side of calling an ambulance.
” 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 West London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient qualification for assessment of urgent care patients
Wider context from the report “Mrs Mandal was taken to Croydon University Hospital by her husband. Virgin Care was contracted by the Croydon Clinical Commissioning Group to provide urgent care services, and to stream adult patients arriving at the emergency department. A streaming model was followed by a receptionist who had no medical training and who performed no medical observations. This led to a delay of about an hour before Mrs Mandal was seen by any qualified healthcare professional, by which time her condition was critical.
The streaming model had been approved and commissioned in the contract as recommended by an NHS body called the Emergency Care Intensive Support Team. The system at Croydon has changed since Mrs Mandal’s death but concerns remain about the level of qualification for assessment of patients , and there may be lessons for other Trusts who contract out the provision of urgent care.
” 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 Use healthcare assistant observations scored with the VIEWS early warning system to identify patients requiring ED transfer or specialist referral after UCC streaming.
Verbatim wording from the response “This issue was reviewed in a workshop with CHS, UCC and commissioner clinicians and executives where it was agreed that a modification would be made to the streaming model on a pilot basis, which has continued, whereby patients streamed to UCC would be given basic observations by a HCA. All observations would be scored using the Vital – Pac Early Warning System (VIEWS). Any patient scoring 4 and below would be asked to remain in the UCC; a score of 5 and above would indicate that the patient was inappropriately streamed and would be sent to ED or referred directly to a specialist. The VIEWS assessment not only gives assurance to the Trust about when patients are handed over but it is also compliant with guidance from the London Standards. The model has evidenced that less than 1% of patients initially streamed to the UCC are transferred to ED following the observations review.” Source location MMandal-Response3
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 Introduce clinical streaming at the front end of A&E following the changed layout and redevelopment of the ED department.
Verbatim wording from the response “from the ED Department, clinical streaming has now been introduced at the front end of A&E. We are currently commencing re-procurement of urgent care services in Croydon and the specification for the new service will continue to require that effective streaming process are in place. The VIEWS process however continues to be used in the UCC.” Source location MMandal-Response3
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 current streaming model and joint standard operating policy to direct patients to UCC or ED according to presenting complaints.
Verbatim wording from the response “By way of back ground the service was initially implemented using the Manchester Triaging model, which required the triaging of all patients (primary care and otherwise). As a consequence there was a significant impact on performance due to the delays this introduced into patient flows. The national Emergency Intensive Support Team (ECIST) supported a local review of the model, which led to a joint agreement by ED consultants, urgent care and CCG GP clinicians and implementation of the current streaming model and a joint standard operating policy agreed and implemented on the 9th October 2012. The model was based on trained appropriately experienced streaming patients to either the UCC or ED depending on their presenting complaint, with the aid of the streaming protocol.” Source location MMandal-Response3
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 clinical streaming and VIEWS processes are considered sufficient to ensure effective streaming of patients entering the urgent care centre.
Verbatim wording from the response “from the ED Department, clinical streaming has now been introduced at the front end of A&E. We are currently commencing re-procurement of urgent care services in Croydon and the specification for the new service will continue to require that effective streaming process are in place. The VIEWS process however continues to be used in the UCC.” Source location MMandal-Response3
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Request correction
Addressed to NHS Wandsworth Clinical Commissioning Group, now represented here by NHS South West London Integrated Care Board.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations