Concerns raised 11 Lack of robust clinical governance and multidisciplinary team processes for community urology services View source Delays in assessment, diagnosis, treatment and transfer of postoperative sepsis View source Lack of robust assessment and guidelines for independent private-sector practising privileges View source Lack of appraisal and mandatory assessment of community urology clinicians View source Lack of multidisciplinary assessment and senior consultant oversight of community urology patients View source Lack of independent review of deaths for learning and practice change View source Failure of senior clinicians to retain responsibility for patients throughout private hospital care View source Lack of regular morbidity and mortality review of community urology complications View source Failure to assess whether patients are fit for operative procedures at the hospital View source Failure to fully inform patients of clinicians’ relevant experience View source Failure to integrate community urology services with hospital-based consultant-led urology services View source See 8 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
Keith James Hankin · 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
Keith James Hankin was admitted for an elective optical urethrotomy on 8 September 2023, developed sepsis shortly after the procedure, was transferred to Worthing Hospital, and died there on 11 September 2023. The report identifies concerns about poor clinical governance and lack of integration, oversight and clinician assessment within the Community Urology Service, as well as multiple omissions in his pre-operative, intra-operative and post-operative care at Goring Hall Hospital, including delays in recognising and treating sepsis and transferring him for further management.
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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of robust clinical governance and multidisciplinary team processes for community urology services
Wider context from the report “1. Lack of clinical governance of the Community Urology Service (CUS) by the Integrated Care Board (ICB) who commissioned the service and Sussex Medical Chambers (SMC) who were responsible for providing the service
The Integrated Care Board contracted Sussex Medical Chambers to provide a Community Urology Service through any qualified provider in 2015 and renewed the contract through a competitive tendering process twice subsequently. The ICB used a generic contract supplied by NHS England to contract the service. Neither the IB nor SMC were able to provide any evidence of robust clinical governance or multi-disciplinary team processes to ensure best practice of urology services from inception to date.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in assessment, diagnosis, treatment and transfer of postoperative sepsis
Wider context from the report “6. Management of Mr Hankin at Goring Hall Hospital
There were multiple omissions in the pre-operative, intra-operative and post operative care provided by Goring Hall Hospital which individually and collectively contributed to Mr Hankin’s death. This included a failure to recognise Mr Hankin underlying medical co-morbidities rendered him unfit to have his operative procedure at the hospital. More specifically the post-operative assessment and support provided by the consultant anaesthetist and surgeon led to a delay in assessing and diagnosing sepsis and thereafter giving appropriate and timely antibiotics and facilitating an earlier transfer to the NHS Hospital for further management . This gives rise to a concern that there was a lack of understanding by the senior clinicians (in the absence of any local and national guidelines provided at the inquest) requiring them to remain responsible for the care of patients throughout their time in a private hospital rather than delegating the care to a Resident Medical Officer who is more likely than not to be insufficiently experienced in managing such critical situations.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of robust assessment and guidelines for independent private-sector practising privileges
Wider context from the report “4. Practicing Privileges within the private sector
████████ set up and led the CUS under the auspices of SMC. The ICB contractually required this service to be run by a consultant urologist. ████████ had not held a formal consultant urologist position within the NHS prior to tendering for this work. It remains unclear as to how ████████ was provided with practicing privileges at a private hospital as a consultant and was therefore able to practice independently and without scrutiny. This gives rise to a concern that there is a lack of robust assessment and guidelines, both locally and nationally, as to how clinicians are given practising privileges to work independently outside of the NHS to the potential detriment of patient care. It also gives rise to a concern that patients are not being fully informed of the relevant experience of such clinicians thereby breaching the statutory duty of candour responsibility of all hospitals.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of appraisal and mandatory assessment of community urology clinicians
Wider context from the report “3. Lack of appraisal and mandatory assessment of clinicians employed by CUS
There was an absence of any appraisal and/or mandatory assessments within the CUS or the ICB and SMC for the associate specialist clinicians who were working extra-contractually outside of their NHS work. No evidence was provided as to their experience and competency. This gives rise to a concern that their working practices are insufficiently assessed and fails to fulfil GMC ‘good practice’ guidelines. Likewise, no evidence was provided regarding regular morbidity and mortality reviews of complications by the ICB, CUS and SMC such as when patients re-present to NHS hospitals with complications arising from the CUS.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of multidisciplinary assessment and senior consultant oversight of community urology patients
Wider context from the report “2. Lack of Integration of the Community Urology service with NHS Hospital Urology Services
The CUS provided community-based urology services with non-consultant grade urologists without any oversight or integration with hospital-based consultant led urology services. Whilst there was an opportunity for CUS to refer more complex patients to NHS Hospital Trusts the ‘silo’ effect of these 2 services was such that they effectively worked independently of each other. The absence of a robust multidisciplinary team assessment within the CUS and the lack of senior clinical oversight of community urology patients by NHS consultant clinicians leads to a concern that the urology service is fragmented and does not effectively support urology patients within the region to confirm best practice and optimal treatment.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of independent review of deaths for learning and practice change
Wider context from the report “5. Learning from Mr Hankin’s death
The ICB did not independently review the circumstances of Mr Hankin’s death to confirm if there was any learning or changes in practice to prevent further deaths. Likewise, SMC relied on ████████ to inform them and investigate Mr Hankin’s death without considering the inherent conflict of interest in so doing . The lack of an independent review prevented any proactive learning and changes in practice following the death of Mr Hankin. This gives rise to a concern that the system within the ICB and SMC are insufficiently robust and could – as it was with Mr Hankin – prevent transparency and openness as to the circumstances of his death and limit any learning and or necessary changes in practice to prevent future deaths.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of senior clinicians to retain responsibility for patients throughout private hospital care
Wider context from the report “6. Management of Mr Hankin at Goring Hall Hospital
There were multiple omissions in the pre-operative, intra-operative and post operative care provided by Goring Hall Hospital which individually and collectively contributed to Mr Hankin’s death. This included a failure to recognise Mr Hankin underlying medical co-morbidities rendered him unfit to have his operative procedure at the hospital. More specifically the post-operative assessment and support provided by the consultant anaesthetist and surgeon led to a delay in assessing and diagnosing sepsis and thereafter giving appropriate and timely antibiotics and facilitating an earlier transfer to the NHS Hospital for further management. This gives rise to a concern that there was a lack of understanding by the senior clinicians (in the absence of any local and national guidelines provided at the inquest) requiring them to remain responsible for the care of patients throughout their time in a private hospital rather than delegating the care to a Resident Medical Officer who is more likely than not to be insufficiently experienced in managing such critical situations.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of regular morbidity and mortality review of community urology complications
Wider context from the report “3. Lack of appraisal and mandatory assessment of clinicians employed by CUS
There was an absence of any appraisal and/or mandatory assessments within the CUS or the ICB and SMC for the associate specialist clinicians who were working extra-contractually outside of their NHS work. No evidence was provided as to their experience and competency. This gives rise to a concern that their working practices are insufficiently assessed and fails to fulfil GMC ‘good practice’ guidelines. Likewise, no evidence was provided regarding regular morbidity and mortality reviews of complications by the ICB, CUS and SMC such as when patients re-present to NHS hospitals with complications arising from the CUS.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to assess whether patients are fit for operative procedures at the hospital
Wider context from the report “6. Management of Mr Hankin at Goring Hall Hospital
There were multiple omissions in the pre-operative, intra-operative and post operative care provided by Goring Hall Hospital which individually and collectively contributed to Mr Hankin’s death. This included a failure to recognise Mr Hankin underlying medical co-morbidities rendered him unfit to have his operative procedure at the hospital . More specifically the post-operative assessment and support provided by the consultant anaesthetist and surgeon led to a delay in assessing and diagnosing sepsis and thereafter giving appropriate and timely antibiotics and facilitating an earlier transfer to the NHS Hospital for further management. This gives rise to a concern that there was a lack of understanding by the senior clinicians (in the absence of any local and national guidelines provided at the inquest) requiring them to remain responsible for the care of patients throughout their time in a private hospital rather than delegating the care to a Resident Medical Officer who is more likely than not to be insufficiently experienced in managing such critical situations.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to fully inform patients of clinicians’ relevant experience
Wider context from the report “4. Practicing Privileges within the private sector
████████ set up and led the CUS under the auspices of SMC. The ICB contractually required this service to be run by a consultant urologist. ████████ had not held a formal consultant urologist position within the NHS prior to tendering for this work. It remains unclear as to how ████████ was provided with practicing privileges at a private hospital as a consultant and was therefore able to practice independently and without scrutiny. This gives rise to a concern that there is a lack of robust assessment and guidelines, both locally and nationally, as to how clinicians are given practising privileges to work independently outside of the NHS to the potential detriment of patient care. It also gives rise to a concern that patients are not being fully informed of the relevant experience of such clinicians thereby breaching the statutory duty of candour responsibility of all hospitals.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to integrate community urology services with hospital-based consultant-led urology services
Wider context from the report “2. Lack of Integration of the Community Urology service with NHS Hospital Urology Services
The CUS provided community-based urology services with non-consultant grade urologists without any oversight or integration with hospital-based consultant led urology services . Whilst there was an opportunity for CUS to refer more complex patients to NHS Hospital Trusts the ‘silo’ effect of these 2 services was such that they effectively worked independently of each other . The absence of a robust multidisciplinary team assessment within the CUS and the lack of senior clinical oversight of community urology patients by NHS consultant clinicians leads to a concern that the urology service is fragmented and does not effectively support urology patients within the region to confirm best practice and optimal treatment.
” 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 Follow up completion of serious-incident recommendations through enhanced contract quality meetings.
Verbatim wording from the response “Following the Inquest Goring Hall Hospital have submitted the final version of the Serious Incident which has followed the Serious Incident Framework. NHS Sussex have reviewed the incident and have identified that all learning and recommendations have been identified. NHS Sussex through enhanced contract quality meetings will follow up to ensure that recommendations are complete. The next meeting is on 14th November 2025.” Source location Response from NHS Sussex
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 Set clinical governance, effectiveness, patient safety and experience expectations for all commissioned services in 2026/2027 contract negotiations.
Verbatim wording from the response “• For 2026/2027 NHS Contract negotiations, NHS Sussex has set out its expectations in relation to quality standards which includes Clinical Governance and Effectiveness, Patient Safety and Experience for all commissioned services.” Source location Response from NHS Sussex
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 Issue a Contract Performance Notice to Sussex Medical Chambers requiring evidence of its clinical governance framework.
Verbatim wording from the response “Following the conclusion of the inquest which highlighted HM Coroner’s concerns about Sussex Medical Chamber (SMC) clinical governance NHS Sussex took the following action:” Source location Response from NHS Sussex
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 Serve a Contract Performance Notice on Goring Hall Hospital concerning clinical governance, serious-incident learning and quality assurance failures.
Verbatim wording from the response “Management of Mr Hankin at Goring Hall Hospital.
NHS Sussex ICB have served a contract performance notice to Goring Hall Hospital (Circle Health Group) in respect of services delivered at Goring Hall Hospital, following concerns about the governance and response to a serious patient safety incident. The CPN cited breaches of the NHS Standard Contract, including failure to meet clinical standards, failure to act meaningfully on serious incident learning, and lack of transparent quality assurance.” Source location Response from NHS Sussex
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the serious incident and identify all associated learning and recommendations.
Verbatim wording from the response “Learning from Mr Hankin’s death.
NHS Sussex ICB is not responsible for conducting serious incident (SI) investigations regarding individual patient care this is the responsibility of the providers in line with National NHSSE Serious Incident Framework which was in place in 2023. Goring Hall Hospital completed the appropriate notifications to NHS Sussex.” Source location Response from NHS Sussex
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 Appraisal and mandatory assessment of clinicians are the responsibility of their employers, Sussex Medical Chambers and Goring Hall Hospital.
Verbatim wording from the response “Lack of appraisal and mandatory assessment of clinicians employed by CUS.
NHS Sussex ICB does not directly employ the clinicians and is therefore not responsible for the appraisal or mandatory assessment of individual clinicians who are working either for the NHS or extra-contractually outside their NHS work. It is compulsory for a medical clinician to have valid GMC registration and to belong to a medical defence organisation. Appraisal and mandatory assessment are the responsibility of the employer which in this case was Sussex Medical Chambers and Goring Hall Hospital.” Source location Response from NHS Sussex
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The ICB monitors commissioned services organisationally and does not review individual patient-level information.
Verbatim wording from the response “The role of NHS Sussex ICB through contractual management processes is to ensure that the organisational quality assurance, oversight and clinical governance processes are in place and to seek assurance where improvements are required. ICBs are required to monitor at an organisational level and do not review individual patient level information.” Source location Response from NHS Sussex
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The ICB does not employ clinicians and is therefore not responsible for their appraisal or mandatory assessment.
Verbatim wording from the response “Lack of appraisal and mandatory assessment of clinicians employed by CUS.
NHS Sussex ICB does not directly employ the clinicians and is therefore not responsible for the appraisal or mandatory assessment of individual clinicians who are working either for the NHS or extra-contractually outside their NHS work. It is compulsory for a medical clinician to have valid GMC registration and to belong to a medical defence organisation. Appraisal and mandatory assessment are the responsibility of the employer which in this case was Sussex Medical Chambers and Goring Hall Hospital.” Source location Response from NHS Sussex
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The ICB has no power over which clinicians receive practising privileges or admitting rights.
Verbatim wording from the response “Goring Hall Hospital is responsible for decisions regarding Practising Privileges and NHS Sussex ICB has no power over the system of who is granted admitting rights.” Source location Response from NHS Sussex
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The ICB is not responsible for investigating serious incidents involving individual patient care.
Verbatim wording from the response “Learning from Mr Hankin’s death.
NHS Sussex ICB is not responsible for conducting serious incident (SI) investigations regarding individual patient care this is the responsibility of the providers in line with National NHSSE Serious Incident Framework which was in place in 2023. Goring Hall Hospital completed the appropriate notifications to NHS Sussex.” Source location Response from NHS Sussex
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 Statutory provider choice, professional standards and referral pathways allow community urology services to manage suitable patients safely.
Verbatim wording from the response “Lack of Integration of the Community Urology service with the NHS Hospital Urology Services.
Through legislation, patients have a statutory right at the point of referral from general practice to choose any available consultant-led provider able to deliver the care they require (NHS Commissioning Board and CCG (Responsibilities and Standing Rules) Regulations 2012). For non-complex Urology cases, this choice includes community providers, able to deliver more timely care for a range of minor conditions than local NHS providers.” Source location Response from NHS Sussex
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 Providers are responsible for conducting serious incident investigations under the applicable Serious Incident Framework.
Verbatim wording from the response “Learning from Mr Hankin’s death.
NHS Sussex ICB is not responsible for conducting serious incident (SI) investigations regarding individual patient care this is the responsibility of the providers in line with National NHSSE Serious Incident Framework which was in place in 2023. Goring Hall Hospital completed the appropriate notifications to NHS Sussex.” Source location Response from NHS Sussex
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 Goring Hall Hospital is responsible for decisions about practising privileges and admitting rights.
Verbatim wording from the response “Goring Hall Hospital is responsible for decisions regarding Practising Privileges and NHS Sussex ICB has no power over the system of who is granted admitting rights.” Source location Response from NHS Sussex
Open published response
Concerns raised 1 Lack of information being made available to the GP to prevent duplicitous prescribing View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Margaret Kagure Pauline REECE · 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
Margaret Kagure Pauline Reece died on 7 March 2023 after being found hanging at her home address. The principal concern was that inadequate information-sharing between mental health services and the GP could result in patients receiving no medication or excessive medication due to duplicitous prescribing.
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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of information being made available to the GP to prevent duplicitous prescribing
Wider context from the report “The MATTERS OF CONCERN are that in the absence of information being made available to the GP there is a risk that patients will not receive any medication or receive excessive amounts of medication due to the risk of duplicitous prescribing .
” 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 Roll out the shared care record to primary care during the 2025/2026 financial year.
Verbatim wording from the response “NHS Sussex is in the process of rolling out the shared care record to primary care in this financial year (2025/2026). In the coming years the information NHS providers will be able to access about a patient will be replaced by the national Shared Care Record which NHS England is currently developing.” Source location Response from NHS Sussex
Open published response
Concerns raised 2 Lack of inpatient psychiatric beds causing unacceptable A&E waits for people awaiting mental health beds View source Unsuitability of A&E as a holding environment for people awaiting mental health beds View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sapphire Kathleen BERNARD · 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
Sapphire Kathleen BERNARD was detained under the Mental Health Act and waited 19 days in an A&E department for a psychiatric bed while continuing to self-ligature. After admission to Langley Green Hospital, she self-tied a ligature while on intermittent observations and died at East Surrey Hospital on 30 October 2023. The principal concerns were the lack of psychiatric beds, the unsuitability of A&E as a holding environment for people needing mental health care, and vulnerabilities in the risk assessment and observation requirements at Langley Green Hospital.
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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of inpatient psychiatric beds causing unacceptable A&E waits for people awaiting mental health beds
Wider context from the report “1. The lack of inpatient beds leading to the unacceptable wait time in A&E for those suffering with their mental health who are awaiting a psychiatric beds .
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unsuitability of A&E as a holding environment for people awaiting mental health beds
Wider context from the report “3. The unsuitability of the environment of A&E as a holding place for those in need of a mental health bed .
4. The evidence was that the environment in A&E as a holding place is not conducive for those suffering with Autism and/or who are neurodiverse . The environment in A&E can exacerbate and cause further deterioration in their mental health
” 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 Work with partners to improve timely discharge and support prompt admission for people awaiting mental health inpatient care.
Verbatim wording from the response “NHS Sussex recognises that some people wait longer than we would like to access mental health inpatient care due to patient flow and acuity of patients, NHS Sussex are working closely with partners to improve timely discharge to support prompt admission.” Source location Response from NHS Sussex Integrated Care Board
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 Commission and extend 14 additional independent-sector acute adult mental health beds to support winter pressures and capacity.
Verbatim wording from the response “There are 302 commissioned acute adult care beds and 40 Independent sector beds. In addition to the 40 acute adult beds in the independent sector NHS Sussex and Sussex Partnership commissioned an additional 14 beds between January- March 2025 to support winter pressures. These have now been extended for Quarter one 2025/26 taking the total number of acute adult beds in the independent sector to 54. Further to this, SPFT have redesigned their acute dementia ward in Brighton & Hove to support population need which will reopen in May 2025 as an adult ward and increase the SPFT bed base by 15 adult beds.” Source location Response from NHS Sussex Integrated Care Board
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 NHS provider organisations are responsible for ensuring existing environments follow national guidance and undertaking required risk assessments.
Verbatim wording from the response “ESHT is working to review and where appropriate to improve Mental Health patient safety, for example in the Mental Health rooms in A&E. NHS Sussex has no role in the set up or environment of an NHS Provider, however, updates are required for any new construction projects as part of the Commissioning process. For existing environments, it is the responsibility of NHS provider organisations to ensure they follow national guidance on the built environment and undertake national risk assessments.” Source location Response from NHS Sussex Integrated Care Board
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 SPFT manages Sussex’s inpatient mental health bed capacity and clinically prioritises patients according to need.
Verbatim wording from the response “SPFT as the lead Mental Health service provider manages the inpatient bed capacity to best support the needs of all mental health patients in Sussex and they will then clinically prioritise accordingly. Sussex Partnership Foundation Trust can flex their capacity on a gender basis within their overall number of beds.” Source location Response from NHS Sussex Integrated Care Board
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 NHS Sussex has no role in setting up or managing NHS provider environments, including A&E mental health facilities.
Verbatim wording from the response “ESHT is working to review and where appropriate to improve Mental Health patient safety, for example in the Mental Health rooms in A&E. NHS Sussex has no role in the set up or environment of an NHS Provider, however, updates are required for any new construction projects as part of the Commissioning process. For existing environments, it is the responsibility of NHS provider organisations to ensure they follow national guidance on the built environment and undertake national risk assessments.” Source location Response from NHS Sussex Integrated Care Board
Open published response
Concerns raised 8 Shortage of mixed-ward beds for transgender patients View source Gap in services for people too high risk to go home but not ill enough for detention View source Failure to collect, monitor and act on lengthy A&E stays View source Lack of inpatient mental health beds causing unacceptable A&E waits View source Unsuitable A&E holding environment for autistic or neurodiverse people needing mental health beds View source Delays in referral to the Assessment and Treatment Service and therapeutic input View source Gaps in psychosocial support services for transgender, non-binary and intersex adults View source Shortage of inpatient beds able to accept autistic patients View source See 5 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
Matthew Zak Sheldrick (Matty) · 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
Matthew Zak Sheldrick (Matty), who identified as non-binary, attended A&E in crisis on 3 November 2022 following deteriorating mental health and intense suicidal thoughts. After being assessed under the Mental Health Act and not detained, Matty left the hospital and was found suspended by a ligature in the hospital grounds. The report identified concerns including the lack of suitable inpatient beds, the unsuitability of A&E for neurodivergent patients, gaps in service provision, and shortcomings in the mental health assessment and discharge care planning.
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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Shortage of mixed-ward beds for transgender patients
Wider context from the report “3. There being a shortage of beds for transgender patients who are in need of a mixed ward .
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Gap in services for people too high risk to go home but not ill enough for detention
Wider context from the report “6. There is a gap in services for those who are not ill enough to be detained but who are too high risk to be sent home .
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to collect, monitor and act on lengthy A&E stays
Wider context from the report “4. In Matty’s case it appears there was a lack of appreciation by the ICB of his extensive length of stay in A&E. It appears that this information (and others who had lengthy stays) was not at that time being collected, monitored and acted on by the ICB .
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of inpatient mental health beds causing unacceptable A&E waits
Wider context from the report “1. The lack of inpatient beds leading to the unacceptable wait time in A&E for those suffering with their mental health who are awaiting beds . In Matty’s case a bed was not found for them within a 26-day period.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unsuitable A&E holding environment for autistic or neurodiverse people needing mental health beds
Wider context from the report “5. The unsuitability of the environment of A&E as a holding place for those in need of a mental health bed . The evidence was that the environment in A&E as a holding place is not conducive for those suffering with Autism and/or who are neurodiverse . The environment in A&E can exacerbate and cause further deterioration in their mental health.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in referral to the Assessment and Treatment Service and therapeutic input
Wider context from the report “7. There is a significant wait time for referral to the Assessment and Treatment Service . Therefore, any therapeutic input is delayed , and this results in repetitive attendances at A&E when in crisis.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Gaps in psychosocial support services for transgender, non-binary and intersex adults
Wider context from the report “8. Current gaps in service around psychosocial support for transgender, non-binary and intersex adults have been provided by third party charitable organisations. It is understood that much of their funding has recently been withdrawn by the ICB . This is of particular concern as Brighton is recognised as having one of the largest trans communities in the Country
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Shortage of inpatient beds able to accept autistic patients
Wider context from the report “2. There being a shortage of beds for Autistic patients (both informal and detained) within the private sector that are being funded by the ICB . Evidence was heard that those providing beds within the public sector very often refused to accept autistic patients due to their additional risks .
” 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 Operate live reporting and escalation arrangements to identify patients waiting for mental health beds, review prolonged A&E waits, and support movement between services.
Verbatim wording from the response “In 2021, NHS Sussex did not routinely capture information on the numbers of mental health patients waiting in emergency departments. Since then, we have improved our oversight of patients who have increased waits within A&E’s.” Source location Response from Sussex 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 Increase commissioned inpatient capacity by 27 acute beds, representing a net increase of 17 beds, by the end of March 2025.
Verbatim wording from the response “By the end of March 2025, this will increase, including 27 acute beds (net increase 17). A business case for further beds in 2025-26, to ensure timely access to inpatient care when required, is being developed.” Source location Response from Sussex 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 Monitor Assessment and Treatment Service waiting times and manage improvement through monthly Quality Review Meetings with SPFT.
Verbatim wording from the response “NHS Sussex has oversight of all performance targets and waiting times and has assurance conversations monthly with SPFT. NHS Sussex has the overarching commissioning responsibility for the totality of the contract with the SPFT, however the flexibility within the services is the responsibility of the Trust. The Trust report to NHS Sussex on performance both internally and publicly and manage the risks within their services.” Source location Response from Sussex 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 Request a formal review of SPFT and subcontracted inpatient-bed use to ensure patients’ needs, including autistic patients’ needs, are appropriately accommodated.
Verbatim wording from the response “Matty’s inquest, NHS Sussex will formally request a review of the use of all SPFT inpatient beds and subcontracted inpatient beds to provide oversight to ensure patients’ needs are accommodated appropriately, including autistic patients. This will be formally requested at the Quality Review Meeting in April 2025, which is a regular assurance meeting that takes place each month between NHS Sussex and each of the statutory providers in Sussex.” Source location Response from Sussex 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 Review the availability of mixed-sex beds at the SPFT Quality Review Meeting during Quarter 1 2025/26.
Verbatim wording from the response “SPFT have a Mixed Sex Accommodation Policy Maximising Individual Dignity, which states where possible transgender patients are accommodated according to their preference (this may consider the pronouns that they currently use), with all transgender patients cared for in single rooms. NHS Sussex to undertake a review of the availability of mixed sex beds during quarter 1 2025/26 at the SPFT Quality Review Meeting.” Source location Response from Sussex 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 Ensure SPFT audits potential voluntary admissions to test the pathway available for high-risk patients who are not detained and cannot safely return home.
Verbatim wording from the response “Following clinical assessment, a patient who is not detained under the Mental Health Act but remains high risk to be sent home with community services support could be recommended for voluntary admission to an inpatient bed.” Source location Response from Sussex 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 Develop a business case for further inpatient beds in 2025–26 to support timely access to inpatient care.
Verbatim wording from the response “By the end of March 2025, this will increase, including 27 acute beds (net increase 17). A business case for further beds in 2025-26, to ensure timely access to inpatient care when required, is being developed.” Source location Response from Sussex ICB
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 Sussex has above-average acute mental-health bed provision nationally, challenging the premise that insufficient beds explain the concern.
Verbatim wording from the response “To note, Sussex benchmarks above average for the number of beds in acute mental health wards for benchmarked areas nationally (as of 31st March 2023). There are 25 beds per 100,000 population in Sussex, compared to a national mean of 23, where the upper quartile is 27 and the lower quartile 17.4. This position does not change when looking at weighted population whereby in Sussex the beds per 100,000 weighted population is 23.3. compared to a national mean of 18.9.” Source location Response from Sussex ICB
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 No formal provider report indicates a significant referral risk for the Assessment and Treatment Service.
Verbatim wording from the response “NHS Sussex has not received a formal report from providers that there is a significant risk for referral to the Assessment and Treatment Service.” Source location Response from Sussex ICB
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The setup and environment of existing provider premises fall outside NHS Sussex’s role; providers must follow national guidance and conduct risk assessments.
Verbatim wording from the response “NHS Sussex has no role in the set up or environment of an NHS Provider, however, updates are required for any new construction projects. For existing environments, it is the responsibility of NHS provider organisations to ensure they follow national guidance on the built environment and undertake national risk assessments.” Source location Response from Sussex ICB
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 No formal reports substantiate claims that public or private providers refused autistic patients because of their additional risks.
Verbatim wording from the response “NHS Sussex has not had any formal reports that providers within the public or private sector are refusing autistic patients due to their additional risks. As a result of the feedback shared during” Source location Response from Sussex ICB
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 SPFT manages inpatient capacity and can flex beds by gender, while NHS Sussex does not specify mixed-sex bed numbers.
Verbatim wording from the response “SPFT as the lead provider manages the inpatient bed capacity to best support the needs of all mental health patients in Sussex and they clinically prioritise accordingly. SPFT can flex their capacity on a gender basis within their overall number of beds.” Source location Response from Sussex ICB
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 Current data capture, monitoring and escalation arrangements are considered sufficient to identify and act on extensive emergency-department waits.
Verbatim wording from the response “In 2021, NHS Sussex did not routinely capture information on the numbers of mental health patients waiting in emergency departments. Since then, we have improved our oversight of patients who have increased waits within A&E’s.” Source location Response from Sussex ICB
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 Flexibility within mental-health services is the Trust’s responsibility, while NHS Sussex retains overarching commissioning responsibility.
Verbatim wording from the response “NHS Sussex has oversight of all performance targets and waiting times and has assurance conversations monthly with SPFT. NHS Sussex has the overarching commissioning responsibility for the totality of the contract with the SPFT, however the flexibility within the services is the responsibility of the Trust. The Trust report to NHS Sussex on performance both internally and publicly and manage the risks within their services.” Source location Response from Sussex ICB
Open published response
Concerns raised 3 Lack of awareness of hyponatremia developing in birthing women View source Failure to recognise the risk of hyponatremia when giving intravenous fluids View source Failure to keep accurate records of fluid input and output 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
Orlando NOVA DAVIS · 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
Orlando Nova DAVIS suffered an irreversible brain injury after his mother developed unrecognised hyponatremia and seizures during labour, restricting oxygen before his birth. He died aged 14 days on 24 September 2021; the principal concerns were a lack of recognition and understanding of hyponatremia among midwives and clinicians, and inaccurate recording of fluid input and output despite additional fluids being given.
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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of hyponatremia developing in birthing women
Wider context from the report “Orlando was caused an irreversible brain injury when his mother suffered a seizure having developed hyponatremia during her labour. The concern is that the midwifes (in the community and in the hosptial, who had cared for Orlando’s mother) were completely unaware of this potential condition developing in birthing women .
In this case due to Orlando developing a tachicardia during labour Orlando’s mothers was actively encouraged to take in more fluid yet there was no accurate record kept of either input or output of fluid. Again when in hospital further fluids were given intravenously with no recognition of any potential risk of hyponatremia developing by the midwives or the Doctor on duty.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the risk of hyponatremia when giving intravenous fluids
Wider context from the report “Orlando was caused an irreversible brain injury when his mother suffered a seizure having developed hyponatremia during her labour. The concern is that the midwifes (in the community and in the hosptial, who had cared for Orlando’s mother) were completely unaware of this potential condition developing in birthing women.
In this case due to Orlando developing a tachicardia during labour Orlando’s mothers was actively encouraged to take in more fluid yet there was no accurate record kept of either input or output of fluid. Again when in hospital further fluids were given intravenously with no recognition of any potential risk of hyponatremia developing by the midwives or the Doctor on duty .
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to keep accurate records of fluid input and output
Wider context from the report “Orlando was caused an irreversible brain injury when his mother suffered a seizure having developed hyponatremia during her labour. The concern is that the midwifes (in the community and in the hosptial, who had cared for Orlando’s mother) were completely unaware of this potential condition developing in birthing women.
In this case due to Orlando developing a tachicardia during labour Orlando’s mothers was actively encouraged to take in more fluid yet there was no accurate record kept of either input or output of fluid . Again when in hospital further fluids were given intravenously with no recognition of any potential risk of hyponatremia developing by the midwives or the Doctor on duty.
” 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 Oversee further fluid-balance audits across all maternity birth settings and receive the results through perinatal quality surveillance arrangements.
Verbatim wording from the response “Both Trusts are also auditing compliance with the completion of fluid balance charts, and we have requested another audit is completed before the end of the year. A leaflet has been developed advising mothers about fluid intake in early labour. The leaflet has been published by UHSx and a publication is being considered by ESHT for inclusion on their website.” Source location Response from NHS Sussex
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request completion of an additional fluid-balance compliance audit before the end of the year.
Verbatim wording from the response “Both Trusts are also auditing compliance with the completion of fluid balance charts, and we have requested another audit is completed before the end of the year. A leaflet has been developed advising mothers about fluid intake in early labour. The leaflet has been published by UHSx and a publication is being considered by ESHT for inclusion on their website.” Source location Response from NHS Sussex
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 Share NHS Sussex’s hyponatraemia and labour fluid-balance work with NHS England’s Regional Maternity Team to disseminate learning across Integrated Care Systems.
Verbatim wording from the response “In order to enable the learning to be shared more widely with other Integrated Care Systems, our work on hyponatraemia and fluid balance in labour was shared with the Regional Maternity Team at NHS England in 2022, as part of the perinatal quality surveillance process, put in place following the Ockenden Review.” Source location Response from NHS Sussex
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 At the time, applicable guidance did not require accurate fluid-balance monitoring during labour.
Verbatim wording from the response “There are two particular issues that arise from HM Coroners concerns regarding the care of ████████ and Orlando Nova Davis during labour. The first is regarding the failure of the midwives to monitor fluid balance and to record the fluids accurately during labour in the community and in Hospital, although we are advised by UHSx that the guidance at the time did not require accurate monitoring of fluid balance during labour, and the second is the lack of knowledge and education amongst both doctors and midwives in relation to the rare complication of hyponatraemia in labour.” Source location Response from NHS Sussex
Open published response
Concerns raised 2 Failure by ambulance crews to consider possible medication toxicity View source Lack of ambulance service access to GP records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Susan Mary Young · 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
Susan Mary Young died at home on 20 December 2022 after accidentally taking too many prescribed co-codamol tablets over a short period, causing fatal toxicity. The report identified that ambulance staff did not consider possible co-codamol toxicity because they did not have access to her GP records, and stated that earlier recognition and administration of Naloxone could have provided a good chance of survival.
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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure by ambulance crews to consider possible medication toxicity
Wider context from the report “The possible toxicity from the Co-codamol tablets was not a considered by the ambulance crew who attended to Mrs Young following a 999 call. The Ambulance Service was not aware that Mrs Young had recently been prescribed Co-Codamol as the Ambulance service does not currently have access to GP records.
There was a short period of time in which the Naloxone antidote could have been given and evidence was heard from the expert at the Inquest that if the toxicity had been recognised earlier and Naloxone administered there was a good chance that Mrs Young would have survived. As the Ambulance Service did not have the GP records readily available to them this meant that there was a missed opportunity to treat Mrs Young appropriately.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of ambulance service access to GP records
Wider context from the report “The possible toxicity from the Co-codamol tablets was not a considered by the ambulance crew who attended to Mrs Young following a 999 call. The Ambulance Service was not aware that Mrs Young had recently been prescribed Co-Codamol as the Ambulance service does not currently have access to GP records .
There was a short period of time in which the Naloxone antidote could have been given and evidence was heard from the expert at the Inquest that if the toxicity had been recognised earlier and Naloxone administered there was a good chance that Mrs Young would have survived. As the Ambulance Service did not have the GP records readily available to them this meant that there was a missed opportunity to treat Mrs Young appropriately.
” Open source report
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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 Intervention is limited to patient-safety issues arising from concerns about the GP practice, not ambulance-service matters.
Verbatim wording from the response “We have investigated the concerns raised by HM Coroner with the GP practice concerned (the Practice). As we are commissioners of primary care in Sussex, we can only intervene in this case in respect of issues that affect patient safety as a consequence of concerns about the GP practice.” Source location Response from NHS Sussex
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The GP practice had appropriate systems for sharing records, with no identified technology problems preventing access by healthcare providers.
Verbatim wording from the response “GP connect allows those with the appropriate access to view the entirety of the GP records. We are assured that the Practice are set up correctly to share their records with other healthcare providers, including SECAmb using the two systems described above.” Source location Response from NHS Sussex
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 Surrey Heartlands ICB, as SECAmb’s commissioner, may hold information needed to assess ambulance crews’ access to GP records.
Verbatim wording from the response “NHS Sussex ICB does not know how SECAmb crews access GP records at the scene of a 999 call, and do not know what systems SECAmb use or what their understanding is of what is available to them from the Practice. Surrey Heartlands ICB who are the commissioners for SECAmb may have that information.” Source location Response from NHS Sussex
Open published response
Concerns raised 1 Failure of Mental Health Liaison teams to detain or hold absconding patients in acute hospitals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rachel Kathleen Garrett · 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
Rachel Kathleen Garrett had been experiencing deteriorating mental health and was found near the cliffs on several occasions. On 29 July 2020, after leaving the Royal Sussex County Hospital for a second time, she returned to the cliffs and ended her life by falling from the cliff top. The report’s principal concern was that mental health liaison staff employed by a separate mental health trust could not themselves use holding powers to prevent a patient leaving an acute hospital, creating a risk when patients with deteriorating mental health attended A&E.
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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of Mental Health Liaison teams to detain or hold absconding patients in acute hospitals
Wider context from the report “Patients who attend a Hospital Accident and Emergency Department with mental health difficulties are in most hospitals seen by a Mental Health Liaison team (made up of Consultant Psychiatrists and Mental Health nurses) These staff are not employed by the Acute Hospital Trust but are employed by a local Mental Health Trust (in this particular case it was the Sussex Partnership Foundation Trust).
As a result of their employment status the Mental Health Liaison team (who have the best knowledge of the patient having been caring for them) cannot invoke the Doctors or Nurses holding powers under Section 5(2) Mental Health Act (Section 5(4) for nurses). If a patient decides to abscond from the Acute Trust Hospital the Mental Health staff cannot detain/hold the patient. They would have to ask a Doctor within the Acute Hospital to do so. This Doctor may not have any knowledge of the patient and would be unlikely to act immediately in a busy A&E. By that time the patient would have been long gone.
Due to this technical issue around the employment status of the Mental Health Team, those suffering with a deteriorating mental health in an acute setting are at risk in these circumstances.
” 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 Review provider workforce and practices to seek a local resolution to Mental Health Liaison Team employment issues.
Verbatim wording from the response “Two of the actions that we will take forwards as a matter of some urgency are to make contact with other ICBs to explore how they are addressing the employment of Mental Health Liaison Teams within the Acute Care hospitals and also to look at workforce and practices within our Providers to try to resolve these issues on a local level. Whilst we are still trying to resolve the concerns that have been raised, this is a recognised National issue and as such we therefore do not yet have a local solution.” Source location Response from NHS Sussex
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 Contact other integrated care boards to explore approaches to employing Mental Health Liaison Teams within acute hospitals.
Verbatim wording from the response “Two of the actions that we will take forwards as a matter of some urgency are to make contact with other ICBs to explore how they are addressing the employment of Mental Health Liaison Teams within the Acute Care hospitals and also to look at workforce and practices within our Providers to try to resolve these issues on a local level. Whilst we are still trying to resolve the concerns that have been raised, this is a recognised National issue and as such we therefore do not yet have a local solution.” Source location Response from NHS Sussex
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 No local solution is currently available because the employment issue is recognised as a national problem.
Verbatim wording from the response “Two of the actions that we will take forwards as a matter of some urgency are to make contact with other ICBs to explore how they are addressing the employment of Mental Health Liaison Teams within the Acute Care hospitals and also to look at workforce and practices within our Providers to try to resolve these issues on a local level. Whilst we are still trying to resolve the concerns that have been raised, this is a recognised National issue and as such we therefore do not yet have a local solution.” Source location Response from NHS Sussex
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 Commissioners do not usually have a role in determining the employment model for particular services.
Verbatim wording from the response “As Commissioners of NHS services, NHS Sussex does not usually have a role in relation to the employment model of staff for particular services. However, if NHS Sussex, are made aware of an issue that is creating a risk for patients then recognising that as the Commissioners, we do have a duty to raise the issue with the Provider/s concerned and to ensure that the issue is addressed.” Source location Response from NHS Sussex
Open published response
Concerns raised 15 Inadequate information and record sharing before EHCP school placements View source Lack of mandatory Autism training for Education and SEN staff View source Lack of training and monitoring programme for EHCP medical advisers View source Failure to establish changed child mental health triage practices in written guidance View source Failure of the threshold of needs document to reflect risks for autistic children View source Lack of specific safeguarding guidance for children with disabilities View source Lack of clarity about schools’ information-sharing powers and duties View source Lack of clinician understanding of EHCP medical advice responsibilities View source Inappropriate closure or referral of child mental health referrals View source Lack of monitoring of access to clinical teams and referral outcomes View source Lack of comprehensive, relevant and mandatory Autism training across state agencies View source Insufficient process, guidance and oversight for effective post-death investigations View source Automatic categorisation of routine referrals as low risk View source Lack of mandatory Autism training for Children’s Services staff View source Lack of mandatory Autism training for child mental health referral triage staff View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
OSKAR MILES NASH · 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
Oskar Nash was 14 when he died by suicide on 9 January 2020 after a history of autism, anxiety, suicidal ideation and self-harm. The report identified failures including the lack of clinical mental-health assessment and support, an inappropriate mainstream-school placement, inadequate information in his Education, Health and Care Plan, and failures by children’s services to assess and respond to his risks. The report also raised ongoing concerns about autism training, referral triage, information sharing, safeguarding guidance and post-death investigations.
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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate information and record sharing before EHCP school placements
Wider context from the report “I am concerned that there is an ongoing risk that placements of children with EHCPs are being made on the basis of inadequate information and record sharing . On the evidence before me, it was clear that, even if an EHCP were comprehensive and fully updated (which may not be the case), it is unlikely to contain all matters of relevance to the question of a prospective school’s ability to meet the child’s needs.
I was given no good reason why fuller information and record sharing, sufficient to ensure that the prospective school can properly assess its ability to meet the child’s needs, should not take place before any child with an EHCP is placed in a new school. I am concerned that there is no system in place, locally or nationally, to ensure this is achieved by the relevant SEN department for every child with an EHCP . I am also concerned that there is an ongoing lack of clarity as to schools’ powers and duties to share information and documents, and any data protection ramifications this may have.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory Autism training for Education and SEN staff
Wider context from the report “The evidence at the inquest revealed that the staff in the Education / SEN Department, including SEN caseworkers, had insufficient understanding of Autism, its links to co-morbid mental health conditions, self-harm and suicidal ideation, and how to communicate with an autistic child. I am concerned that there continues to be no requirement for the staff to undertake relevant Autism training on a mandatory basis .
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of training and monitoring programme for EHCP medical advisers
Wider context from the report “On the basis of the evidence at the prevention of future deaths hearing, I am concerned that there continues to be a lack of understanding amongst the clinicians currently providing medical advice as part of the EHCP process as to their role in that process. I am further concerned that there is in place no programme for the training or monitoring of these clinicians in relation to these responsibilities .
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to establish changed child mental health triage practices in written guidance
Wider context from the report “I was told that the Standard Operating Procedure manual for the triage of referrals to children’s mental health services is to be updated to reflect the Trust’s new working practices but that this has not yet been done. I am concerned that important changes to the system of work (for example, the vital requirement that a referred child’s records are reviewed before any triaging decision is made and the child/family are spoken to) are not yet established in written guidance .
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of the threshold of needs document to reflect risks for autistic children
Wider context from the report “Despite these changes, I remain concerned that the “threshold of needs” document does not adequately and clearly reflect the known risks of mental health difficulties, self-harm, and suicidal ideation for autistic children (given their prevalence in this group of children) and that, consequentially, there is an ongoing risk that an autistic child in these circumstances will be allocated an insufficient level of support , as was the case for Oskar.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of specific safeguarding guidance for children with disabilities
Wider context from the report “I am concerned that “Working Together” does not provide clearer guidance specifically for the safeguarding of children with disabilities, including Autism , and the approach to be taken by agencies to parents and families.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about schools’ information-sharing powers and duties
Wider context from the report “I am concerned that there is an ongoing risk that placements of children with EHCPs are being made on the basis of inadequate information and record sharing. On the evidence before me, it was clear that, even if an EHCP were comprehensive and fully updated (which may not be the case), it is unlikely to contain all matters of relevance to the question of a prospective school’s ability to meet the child’s needs.
I was given no good reason why fuller information and record sharing, sufficient to ensure that the prospective school can properly assess its ability to meet the child’s needs, should not take place before any child with an EHCP is placed in a new school. I am concerned that there is no system in place, locally or nationally, to ensure this is achieved by the relevant SEN department for every child with an EHCP. I am also concerned that there is an ongoing lack of clarity as to schools’ powers and duties to share information and documents , and any data protection ramifications this may have.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of clinician understanding of EHCP medical advice responsibilities
Wider context from the report “On the basis of the evidence at the prevention of future deaths hearing, I am concerned that there continues to be a lack of understanding amongst the clinicians currently providing medical advice as part of the EHCP process as to their role in that process . I am further concerned that there is in place no programme for the training or monitoring of these clinicians in relation to these responsibilities.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inappropriate closure or referral of child mental health referrals
Wider context from the report “However, on the basis of the evidence I heard at the prevention of future deaths hearing, including from a special needs school which has experience of referring its pupils, I am concerned that there is an ongoing risk that some referrals may be inappropriately closed (for example because the child, at an early stage, declines to engage) or inappropriately referred to non-clinical partner agencies . In this context, I am concerned that there is a lack of specific monitoring of what proportion of referred children reach a clinical team and the extent to which the outcomes match the expectations of the referrers (so that any ongoing “barriers” in the system, which may be preventing proper access to the clinical teams, can then be identified and eliminated).
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of monitoring of access to clinical teams and referral outcomes
Wider context from the report “However, on the basis of the evidence I heard at the prevention of future deaths hearing, including from a special needs school which has experience of referring its pupils, I am concerned that there is an ongoing risk that some referrals may be inappropriately closed (for example because the child, at an early stage, declines to engage) or inappropriately referred to non-clinical partner agencies. In this context, I am concerned that there is a lack of specific monitoring of what proportion of referred children reach a clinical team and the extent to which the outcomes match the expectations of the referrers (so that any ongoing “barriers” in the system, which may be preventing proper access to the clinical teams, can then be identified and eliminated).
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of comprehensive, relevant and mandatory Autism training across state agencies
Wider context from the report “At the prevention of future deaths hearing, I heard evidence of more training being available, but also of an ongoing absence of comprehensive, relevant and mandatory training .
I was told that the National Autism Strategy does not currently include a timetabled commitment for relevant mandatory Autism training to be provided to all state agencies working directly with autistic adults and children .
I am concerned that this poses an ongoing risk to autistic children and their ability to access the services they require for their support, welfare, and safeguarding.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient process, guidance and oversight for effective post-death investigations
Wider context from the report “Ineffective review by the child death review processes results in the risk of further deaths in similar circumstances and I am concerned that the local and/or national process, guidance and oversight are insufficient to ensure that an effective post-death investigation , which should not be dependent on the inquest process, is achieved in all cases.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Automatic categorisation of routine referrals as low risk
Wider context from the report “The evidence showed that a referral to the child mental health services is triaged initially as being crisis, urgent, priority or routine. The criteria for crisis, urgent and priority referrals are specific and narrow and, consequently, the great majority of referrals are categorised as routine. I have been told that the routine referrals are automatically categorised as “low risk” . I am concerned about this as it is clear from the evidence that a child may not meet the criteria crisis, urgent or priority but, like Oskar Nash, may nevertheless be at a high or medium risk of harm. The Trust is currently receiving a high volume of referrals and so there is a considerable waiting time for its “routine” cases to be addressed. It seems inevitable, therefore, that there are children in this category who have been wrongly assumed to be at low risk of harm but who, in fact, face a high risk of harm which is currently unrecognised and unmanaged.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory Autism training for Children’s Services staff
Wider context from the report “The evidence at the inquest revealed that the staff in SCC’s Children’s Services Department, including Social Workers and other Team members, had insufficient understanding of Autism, its links to co-morbid mental health conditions, self-harm and suicidal ideation, and how to communicate with an autistic child. I am concerned that there continues to be no requirement for the staff to undertake relevant Autism training on a mandatory basis .
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory Autism training for child mental health referral triage staff
Wider context from the report “The evidence at the inquest revealed that the staff responsible for the triage of referrals to child mental health services had insufficient understanding of Autism, its links to co-morbid mental health conditions, self-harm and suicidal ideation, and how to communicate with an autistic child. I have been told that the triaging process is now undertaken by an “Access and Advice Team” but I am concerned that there continues to be no requirement for the staff in that Team to undertake relevant Autism training on a mandatory basis .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise identified reporting-form and process issues with the National Child Mortality Database for future improvement.
Verbatim wording from the response “Working Together to Safeguard Children (2018 p.103) states – “All practitioners participating in the child death review process should notify, report, and scrutinise child deaths using the standardised templates”. The templates are nationally agreed and available from the website www.gov.uk/government/publications/child-death-reviews-forms-for-reporting-child-deaths. The NCMD have replicated these templates for use within the electronic reporting system used in most areas across England, including Surrey (eCDOP). The majority of the boxes are direct questions with multiple choice answers, some provide free text. The format of the forms is nationally agreed, therefore, Surrey CDR team are not able to amend these forms at a local level. However, we will raise the issues identified with the NCMD to identify future improvements in processes.” Source location 2022-0031-Response-from-Surrey-Heartlands-CCG_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a multi-agency task-and-finish group and develop an action plan addressing thematic-review learning and missed opportunities.
Verbatim wording from the response “An Action Plan was developed in response to learning from the Thematic review” Source location 2022-0031-Response-from-Surrey-Heartlands-CCG_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request an independent national review of Surrey’s child death review process.
Verbatim wording from the response “Additionally, we are asking the National Team to undertake a review of the Surrey CDR process. This will provide an independent view of our CDR process, identifying any areas of improvement and/or assurance. We would be pleased to share this, and any resultant action plan for improvement with you.” Source location 2022-0031-Response-from-Surrey-Heartlands-CCG_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold themed child death overview panels on a repeating cycle to identify themes, assess whether learning is embedded and identify ongoing concerns.
Verbatim wording from the response “Oskar’s death, including all information gathered throughout the CDR process, will be presented at the next suicide themed CDOP meeting; any additional learning and action required from Oskar’s death will be shared across services/multi-professionals in Surrey and nationally via NCMD. We have transitioned to holding themed panels on a repeating cycle which allows for better identification of themes. This will also allow an opportunity to review whether prior learning has been embedded in practice and identify any ongoing areas of concern.” Source location 2022-0031-Response-from-Surrey-Heartlands-CCG_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a thematic review of probable suicide deaths among children and young people.
Verbatim wording from the response “In addition to the CDR process, to identify learning from a number of deaths from probable suicide and to help prevent future deaths, the CDR and the SSCP team undertook a thematic review in 2020. In response to concerns raised by parents, who reported that they had struggled to find information of where to access help and support, a Suicide Prevention Toolbox was developed. This is designed to be a living document which will be reviewed and updated as required. The Thematic Review was well received both locally and nationally and was used to challenge and influence the development of the design and offer of the new services in Mindworks Surrey. The action taken to date to prevent future similar deaths is as follows:” Source location 2022-0031-Response-from-Surrey-Heartlands-CCG_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate thematic-review learning and the Suicide Prevention Toolbox through accredited events, webinars, training, publications and professional meetings.
Verbatim wording from the response “Dissemination of learning from the thematic review:” Source location 2022-0031-Response-from-Surrey-Heartlands-CCG_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consult with national and academic experts about improving Surrey’s child death review process.
Verbatim wording from the response “On 17 March 2022, the Surrey CDR team met with Professor ████████, Professor of Infant Health & Developmental Physiology, University of Bristol and an academic at” Source location 2022-0031-Response-from-Surrey-Heartlands-CCG_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Meet national colleagues to discuss learning from reporting-form completion and improvements to child death review processes.
Verbatim wording from the response “Surrey CDR team have arranged a meeting with national colleagues in the NCMD to discuss the learning identified in relation to the completion of reporting form B’s and improvements needed to the Child Death Review processes.” Source location 2022-0031-Response-from-Surrey-Heartlands-CCG_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement recommendations arising from the national review of joint agency responses.
Verbatim wording from the response “the National Childhood Mortality Database (NCMD) to discuss the CDR process in Surrey. NCMD are currently undertaking a review of Joint Agency responses nationally (which include Surrey cases) to improve, strengthen and review the process. Any recommendations from this review will be fully implemented in Surrey.” Source location 2022-0031-Response-from-Surrey-Heartlands-CCG_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request greater detail from agencies when child death reporting forms contain insufficient information.
Verbatim wording from the response “The CDR Team accept that the reporting forms (Form B’s) received were minimally completed. The CDR Team do not have direct access to any agency records and rely on professional accountability and integrity when completing the Reporting Form B. However, we will take forward this learning to ensure when forms are received providing minimal information, we go back and request greater detail from agencies to ensure we have a complete account of their involvement in that child’s life. In addition, a learning event has been arranged to support and provide guidance to professionals when completing a Form B.” Source location 2022-0031-Response-from-Surrey-Heartlands-CCG_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a learning event providing guidance to professionals completing child death reporting forms.
Verbatim wording from the response “The CDR Team accept that the reporting forms (Form B’s) received were minimally completed. The CDR Team do not have direct access to any agency records and rely on professional accountability and integrity when completing the Reporting Form B. However, we will take forward this learning to ensure when forms are received providing minimal information, we go back and request greater detail from agencies to ensure we have a complete account of their involvement in that child’s life. In addition, a learning event has been arranged to support and provide guidance to professionals when completing a Form B.” Source location 2022-0031-Response-from-Surrey-Heartlands-CCG_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing statutory Child Death Review process, including CDOP review after investigations, is relied on to capture all learning from a child’s death.
Verbatim wording from the response “The Child Death Review (CDR) following Oskar’s death is still open and is being completed in line with Statutory Process as outlined within the National Statutory Guidelines: Child death review: statutory and operational guidance (England). The review at the Child Death Overview Panel (CDOP) has not yet taken place, as CDOP do not consider any case until all investigations are completed, including the Coroner’s Inquest and any further investigations, like a PFD hearing, as these are an integral part of the CDR process. This is to ensure that every opportunity to capture learning is taken up before the CDOP review.” Source location 2022-0031-Response-from-Surrey-Heartlands-CCG_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The local Child Death Review team cannot amend nationally agreed reporting forms, but can raise identified issues with the national database team.
Verbatim wording from the response “Working Together to Safeguard Children (2018 p.103) states – “All practitioners participating in the child death review process should notify, report, and scrutinise child deaths using the standardised templates”. The templates are nationally agreed and available from the website www.gov.uk/government/publications/child-death-reviews-forms-for-reporting-child-deaths. The NCMD have replicated these templates for use within the electronic reporting system used in most areas across England, including Surrey (eCDOP). The majority of the boxes are direct questions with multiple choice answers, some provide free text. The format of the forms is nationally agreed, therefore, Surrey CDR team are not able to amend these forms at a local level. However, we will raise the issues identified with the NCMD to identify future improvements in processes.” Source location 2022-0031-Response-from-Surrey-Heartlands-CCG_Published
Open published response
3 Aug 2021 Pauline McInroy ALLISON · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 2 Failure to refer patients using emollient creams to their local Fire & Rescue Service for advice and assistance View source Insufficient provision of fire-risk information to patients, families and carers using emollient creams 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
Pauline McInroy ALLISON · 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
Pauline McInroy Allison died at hospital on 26 March 2021 from significant burns sustained in a house fire after smoking materials came into contact with flammable materials on her bed. She was largely bedbound and unable to escape. The principal concerns were the fire risks associated with emollient creams, smoking in bed, and air mattresses, and whether patients, families and carers were sufficiently aware of these risks and referred for fire safety advice.
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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to refer patients using emollient creams to their local Fire & Rescue Service for advice and assistance
Wider context from the report “(1) Mrs Allison used emollient creams containing flammable ingredients. I heard evidence that these ingredients can build up on clothing and bedding. The effect of this build up is to make material ignite more easily and burn more quickly.
In addition to this the presence of an air mattress (often used by those with limited mobility) can further facilitate the ignition and spread of a fire by introducing additional air to the fire if it melts or punctures.
The West Sussex Fire & Rescue Service informed me that they are trying to improve awareness amongst families, care providers and GPs of the increased risk of fire posed by the use of these types of emollient creams especially by immobile persons who smoke.
I am concerned that not enough is being done to ensure that these patients, their families, and carers are aware of the risks and to ensure that they are referred to their local Fire & Rescue Service for advice and assistance .
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient provision of fire-risk information to patients, families and carers using emollient creams
Wider context from the report “(1) Mrs Allison used emollient creams containing flammable ingredients. I heard evidence that these ingredients can build up on clothing and bedding. The effect of this build up is to make material ignite more easily and burn more quickly.
In addition to this the presence of an air mattress (often used by those with limited mobility) can further facilitate the ignition and spread of a fire by introducing additional air to the fire if it melts or punctures.
The West Sussex Fire & Rescue Service informed me that they are trying to improve awareness amongst families, care providers and GPs of the increased risk of fire posed by the use of these types of emollient creams especially by immobile persons who smoke.
I am concerned that not enough is being done to ensure that these patients, their families, and carers are aware of the risks and to ensure that they are referred to their local Fire & Rescue Service for advice and assistance.
” Open source report
Concerns raised 1 Denial of mental health support for people in crisis with co-occurring substance abuse 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
Nicholas Jonathan SPOONER · 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
Nicholas Spooner had a long-standing dual diagnosis of mental ill health and polysubstance abuse and was moved to Brighton for his own safety. He fell from the window of his third-floor room after removing the window restrictors, sustaining multiple potentially survivable injuries, and later died directly as a result of COVID-19 pneumonitis. The principal concern was the need for specialist dual-diagnosis services, including outreach, drop-in and day-centre support for people experiencing mental health crises entwined with substance abuse.
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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Denial of mental health support for people in crisis with co-occurring substance abuse
Wider context from the report “Specialist dual diagnosis service needed with outreach facilities including drop-in and day centres to provide support for those in mental health crisis which is inextricably entwined with their substance abuse and who are often denied that mental health support .
” Open source report
Concerns raised 12 Poor or inadequate implementation of Care Act assessments View source Failure to seek specialist Acquired Brain Injury support View source Failure to respond to deterioration in living conditions, physical health and drug use View source Failure to repeat Care Act assessments annually View source Lack of training on the Mental Capacity Act and Care Act Codes of Practice View source Lack of lead and coordination View source Failure to use best interests policy appropriately View source Failure to understand how Acquired Brain Injury affects abilities View source Failure to understand the interaction between Acquired Brain Injury and substance use View source Poor communication between teams and individuals View source Inadequate staff training in Acquired Brain Injury View source Lack of capacity assessments View source See 9 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
KEVIN JOHN FITTON · 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
Kevin Fitton suffered a catastrophic stroke in 2010 and died after a cardiac arrest following fluid overload during his final hospital admission on 12 July 2019. The report identified longstanding concerns about inadequate assessment and support for his acquired brain injury, poor coordination and communication, ineffective implementation of care assessments, and failures to recognise and respond to his substance use, self-neglect and deteriorating health. The inquest concluded that a failure to obtain an urgent echocardiogram represented a missed opportunity to diagnose and treat his cardiac condition, and that the outcome may have been different with a correct diagnosis and more controlled fluid administration.
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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Poor or inadequate implementation of Care Act assessments
Wider context from the report “(9) There was a reasonable Care Act Assessment in 2017 however it was poorly/inadequately implemented . It should have been repeated annually – it was not.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to seek specialist Acquired Brain Injury support
Wider context from the report “(2) There was a failure to seek specialist support regarding Acquired Brain Injury (ABI) .
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to respond to deterioration in living conditions, physical health and drug use
Wider context from the report “(7) There was a failure to react to the deterioration in Mr Fitton’s living conditions, his being cuckooed, the downward slide in his physical health and the increase in his drug use .
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to repeat Care Act assessments annually
Wider context from the report “(9) There was a reasonable Care Act Assessment in 2017 however it was poorly/inadequately implemented. It should have been repeated annually – it was not.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of training on the Mental Capacity Act and Care Act Codes of Practice
Wider context from the report “(8) Staff received no adequate training in dealing with ABI. There was no training on the Codes of Practice for the Mental Capacity Act or the Care Act .
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of lead and coordination
Wider context from the report “(6) Lead and Co-ordination were lacking.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to use best interests policy appropriately
Wider context from the report “(1) There was an almost complete reliance of assumption of capacity. The lack of capacity assessments resulted in failure to identify the area and support needed by Mr Fitton and a failure to use best interests policy appropriately .
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to understand how Acquired Brain Injury affects abilities
Wider context from the report “(3) There was a failure to understand the way Mr Fitton’s ABI impacted on his abilities .
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to understand the interaction between Acquired Brain Injury and substance use
Wider context from the report “(4) There was a failure to understand how ABI impacted on Mr Fitton’s substance use and vice versa .
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Poor communication between teams and individuals
Wider context from the report “(5) Communication between the various teams and individuals were poor.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate staff training in Acquired Brain Injury
Wider context from the report “(8) Staff received no adequate training in dealing with ABI . There was no training on the Codes of Practice for the Mental Capacity Act or the Care Act.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of capacity assessments
Wider context from the report “(1) There was an almost complete reliance of assumption of capacity. The lack of capacity assessments resulted in failure to identify the area and support needed by Mr Fitton and a failure to use best interests policy appropriately.
” Open source report
Concerns raised 2 Fragmented provision of homeless care and support services requiring extensive travel between locations View source Lack of safe accommodation and associated basic hygiene, bedding, food and drink for people sleeping rough 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
Mr. Joseph John MOCHAN (otherwise Joseph John LOPEZ) · 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
Joseph John Mochan, otherwise Joseph John Lopez, was living in a tent in Brighton and died on 11 October 2019. The inquest concluded that the death was misadventure and drug-related. The report raised concerns about homelessness and the lack of coordinated access to safe accommodation, hygiene, food, warmth, and healthcare services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Fragmented provision of homeless care and support services requiring extensive travel between locations
Wider context from the report “There is it seems a political will to help homeless people in Brighton.
On any given night there may be 50 to 200 people sleeping rough on the streets of the city.
Many of them will be using drugs with the violence and criminality associated with this world.
Many will have (associated) mental health problems and likely physical ailments as well.
They have no toilet or washing facilities, no basic hygiene equipment; no change of clothing; no proper bedding; no access to healthy food and drink.
The City has a large number of organisations some charitable, who are dedicated to trying to help and to give the care and support which is needed.
████████ explained to me that there are things which could help.
Such helps centres around a safe place to be and availability of the services which are needed, provided at or adjacent to the safe place.
He told me that it is quite possible for a homeless person to walk 5 to 10 miles a day around the city trying to access the different places where help might be available.
By the time they have arrived at one place they have probably missed another appointment on the other side of the City.
████████ said that he felt there were two main things which if they could be put in place would dramatically improve the plight of the people who are the subject of this report.
Additionally, and in many ways as importantly for all those involved, the services would reduce the amount of spending. Such services, if they existed would provide joined up care, accommodation and support.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of safe accommodation and associated basic hygiene, bedding, food and drink for people sleeping rough
Wider context from the report “There is it seems a political will to help homeless people in Brighton.
On any given night there may be 50 to 200 people sleeping rough on the streets of the city.
Many of them will be using drugs with the violence and criminality associated with this world.
Many will have (associated) mental health problems and likely physical ailments as well.
They have no toilet or washing facilities, no basic hygiene equipment; no change of clothing; no proper bedding; no access to healthy food and drink.
The City has a large number of organisations some charitable, who are dedicated to trying to help and to give the care and support which is needed.
████████ explained to me that there are things which could help.
Such helps centres around a safe place to be and availability of the services which are needed, provided at or adjacent to the safe place.
He told me that it is quite possible for a homeless person to walk 5 to 10 miles a day around the city trying to access the different places where help might be available.
By the time they have arrived at one place they have probably missed another appointment on the other side of the City.
████████ said that he felt there were two main things which if they could be put in place would dramatically improve the plight of the people who are the subject of this report.
Additionally, and in many ways as importantly for all those involved, the services would reduce the amount of spending. Such services, if they existed would provide joined up care, accommodation and support.
” Open source report
Concerns raised 11 Absence of dedicated entrance security staff during patient and visitor arrival hours View source Lack of ward management and matron leadership View source Insufficient substantive staffing and reliance on bank and agency staff View source Inadequate emergency life support and first aid training for healthcare staff View source Lack of patient-centred involvement in care plan updating View source Failure to meaningfully update care plans View source Inadequate completion of accompanying documentation View source Inadequate shift handovers View source Failure to maintain an effective searching system for patients and visitors View source Incomplete and flawed checks and removal of dangerous items from patient rooms View source Failure to properly train staff to carry out patient room checks View source See 8 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
Bethany Tengquist · 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
Bethany Tengquist hanged herself on 29 December 2018 after two telephone charging cables had been removed from her room but her dressing gown cord remained available. The report raises concerns that room checks and the removal of dangerous items were incomplete and flawed, and that staff may not have been properly trained.
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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Absence of dedicated entrance security staff during patient and visitor arrival hours
Wider context from the report “1. The search policy and Beth’s access to alcohol on a frequent basis
Given Beth’s extremely high risk of self-harm or suicide (described by the her Responsible Clinician, a highly experienced psychologist, as one of the very highest risk patients she had encountered in her lengthy career) and characterised by high levels of impulsivity, I have grave concerns that Beth had frequent access to alcohol whilst detained under section 3 of the MHA on an acute ward. It was, or should have been, widely recognised by all staff that an even greater elevation of the already exceptionally high risk of self-harm or suicide would be occasioned by Beth’s access to alcohol; the jury have confirmed that, notwithstanding this clear danger to her safety, there was a persistent and on-going failure to ensure all reasonable steps were taken to ensure that alcohol was not available on the ward. It has been conceded by the Trust that searching policy was inconsistent and ineffective. Whilst I have received evidence with respect to a more robust approach to daily environmental checks having now been introduced, I remain concerned that there is an insufficiently robust and effective system in place for the effective searching of voluntary patients, those detained patients returning from section 17 leave and all visitors to Caburn Ward. The continued absence of dedicated security staff at the entrance to Caburn Ward, during the hours that patients and visitors may arrive , gives rise to a risk of future deaths should alcohol continue to find a route onto the ward.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of ward management and matron leadership
Wider context from the report “5. Staffing levels.
It was accepted by the Unit Co-ordinator, the Clinical Lead Nurse Manager and on behalf of the Trust, that on 29th December 2018 staffing levels on Caburn Ward had reached crisis point: there had been no Ward Manager and no Matron in post and available for a significant period of time , in conjunction with a 50% reduction of substantive staff. There was a reliance on bank and agency staff, and - unsurprisingly in my view - low staff morale. A number of members of staff in evidence emphasised that they had raised the issue of staffing and their concerns with managers and senior managers, to no avail. The obvious concern is that in the context of an acute female ward, such as Caburn, but equally applicable to the male acute ward, where the cohort of patients have such complex and challenging mental health issues, it is critically important that there is a consistency of staffing, management and leadership. The conclusion of the jury reflects and reinforces my concern that the extensive reliance on bank and agency staff undermines the safe operation of the acute wards at Mill View Hospital and, should the position persist, gives rise to the risk of future deaths.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient substantive staffing and reliance on bank and agency staff
Wider context from the report “5. Staffing levels.
It was accepted by the Unit Co-ordinator, the Clinical Lead Nurse Manager and on behalf of the Trust, that on 29th December 2018 staffing levels on Caburn Ward had reached crisis point: there had been no Ward Manager and no Matron in post and available for a significant period of time, in conjunction with a 50% reduction of substantive staff . There was a reliance on bank and agency staff , and - unsurprisingly in my view - low staff morale. A number of members of staff in evidence emphasised that they had raised the issue of staffing and their concerns with managers and senior managers, to no avail. The obvious concern is that in the context of an acute female ward, such as Caburn, but equally applicable to the male acute ward, where the cohort of patients have such complex and challenging mental health issues, it is critically important that there is a consistency of staffing, management and leadership. The conclusion of the jury reflects and reinforces my concern that the extensive reliance on bank and agency staff undermines the safe operation of the acute wards at Mill View Hospital and, should the position persist, gives rise to the risk of future deaths.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate emergency life support and first aid training for healthcare staff
Wider context from the report “3. First aid training.
I am gravely concerned by the evidence that not all health care staff working on Caburn Ward were adequately trained in emergency life support or first aid . It is axiomatic that all members of health care staff must be competent and able to deal with circumstances were first aid skills may need to be deployed . At least one member of staff admitted that she did not have these skills even when she gave evidence to the jury, notwithstanding that she had been appointed as a substantive member of staff some seven months following the death, and three months before she gave evidence.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of patient-centred involvement in care plan updating
Wider context from the report “4. Care Plan not Up-dated.
It was accepted by the Trust that Beth’s Care Plan had not, contrary to requirements of the Care Programme Arrangement, been updated in any meaningful way throughout Beth’s three month section 3 detention prior to her death. As the Clinical Lead Nurse Manager conceded, in the absence of patient centred involvement in the up-dating of the Care Plan , it risks becoming “meaningless” to the patient. In circumstances where a co-authored and co-produced document that actively involves and engages the patient is simply not up-dated meaningfully at all, then the aims and purposes of the CPA risk being undermined. In the context of a patient with Beth’s co-morbidities, the impact may be very serious indeed. The jury’s conclusions in this respect are informative and clear.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to meaningfully update care plans
Wider context from the report “4. Care Plan not Up-dated.
It was accepted by the Trust that Beth’s Care Plan had not, contrary to requirements of the Care Programme Arrangement, been updated in any meaningful way throughout Beth’s three month section 3 detention prior to her death. As the Clinical Lead Nurse Manager conceded, in the absence of patient centred involvement in the up-dating of the Care Plan, it risks becoming “meaningless” to the patient. In circumstances where a co-authored and co-produced document that actively involves and engages the patient is simply not up-dated meaningfully at all, then the aims and purposes of the CPA risk being undermined. In the context of a patient with Beth’s co-morbidities, the impact may be very serious indeed. The jury’s conclusions in this respect are informative and clear.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate completion of accompanying documentation
Wider context from the report “2. Staff training and auditing.
The evidence regarding the wholly inadequate completion of the handover and the accompanying documents in this case is of serious concern, again as reflected by the jury’s conclusion. The handover from late to night shift was chaotic and confused at best. The paperwork was in large parts either wholly inadequately completed or simply not completed at all. All of the agency and bank staff were either new, or at best, had only had a few shifts on Caburn. This clearly elevates the critical importance of a detailed, thorough and professional handover together with full and far more professional completion of the accompanying documentation . I specifically require identification of the steps proposed to dramatically improve these matters.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate shift handovers
Wider context from the report “2. Staff training and auditing.
The evidence regarding the wholly inadequate completion of the handover and the accompanying documents in this case is of serious concern, again as reflected by the jury’s conclusion. The handover from late to night shift was chaotic and confused at best. The paperwork was in large parts either wholly inadequately completed or simply not completed at all. All of the agency and bank staff were either new, or at best, had only had a few shifts on Caburn. This clearly elevates the critical importance of a detailed, thorough and professional handover together with full and far more professional completion of the accompanying documentation. I specifically require identification of the steps proposed to dramatically improve these matters.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an effective searching system for patients and visitors
Wider context from the report “1. The search policy and Beth’s access to alcohol on a frequent basis
Given Beth’s extremely high risk of self-harm or suicide (described by the her Responsible Clinician, a highly experienced psychologist, as one of the very highest risk patients she had encountered in her lengthy career) and characterised by high levels of impulsivity, I have grave concerns that Beth had frequent access to alcohol whilst detained under section 3 of the MHA on an acute ward. It was, or should have been, widely recognised by all staff that an even greater elevation of the already exceptionally high risk of self-harm or suicide would be occasioned by Beth’s access to alcohol; the jury have confirmed that, notwithstanding this clear danger to her safety, there was a persistent and on-going failure to ensure all reasonable steps were taken to ensure that alcohol was not available on the ward. It has been conceded by the Trust that searching policy was inconsistent and ineffective. Whilst I have received evidence with respect to a more robust approach to daily environmental checks having now been introduced, I remain concerned that there is an insufficiently robust and effective system in place for the effective searching of voluntary patients, those detained patients returning from section 17 leave and all visitors to Caburn Ward . The continued absence of dedicated security staff at the entrance to Caburn Ward, during the hours that patients and visitors may arrive, gives rise to a risk of future deaths should alcohol continue to find a route onto the ward.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Incomplete and flawed checks and removal of dangerous items from patient rooms
Wider context from the report “During the course of the Pre-Inquest reviews it has become apparent that vulnerable patients are continuing to self-harm.
The checks which are made and the removal of items which are considered dangerous to patients is clearly incomplete and flawed.
The example with regard to Bethany Tengquist concerns the fact that on the 29th December 2018 when she hanged herself – a short time before she was found, two telephone charging cables were removed from her room and yet her dressing gown cord was left available for her to use to hang herself.
Clearly the system in place to carry out these room checks is unsatisfactory and/or staff are not properly trained to do them.
Please tell me precisely how you are going to put this right.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to properly train staff to carry out patient room checks
Wider context from the report “During the course of the Pre-Inquest reviews it has become apparent that vulnerable patients are continuing to self-harm.
The checks which are made and the removal of items which are considered dangerous to patients is clearly incomplete and flawed.
The example with regard to Bethany Tengquist concerns the fact that on the 29th December 2018 when she hanged herself – a short time before she was found, two telephone charging cables were removed from her room and yet her dressing gown cord was left available for her to use to hang herself.
Clearly the system in place to carry out these room checks is unsatisfactory and/or staff are not properly trained to do them .
Please tell me precisely how you are going to put this right.
” Open source report
Concerns raised 6 Risk of using prescribed Propranolol for overdose View source Failure to agree and update a common action plan for revoked s.17 leave View source Failure to collect and return patients to the ward when s.17 leave is revoked View source Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol View source Failure to finalise the formal revocation of s.17 leave View source Lack of shared awareness of powers and responsibilities when s.17 leave is revoked View source See 3 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
Sasha Sabrina FORSTER · 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
Sasha Sabrina FORSTER, a 20-year-old woman with a lengthy history of mental health disorders, self-harm and overdoses, died by suicide following deliberate ingestion of a fatal overdose of Propranolol tablets. The inquest identified concerns that hospitals and police forces were not always aware of their powers and responsibilities when her section 17 leave was revoked, or had not agreed and updated a common plan, resulting in inconsistent actions and an increased risk to Sasha.
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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Risk of using prescribed Propranolol for overdose
Wider context from the report “Evidence was heard at the inquest that after her treating psychiatrist had stopped prescribing her Propranolol, due to the risk of overdose, Sasha visited two private GPs at a clinic in London, on occasions two weeks apart.
In each consultation Sasha:
- requested Propranolol, on the basis that it was currently being prescribed to her for anxiety;
- revealed a limited history of mental health issues;
- failed to reveal either her extensive overdose history or the fact that her treating psychiatrist had stopped prescribing her Propranolol.
Without details of Sasha’s GP or her treating psychiatrist, or her consent to contact them ( neither of which was given ), neither GP had the means of discovering her worrying psychiatric background. Had they had those means, it is likely that neither GP would have given her a 28 day supply of Propranolol.
Whilst it could not be proven that the Propranolol prescribed by these GPs was the Propranolol used by Sasha for her final, fatal overdose, there remained at the time a considerable risk that she would so use 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to agree and update a common action plan for revoked s.17 leave
Wider context from the report “Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked, or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances .
As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or not.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to collect and return patients to the ward when s.17 leave is revoked
Wider context from the report “(1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked , was that they did not have the resources to allow them to do this , despite it being their legal responsibility so to do .
(2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked , placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request.
(3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised, Sasha’s mother was given to believe that it would be, and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol
Wider context from the report “Evidence was heard at the inquest that after her treating psychiatrist had stopped prescribing her Propranolol, due to the risk of overdose, Sasha visited two private GPs at a clinic in London, on occasions two weeks apart.
In each consultation Sasha:
- requested Propranolol, on the basis that it was currently being prescribed to her for anxiety;
- revealed a limited history of mental health issues;
- failed to reveal either her extensive overdose history or the fact that her treating psychiatrist had stopped prescribing her Propranolol.
Without details of Sasha’s GP or her treating psychiatrist, or her consent to contact them ( neither of which was given ), neither GP had the means of discovering her worrying psychiatric background. Had they had those means, it is likely that neither GP would have given her a 28 day supply of Propranolol.
Whilst it could not be proven that the Propranolol prescribed by these GPs was the Propranolol used by Sasha for her final, fatal overdose, there remained at the time a considerable risk that she would so use 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to finalise the formal revocation of s.17 leave
Wider context from the report “(1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked, was that they did not have the resources to allow them to do this, despite it being their legal responsibility so to do.
(2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked, placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request.
(3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised , Sasha’s mother was given to believe that it would be , and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of shared awareness of powers and responsibilities when s.17 leave is revoked
Wider context from the report “Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked , or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances.
As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or not.
” Open source report
Concerns raised 2 Failure to apply adequate safeguards when prescribing potentially dependence-forming or misused medication View source Failure of prescribing-system warnings to prevent inappropriate override View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Darren James CARRINGTON · 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
Darren James CARRINGTON died after collapsing with a fatal level of Zopiclone in his blood and did not recover. The inquest concluded that the death was misadventure, being an impulsive overdose while under the influence of alcohol. Concerns included the prescribing of potentially dependency-forming medication, excessive Zopiclone prescribing over 57 days, and the ability of receptionists and clinicians to override computer warnings and other safeguards.
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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to apply adequate safeguards when prescribing potentially dependence-forming or misused medication
Wider context from the report “The method of prescribing medication such as Zopiclone (in this case), Codeine, Morphine, Benzodiazepines etc. to patients which suggests that they either are or are very likely to be becoming dependent upon such medications or are misusing them.
Examples of both the above would be too frequent requests for repeat prescriptions and information concerning a history of overdoses.
The Inquest discussed whether circumstances, including those outlined above should trigger an automatic/mandatory medication review conducted with the patient; consideration of a different prescribing period and very careful monitoring of the online requests for repeat prescriptions.
Alternatively, there could be a ban on the requests for repeat prescriptions with the repeats simply being issued for an appropriate period of time “automatically”.
In this case as you will see from ████████ report, over twice the appropriate amount of Zopiclone was issued over a period of 57 days.
The patient in question had Zopiclone present at a fatal level in his blood at the time of his collapse from which he never recovered.
I remain very worried about these prescribing issues and about the fact that apparently receptionists and clinicians can override the warnings in the surgery’s computer system. I should like this to be carefully investigated and look forward to hearing with a response within the relevant time period.
I realise that the situation may be exacerbated by GPs working part time and many part time practitioners being involved in the prescribing procedure as well as many receptionists being involved in it but if this is the trend then it seems to me the safeguards must be extended not made easier to override.
The other ‘failsafe device’ is the dispensing pharmacist. When repeats are requested online there is a designated pharmacy. They receive emailed scripts. Their own systems should flag up cases of over or too frequent prescribing as well as other matters.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of prescribing-system warnings to prevent inappropriate override
Wider context from the report “The method of prescribing medication such as Zopiclone (in this case), Codeine, Morphine, Benzodiazepines etc. to patients which suggests that they either are or are very likely to be becoming dependent upon such medications or are misusing them.
Examples of both the above would be too frequent requests for repeat prescriptions and information concerning a history of overdoses.
The Inquest discussed whether circumstances, including those outlined above should trigger an automatic/mandatory medication review conducted with the patient; consideration of a different prescribing period and very careful monitoring of the online requests for repeat prescriptions.
Alternatively, there could be a ban on the requests for repeat prescriptions with the repeats simply being issued for an appropriate period of time “automatically”.
In this case as you will see from ████████ report, over twice the appropriate amount of Zopiclone was issued over a period of 57 days.
The patient in question had Zopiclone present at a fatal level in his blood at the time of his collapse from which he never recovered.
I remain very worried about these prescribing issues and about the fact that apparently receptionists and clinicians can override the warnings in the surgery’s computer system . I should like this to be carefully investigated and look forward to hearing with a response within the relevant time period.
I realise that the situation may be exacerbated by GPs working part time and many part time practitioners being involved in the prescribing procedure as well as many receptionists being involved in it but if this is the trend then it seems to me the safeguards must be extended not made easier to override .
The other ‘failsafe device’ is the dispensing pharmacist. When repeats are requested online there is a designated pharmacy. They receive emailed scripts. Their own systems should flag up cases of over or too frequent prescribing as well as other matters.
” 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 Discuss sharing the high-risk medication review protocol with a linked practice.
Verbatim wording from the response “• Ongoing discussions with linked Practice around sharing high risk medication review protocol.” Source location 2018-0181-Response-from-Commission-Alliance-
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 Lower computer-alert thresholds for early prescription ordering and increase awareness of relevant alerts.
Verbatim wording from the response “• Computer settings changed with a view to lower thresholds for flagging up early ordering of scripts and increased awareness around the potential significance of these and other alerts.” Source location 2018-0181-Response-from-Commission-Alliance-
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 Embed the high-risk drug review protocol with support from the Medication Management team.
Verbatim wording from the response “Our Medication Management team are providing ongoing support. In particular, around embedding The High Risk Drug review protocol mentioned above, as well as ensuring that the new Practice Repeat Prescribing Policy covers current best practice.” Source location 2018-0181-Response-from-Commission-Alliance-
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 protected administrative and clinical staff time to manage prescription requests.
Verbatim wording from the response “• Arrangements have been made to ensure administrative and clinical staff have adequate, protected time to manage prescription requests.” Source location 2018-0181-Response-from-Commission-Alliance-
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 Ensure the new Practice Repeat Prescribing Policy covers current best practice.
Verbatim wording from the response “Our Medication Management team are providing ongoing support. In particular, around embedding The High Risk Drug review protocol mentioned above, as well as ensuring that the new Practice Repeat Prescribing Policy covers current best practice.” Source location 2018-0181-Response-from-Commission-Alliance-
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 high-risk prescribing records and remove online prescription-request access for weekly, controlled, dependency-forming and potentially abusive medicines.
Verbatim wording from the response “• Records of all patients receiving weekly prescriptions have been reviewed and access to on-line requests have been removed.” Source location 2018-0181-Response-from-Commission-Alliance-
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 Increase staff awareness of frequent requests for small medication quantities as potential risk indicators.
Verbatim wording from the response “I can confirm that the following changes have been implemented at North Laine Surgery via a Practice Meeting attended by all staff:-” Source location 2018-0181-Response-from-Commission-Alliance-
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 Audit records of patients receiving Zopiclone and review their prescribed quantities.
Verbatim wording from the response “I can confirm that the following changes have been implemented at North Laine Surgery via a Practice Meeting attended by all staff:-” Source location 2018-0181-Response-from-Commission-Alliance-
Open published response
Concerns raised 1 Failure to provide adequate information during transfer of patients between GP practices View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ross REEVES · 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
Ross REEVES died after taking more than one week’s worth of Gabapentin, Zomorph and Mirtazapine, which caused profound stupor and respiratory depression; he subsequently developed lobar pneumonia. The principal concern was that his transfer to a new GP was likely unsafe and that better handover information might have led to different prescribing arrangements.
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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate information during transfer of patients between GP practices
Wider context from the report “(1) The transfer of this patient to his new GP was likely ‘unsafe’.
I am particularly concerned because in Brighton and Hove we have an extremely high rate of drug related deaths.
It seems to me that there were clues to this man’s death and if there had been more information available to the new GP it is highly likely that they would have taken different action with regard to him . In particular, they may well have prescribed his medications weekly rather than monthly.
At the Inquest it was clear that only he had access to the medications that he collected on the 3rd October, 2017 and that with regard to Gabapentin, Zomorph and Mirtazapine he took over one week’s worth of each. This caused his sudden collapse, his state of profound stupor and his ultimate death due to a lobar pneumonia which developed during the time he was in such a state of profound respiratory depression due to the drugs that he had been able to take.
I would like it made clear that the Inquest is not a vehicle for apportioning blame however lessons must be learned and it was clear that better hand over of patients from one practice to another would provide a better chance for the manipulative patient who lies to his new GP to be picked up and dealt with adequately , hopefully preventing his death.
” 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 Clarify the digital issues causing corruption or loss of correspondence during GP-to-GP data transfer.
Verbatim wording from the response “On registration, St Peter’s asked for a faxed summary (from RR’s previous Practice) that arrived promptly, as did an electronic summary via the ‘GP to GP’ process. Unfortunately, St Peter’s were unable to access details of correspondence via the electronic record; the digital explanation for this is unclear and requires urgent clarification, as full access was not possible until after RR’s death.” Source location 2018-0093-Response-by-Brighton-Hove-CCG
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 Clarify the reasons for delayed paper-record transfers against Primary Care Support England’s contractual obligations.
Verbatim wording from the response “The paper records arrived on 12/12/2017 having been requested on 10/10/2017. The records were requested urgently; this delay is very concerning and warrants clarification as a priority.” Source location 2018-0093-Response-by-Brighton-Hove-CCG
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 Alert local primary care to safe data transfer, robust coding and restricted medication quantities for high-risk patients, advising practices to adopt a blanket policy.
Verbatim wording from the response “1. Alert to local Primary Care, highlighting issues around safe transfer of data [paper and electronic] during patient transfer, robust coding and the importance of restricting quantities of medication in patients identified as high risk until relevant clinical notes are available, and a period of assessment has reassured the new practice that prescribed medicines are used according to directions. Practices will be advised to adopt a blanket policy thereby removing the need for negotiation with individual patients.” Source location 2018-0093-Response-by-Brighton-Hove-CCG
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 Have the Task and Finish group report on prescribing-safety and patient-transfer issues within six to eight weeks.
Verbatim wording from the response “This Task and Finish group will aim to report over the next 6-8 weeks. In addition to covering the issues raised above, I envisage:” Source location 2018-0093-Response-by-Brighton-Hove-CCG
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 NHSE commissions Primary Care Support England, which is responsible for the paper-record transfer service.
Verbatim wording from the response “3. Clarification as to reasons for delay in paper records arriving in the context of contractual obligation of Primary Care Support England. Commissioning of this service is via NHSE.” Source location 2018-0093-Response-by-Brighton-Hove-CCG
Open published response
Concerns raised 3 Failure to conduct timely and sufficiently informed medication reviews for long-term repeat prescriptions View source Inadequate recording of medication reviews and reasons for repeat prescribing View source Failure to establish and record arrangements for repeat prescription collection, delivery and pharmacy coordination 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
David Edward Jackson · 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
David Edward Jackson, a 76-year-old man, fell at home and remained on the floor for about two weeks before he died on 17 July 2017. His death was recorded as accidental, with severe pressure sores associated with sepsis, toxaemia and rhabdomyolysis following prolonged immobility. Concerns included long-term repeat prescribing of Co-dydramol and Soneryl without regular face-to-face medical review, and unclear arrangements for prescription collection or delivery.
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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct timely and sufficiently informed medication reviews for long-term repeat prescriptions
Wider context from the report “Over the next 10 years, the records note a medication review was conducted by ████████ on 21 Oct 2008 and 2 March 2010 but on the records alone . There is one entry on the patient record for ████████ on 23 November 2015 noting only ‘medication review done’. When giving evidence, ████████ indicated that when ████████ retired in 2015 she took over Mr Jackson as a patient but she had never actually seen him . Her recollection was that she had conducted annual medication reviews by considering the patient's past history but only one is noted on the record printout.
GMC good practice guidance was discussed with ████████ as follows:
• Good medical practice (2013) – para 16: In providing clinical care you must prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient's health, and are satisfied that the drugs or treatment serve the patient's needs; and,
• Prescribing and Managing Medicines (2013) – paragraphs 51; 54; 55; 56; 59
o 51: Whether you prescribe with repeats or on a oneoff basis, you must make sure that suitable arrangements are in place for monitoring, follow-up and review, taking account of the patients' needs and any risks arising from the medicines.
o 54: Pharmacists can help improve safety, efficacy and adherence in medicines use, for example by advising patients about their medicines and carrying out medicines reviews. This does not relieve you of your duty to ensure that your prescribing and medicines management is appropriate…
o 55: You are responsible for any prescription you sign, including repeat prescriptions for medicines initiated by colleagues, so you must make sure that any repeat prescription you sign is safe and appropriate. You should consider the benefits of prescribing with repeats to reduce the need for repeat prescribing.
o 56: As with any prescription, you should agree with the patient what medicines are appropriate and how their condition will be managed, including a date for review. You should make clear why regular reviews are important and explain to the patient what they should do if they:
a) suffer side effects or adverse reactions, or
b) stop taking the medicines before the agreed review date (or a set number of repeats have been issued), You must make clear records of these discussions and your reasons for repeat prescribing.
o 59: When you issue repeat prescriptions or prescribe with repeats, you should make sure that procedures are in place to monitor whether the medicine is still safe and necessary for the patient. You should keep a record of dispensers who hold original repeat dispensing prescriptions so that you can contact them if necessary.
1. When asked about current practice in relation to issuing prescriptions for drugs such as Soneryl or Co-dydramol ████████ acknowledged national guidance had tightened up particularly in respect of issuing prescriptions to patients for opiate based drugs. She accepted that medical thinking had moved on considerably. She was candid and accepted that in respect of Mr Jackson he had not been seen for 10 years and must have fallen through the cracks in terms of medication reviews including a period when the surgery had a shortage of doctors. This suggests a need to review:
a. how and when medication reviews are carried out in the Fitzalan Medical Group;
b. a potential training need for group doctors in GMC good practice; or,
c. the development of a local CCG/Group policy.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate recording of medication reviews and reasons for repeat prescribing
Wider context from the report “Over the next 10 years, the records note a medication review was conducted by ████████ on 21 Oct 2008 and 2 March 2010 but on the records alone. There is one entry on the patient record for ████████ on 23 November 2015 noting only ‘medication review done’ . When giving evidence, ████████ indicated that when ████████ retired in 2015 she took over Mr Jackson as a patient but she had never actually seen him. Her recollection was that she had conducted annual medication reviews by considering the patient's past history but only one is noted on the record printout .
GMC good practice guidance was discussed with ████████ as follows:
• Good medical practice (2013) – para 16: In providing clinical care you must prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient's health, and are satisfied that the drugs or treatment serve the patient's needs; and,
• Prescribing and Managing Medicines (2013) – paragraphs 51; 54; 55; 56; 59
o 51: Whether you prescribe with repeats or on a oneoff basis, you must make sure that suitable arrangements are in place for monitoring, follow-up and review, taking account of the patients' needs and any risks arising from the medicines.
o 54: Pharmacists can help improve safety, efficacy and adherence in medicines use, for example by advising patients about their medicines and carrying out medicines reviews. This does not relieve you of your duty to ensure that your prescribing and medicines management is appropriate…
o 55: You are responsible for any prescription you sign, including repeat prescriptions for medicines initiated by colleagues, so you must make sure that any repeat prescription you sign is safe and appropriate. You should consider the benefits of prescribing with repeats to reduce the need for repeat prescribing.
o 56: As with any prescription, you should agree with the patient what medicines are appropriate and how their condition will be managed, including a date for review. You should make clear why regular reviews are important and explain to the patient what they should do if they:
a) suffer side effects or adverse reactions, or
b) stop taking the medicines before the agreed review date (or a set number of repeats have been issued), You must make clear records of these discussions and your reasons for repeat prescribing .
o 59: When you issue repeat prescriptions or prescribe with repeats, you should make sure that procedures are in place to monitor whether the medicine is still safe and necessary for the patient. You should keep a record of dispensers who hold original repeat dispensing prescriptions so that you can contact them if necessary.
1. When asked about current practice in relation to issuing prescriptions for drugs such as Soneryl or Co-dydramol ████████ acknowledged national guidance had tightened up particularly in respect of issuing prescriptions to patients for opiate based drugs. She accepted that medical thinking had moved on considerably. She was candid and accepted that in respect of Mr Jackson he had not been seen for 10 years and must have fallen through the cracks in terms of medication reviews including a period when the surgery had a shortage of doctors. This suggests a need to review:
a. how and when medication reviews are carried out in the Fitzalan Medical Group;
b. a potential training need for group doctors in GMC good practice; or,
c. the development of a local CCG/Group policy.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to establish and record arrangements for repeat prescription collection, delivery and pharmacy coordination
Wider context from the report “2. ████████ was also asked how were repeat prescriptions requested, collected or delivered . She was unable to help me in Mr Jackson's case but referred to a potential patient advocate, I believe meaning the person who nominated to collect his prescription. In this case for some time that was ████████ but given her increasing immobility this may have been a neighbour. ████████ also referred to working with local pharmacists but the details are unclear . This again suggests a need to review:
a. the period of time that Mr Jackson remained on repeat prescriptions without being seen;
b. the unknown arrangements for collection or delivery ; and,
c. possibly the arrangements with local pharmacies .
” Open source report
Concerns raised 3 Lack of local in-patient detoxification facility availability View source Failure to provide collaborative, integrated dual diagnosis treatment and assessment View source Delays in access to in-patient detoxification View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Thomas Christall · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Thomas Christall’s inquest concluded that he took his own life. Concerns included the lack of a local inpatient detoxification facility, long waiting times, and insufficiently collaborative treatment for people with dual diagnosis, with delays and refusals increasing distress and despair.
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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of local in-patient detoxification facility availability
Wider context from the report “(1) That there is no local in-patient detox facility such as used to exist at Millview Hospital . It is not acceptable that local people needing in-patient detox have to travel to Islington away from family and friends. It is also unacceptable that the waiting list is so long especially when often Mental Health will not be fully addressed until detox has taken place. How many dual diagnosis patients are there in the UK?
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide collaborative, integrated dual diagnosis treatment and assessment
Wider context from the report “(2) A much more collaborative approach to dual diagnosis patient's treatment is needed.
The dual diagnosis is at the heart of this problem. It is not appropriate to try to separate each component and only agree to treat/assess one component when the other is dealt with. The dual diagnosis is the person. When in crisis they are doubly at risk. That period of risk should be reduced as quickly as possible. The delays and refusals serve to exacerbate the patient's distress and increase their despair.
As Thomas Wall said in a text message to his supportive ex-wife
‘I want to get better but I can’t do that on my own whereas I can take my life on my own’
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in access to in-patient detoxification
Wider context from the report “(1) That there is no local in-patient detox facility such as used to exist at Millview Hospital. It is not acceptable that local people needing in-patient detox have to travel to Islington away from family and friends. It is also unacceptable that the waiting list is so long especially when often Mental Health will not be fully addressed until detox has taken place. How many dual diagnosis patients are there in the UK?
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an integrated dual-diagnosis service model with co-located workers, shared records, agreed pathways and regular complex-case meetings.
Verbatim wording from the response “Progress has been made in a number of areas including the implementation of a Dual Diagnosis integrated model through the re-procurement of substance misuse services. 3.5 whole-time equivalent DD workers are now co-located with mental health services to increase joint working, engagement with support, and ensure smooth transition. Clinicians within substance misuse services can now access Sussex Partnership electronic patient records and vice versa. There are now agreed pathways between the services with regular meetings where complex cases are discussed to ensure that people receive appropriate support and care and do not fall between the gaps.” Source location 2017-0321-Response-by-Brighton-and-Hove-Clinical-Commissioning-Group
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 Establish dual-diagnosis referral and care protocols, related training, and access to primary-care mental-health support.
Verbatim wording from the response “Agreed referral and care pathway protocols are now in place for those with dual needs including increased awareness and training and increased access to primary care mental health support for those with dual needs which are no longer an automatic exclusion. The new service specification for primary mental health services supports a more proactive approach.” Source location 2017-0321-Response-by-Brighton-and-Hove-Clinical-Commissioning-Group
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 Brighton & Hove City Council’s Public Health department is responsible for commissioning adult and substance misuse inpatient detoxification beds.
Verbatim wording from the response “As a CCG we are very keen to reflect on the services we commission with a view to making improvements and avoiding future patient harm. Brighton & Hove City Council’s Public Health department is the responsible commissioner for the adult and substance misuse in-patient detoxification beds. ████████ Interim Director of Public Health has therefore provided a reply although he and his team were not named in the report.” Source location 2017-0321-Response-by-Brighton-and-Hove-Clinical-Commissioning-Group
Open published response
Concerns raised 3 Failure to ensure telephone clinical advice is accurately recorded and communicated in writing View source Lack of clarity about responsibility for recording visiting GPs' advice in multidisciplinary notes View source Unclear out-of-hours pathology laboratory provision for community care providers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ernest Higgs · 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
Ernest Higgs, a resident of a nursing home, was admitted to hospital after his health deteriorated and died there on 20 January 2015 from aspiration pneumonia. Concerns included unclear and poorly recorded telephone advice from a GP, uncertainty over responsibility for recording clinical advice, and conflicting information about out-of-hours pathology services that contributed to a delay in blood testing.
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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure telephone clinical advice is accurately recorded and communicated in writing
Wider context from the report “(2) Advice given by the GP over the telephone to make Mr Higgs “nil by mouth” was not recorded and no confirmation of that advice in writing was sent by email . There did not appear to be a safe system in place to ensure telephone advice was accurately sent and received.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about responsibility for recording visiting GPs' advice in multidisciplinary notes
Wider context from the report “(1) It was clear from the evidence that confusion arose over what advice had been given by the GP on the 15th January 2015. No record was made in the multi-disciplinary notes by the GP of her attendance at Milner House. Care UK the parent company of Milner House offered to liaise with their local surgeries to ensure the records were made by visiting GPs. However it appears that the BMA advice to GPs “Quality First Managing Workload To Deliver Safer Patient Care” advises against GPs filling in multi-disciplinary notes. There was no clarity about whose responsibility it was to fill in the notes.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unclear out-of-hours pathology laboratory provision for community care providers
Wider context from the report “(3) There was conflicting evidence from Care UK and Epsom hospital about OOH provision at the hospital pathology laboratory for community care providers resulting in a significant delay to a diagnostic blood test being undertaken.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require the Continuing Healthcare team to raise concerns about poor care documentation or communication between general practitioners and care-home staff.
Verbatim wording from the response “5. NHS Surrey Downs CCG leads the Continuing Healthcare (CHC) function on behalf of all CCGs in Surrey, as a ‘spot’ commissioner I have asked the CHC team to raise concerns should they find poor documentation either from the nursing/residential home and/or poorly documented communication between general practitioner and care home staff.” Source location 2016-0181-Response-by-Surrey-Downs-Clinical-Commissioning-Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a nursing-home Primary Care Standard requiring proactive general-practitioner health assessments and interventions at least twice yearly, with documented instructions.
Verbatim wording from the response “3. We are at the final stages of developing a nursing home Primary Care Standard (PCS), the PCS is a proactive health assessment and intervention by a general practitioner at least twice per year for every nursing home resident. I will also ensure that the requirement to clearly document and evidence instructions by a general practitioner is also included.” Source location 2016-0181-Response-by-Surrey-Downs-Clinical-Commissioning-Group
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 Ask Surrey Care Association to communicate the importance of contemporaneous documentation to its members.
Verbatim wording from the response “6. I have asked Surrey Care Association to communicate with its members the importance of contemporaneous documentation, care home and sub contracted staff registered with a professional regulator such as the Nursing and Midwifery Council or General Medical Council have a professional obligation to ensure documentation is accurate and contemporaneous.” Source location 2016-0181-Response-by-Surrey-Downs-Clinical-Commissioning-Group
Open published response
Concerns raised 3 Delays in referral to appropriate specialist services View source Failure to transmit private-sector diagnostic results into the local NHS system View source Failure to recognise and use available expedited referral routes 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
Geoffrey John MOYSE · 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
Geoffrey John MOYSE’s death was the subject of an inquest that concluded with a finding of Medical Misadventure. The report raised concerns about an eight-month delay in referral, poor communication between providers, and failures to transfer investigation results into the NHS system, leaving him unwell, undiagnosed and untreated for too long.
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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in referral to appropriate specialist services
Wider context from the report “(1) Please see the attached letter dated the 19th December 2014 which explains the system which was put in place by the CCG.
Please refer to Part 3 of the attached Record of Inquest to learn what happened in Mr Moyse’s case.
It is clear to me from the evidence I heard at the Inquest that there was a huge delay in referring him (its right to say that some of that delay was due to Mr Moyse being unable to help speed the process up). Nonetheless, it took eight months from referral to seeing the appropriate Surgeon and I should imagine a referral direct to Digestive Diseases would have been substantially quicker than that .
There was no understanding it seems by the people involved in the arrangements that it was probably possible to try and short circuit them. For example, why did the Consultant Gastroenterologist not contact the colorectal clinic himself or even copy his letter and his histology report sent to the GP on the 29th June 2015?
Why did BICS, who were sent a copy of the histology report, not forward this to anyone else e.g. the colo-rectal clinic to see whether it would produce the urgent result which the GP was seeking to achieve?
Could the GP have done a two week referral at the very beginning? Would that have come within Code 2 on the letter of the 19th December 2015? If he had, perhaps the whole system would have worked.
One of the problems in existence appears to be that because the initiative involves private hospitals, some private hospitals will use their own histo-pathologists to analyse results of procedures such as colonoscopies instead of using the National Health laboratories. This means that the results do not automatically feed in to the local NHS system. Surely it would be possible to insist that all x-ray results, MRI scans, CT scans, histopathology reports etc. etc. which arise in this way as part of an NHS initiative involving the private sector must be transmitted back into the NHS system at the earliest possible opportunity.
It just seems to me that this system broke down because these processes seem to work with any reference to a joined up approach and the person who suffers is the patient.
In this case I was eventually satisfied that this did not adversely affect the outcome with Mr Moyse but certainly it meant that the whole process for him was hugely delayed and he was left unwell, undiagnosed and untreated for far, far too long. I would like to see a complete review of this process and I am sure that Mrs Moyse would be happy, suitably anonymised, if Mr Moyse’s case could be used to ensure that this does not happen again to another patient where this delay might have been fatal on its own.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to transmit private-sector diagnostic results into the local NHS system
Wider context from the report “(1) Please see the attached letter dated the 19th December 2014 which explains the system which was put in place by the CCG.
Please refer to Part 3 of the attached Record of Inquest to learn what happened in Mr Moyse’s case.
It is clear to me from the evidence I heard at the Inquest that there was a huge delay in referring him (its right to say that some of that delay was due to Mr Moyse being unable to help speed the process up). Nonetheless, it took eight months from referral to seeing the appropriate Surgeon and I should imagine a referral direct to Digestive Diseases would have been substantially quicker than that.
There was no understanding it seems by the people involved in the arrangements that it was probably possible to try and short circuit them. For example, why did the Consultant Gastroenterologist not contact the colorectal clinic himself or even copy his letter and his histology report sent to the GP on the 29th June 2015?
Why did BICS, who were sent a copy of the histology report, not forward this to anyone else e.g. the colo-rectal clinic to see whether it would produce the urgent result which the GP was seeking to achieve?
Could the GP have done a two week referral at the very beginning? Would that have come within Code 2 on the letter of the 19th December 2015? If he had, perhaps the whole system would have worked.
One of the problems in existence appears to be that because the initiative involves private hospitals, some private hospitals will use their own histo-pathologists to analyse results of procedures such as colonoscopies instead of using the National Health laboratories. This means that the results do not automatically feed in to the local NHS system . Surely it would be possible to insist that all x-ray results, MRI scans, CT scans, histopathology reports etc. etc. which arise in this way as part of an NHS initiative involving the private sector must be transmitted back into the NHS system at the earliest possible opportunity .
It just seems to me that this system broke down because these processes seem to work with any reference to a joined up approach and the person who suffers is the patient.
In this case I was eventually satisfied that this did not adversely affect the outcome with Mr Moyse but certainly it meant that the whole process for him was hugely delayed and he was left unwell, undiagnosed and untreated for far, far too long. I would like to see a complete review of this process and I am sure that Mrs Moyse would be happy, suitably anonymised, if Mr Moyse’s case could be used to ensure that this does not happen again to another patient where this delay might have been fatal on its own.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and use available expedited referral routes
Wider context from the report “(1) Please see the attached letter dated the 19th December 2014 which explains the system which was put in place by the CCG.
Please refer to Part 3 of the attached Record of Inquest to learn what happened in Mr Moyse’s case.
It is clear to me from the evidence I heard at the Inquest that there was a huge delay in referring him (its right to say that some of that delay was due to Mr Moyse being unable to help speed the process up). Nonetheless, it took eight months from referral to seeing the appropriate Surgeon and I should imagine a referral direct to Digestive Diseases would have been substantially quicker than that.
There was no understanding it seems by the people involved in the arrangements that it was probably possible to try and short circuit them . For example, why did the Consultant Gastroenterologist not contact the colorectal clinic himself or even copy his letter and his histology report sent to the GP on the 29th June 2015?
Why did BICS, who were sent a copy of the histology report, not forward this to anyone else e.g. the colo-rectal clinic to see whether it would produce the urgent result which the GP was seeking to achieve?
Could the GP have done a two week referral at the very beginning? Would that have come within Code 2 on the letter of the 19th December 2015? If he had, perhaps the whole system would have worked.
One of the problems in existence appears to be that because the initiative involves private hospitals, some private hospitals will use their own histo-pathologists to analyse results of procedures such as colonoscopies instead of using the National Health laboratories. This means that the results do not automatically feed in to the local NHS system. Surely it would be possible to insist that all x-ray results, MRI scans, CT scans, histopathology reports etc. etc. which arise in this way as part of an NHS initiative involving the private sector must be transmitted back into the NHS system at the earliest possible opportunity.
It just seems to me that this system broke down because these processes seem to work with any reference to a joined up approach and the person who suffers is the patient.
In this case I was eventually satisfied that this did not adversely affect the outcome with Mr Moyse but certainly it meant that the whole process for him was hugely delayed and he was left unwell, undiagnosed and untreated for far, far too long. I would like to see a complete review of this process and I am sure that Mrs Moyse would be happy, suitably anonymised, if Mr Moyse’s case could be used to ensure that this does not happen again to another patient where this delay might have been fatal on its own.
” Open source report
Concerns raised 1 Lack of ready access to necessary dressings for nursing homes and Community Nurses treating pressure sores 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
James Bateley · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Bateley was admitted to Worthing Hospital with severe pressure sores and died on 6 June 2014; the stated cause of death included bronchopneumonia, sepsis, necrotising fasciitis and a pressure wound. The report raised concern that nursing homes and community nurses did not have ready access to necessary dressings, which could take up to 14 days to arrive and meant that, in Mr Bateley’s case, staff borrowed dressings from another resident.
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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of ready access to necessary dressings for nursing homes and Community Nurses treating pressure sores
Wider context from the report “During the evidence it became apparent that neither the nursing home, where Mr Bateley was living, nor the Community Nurses, who had been called in to assist in treating Mr Bateley’s pressure sores had ready access to the necessary dressings . There was evidence given that these dressings are not readily available to nursing homes or the Community Nurses who regularly have to treat this type of ailment . The dressings have to be ordered through the GP and we were told that it could take up to 14 days for them to arrive . In Mr Bateley’s case staff had to borrow and make use other resident’s dressings. Sadly Mr Bateley was taken into hospital before his dressings arrived. Whilst the absence of these dressing was unlikely to have contributed directly to Mr Bateley’s death there is concern for others in the future who cannot rely on others to borrow dressing from.
” Open source report
Concerns raised 14 Insufficiently detailed EDS referral information about low sodium and blood results View source Failure to consider chemical pathology flagging of particularly concerning results View source Lack of a national protocol for assessing seriously ill eating-disorder patients for an organic basis View source No established GP practice system for recognition, assessment and management of electrolyte abnormalities View source Lack of GP routine vital sign monitoring when weight loss is a concern View source Insufficient reinforcement of excluding an organic basis before psychiatric or psychological labelling View source Lack of a documented list of potential diagnoses for exclusion at eating-disorder triage View source Lack of hospital or GP notes available to the post-mortem pathologist View source Failure to robustly assess presenting signs and symptoms and consider or exclude organic causes View source Lack of understanding of hyponatraemia causes, investigation thresholds and required investigations View source Insufficient communication from referral agents to the eating disorder service View source Poor GP documentation View source Insufficiently robust EDS eating-disorder triage proforma for considering and excluding organic causes View source Insufficiently clear published guidance on the causes, investigation and treatment of low blood sodium View source See 11 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
Clare Serena Anke COOPER · 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
Clare Serena Anke Cooper, a young adult, developed weight loss, lassitude, dizziness, nausea, difficulty eating and an intermittently low blood sodium level before dying after a cardiorespiratory arrest and hospital admission. The inquest concluded that she died from the consequences of undiagnosed Addison’s disease and an Addisonian crisis. Principal concerns included inadequate assessment and documentation in primary care, failure to investigate the low sodium and possible physical causes, insufficient eating-disorder service triage processes, and inadequate information available for the post-mortem 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficiently detailed EDS referral information about low sodium and blood results
Wider context from the report “6. Insufficiently detailed referral letter to EDS (mentioning ‘low sodium’ but not accompanied with a copy of the blood results ) and an opportunity was lost for its significance to be considered
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to consider chemical pathology flagging of particularly concerning results
Wider context from the report “4. No established system for recognition, assessment and management of electrolyte abnormalities within the GP practice and/or consideration of the chemical pathology service to ‘flag-up’ particularly concerning results .
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a national protocol for assessing seriously ill eating-disorder patients for an organic basis
Wider context from the report “8. The lack of a national protocol for assessing patients seriously ill with an eating disorder with the possibility of detecting individuals with an organic basis for the condition .
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation No established GP practice system for recognition, assessment and management of electrolyte abnormalities
Wider context from the report “4. No established system for recognition, assessment and management of electrolyte abnormalities within the GP practice and/or consideration of the chemical pathology service to ‘flag-up’ particularly concerning results.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of GP routine vital sign monitoring when weight loss is a concern
Wider context from the report “3. Lack of GP routine vital sign monitoring e.g. heart rate, blood pressure and weight measurement when weight loss is a concern with a lost opportunity to assess the severity of weight loss.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient reinforcement of excluding an organic basis before psychiatric or psychological labelling
Wider context from the report “10. The need to highlight this case nationally to clarify published guidance with regard to the causes, investigation and treatment of low blood sodium and to reinforce the importance of excluding an organic basis of an illness before labelling the condition a psychiatric or psychological disorder .
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a documented list of potential diagnoses for exclusion at eating-disorder triage
Wider context from the report “7. Insufficiently robust EDS proforma used to triage patients for an eating disorder: lack of prompts and a need to emphasise and exclude organic causes, however rare. The lack of a documented list of potential diagnoses to be assessed and excluded at triage, including organic causes. A need to facilitate communication from the referral agents to the eating disorder service.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of hospital or GP notes available to the post-mortem pathologist
Wider context from the report “9. Lack of hospital or GP notes available for the pathologist undertaking the post mortem to facilitate a greater opportunity for clinic-pathological correlation in deaths which are unascertained and a higher level of suspicion to explore rare causes of unexpected death, especially in the young.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to robustly assess presenting signs and symptoms and consider or exclude organic causes
Wider context from the report “2. Lack of evidence of a robust assessment of presenting signs and symptoms with a presumption of a psychological/psychiatric problem without considering or excluding an organic cause .
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of hyponatraemia causes, investigation thresholds and required investigations
Wider context from the report “5. Lack of understanding of the underlying causes of hyponatraemia (consistently or intermittently low) and the level below which will require further investigation, and the investigations that should be carried out , particularly in circumstances when there is no obvious cause of the low sodium.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient communication from referral agents to the eating disorder service
Wider context from the report “7. Insufficiently robust EDS proforma used to triage patients for an eating disorder: lack of prompts and a need to emphasise and exclude organic causes, however rare. The lack of a documented list of potential diagnoses to be assessed and excluded at triage, including organic causes. A need to facilitate communication from the referral agents to the eating disorder service.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Poor GP documentation
Wider context from the report “1. Poor GP documentation
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust EDS eating-disorder triage proforma for considering and excluding organic causes
Wider context from the report “7. Insufficiently robust EDS proforma used to triage patients for an eating disorder: lack of prompts and a need to emphasise and exclude organic causes, however rare. The lack of a documented list of potential diagnoses to be assessed and excluded at triage, including organic causes. A need to facilitate communication from the referral agents to the eating disorder service.
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficiently clear published guidance on the causes, investigation and treatment of low blood sodium
Wider context from the report “10. The need to highlight this case nationally to clarify published guidance with regard to the causes, investigation and treatment of low blood sodium and to reinforce the importance of excluding an organic basis of an illness before labelling the condition a psychiatric or psychological disorder.
” Open source report
Concerns raised 3 Lack of an effective system to issue repeat prescriptions View source Failure to maintain accurate and up-to-date medical records View source Failure to review patients within their own guidelines for repeat prescriptions 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.
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AI-generated summary
Lee Hollman · 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
Lee Hollman, who had a long history of intermittently severe mental ill-health, died after taking an overdose of Quetiapine, Trazodone and alcohol on 28 February 2014. The report identified concerns about inaccurate and outdated medical records, the repeat-prescription system, and failure to review patients in line with relevant guidelines.
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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective system to issue repeat prescriptions
Wider context from the report “4. The lack of an effective system to issue repeat prescriptions
” 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate and up-to-date medical records
Wider context from the report “1. Failure to maintain sufficiently accurate and updated medical records
2. Failure to remove Trazodone from the repeat prescription record
3. Failure to delete the ‘old’ dosage of Quetiapine from the relevant medical 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 Surrey and Sussex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to review patients within their own guidelines for repeat prescriptions
Wider context from the report “5. Failure to review patients within their own guidelines with regard to repeat prescriptions
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations