1 Apr 2026 Lucy Jane PHELAN · Prevention of Future Deaths report Worcestershire
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Concerns raised 2 Failure of alarm monitoring equipment to allow new or different alarms to be distinguished audibly View source Failure of alarm monitoring equipment to record recurrent alarm conditions as new alarms 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
Lucy Jane PHELAN · 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
Lucy Jane Phelan was found unresponsive at home after taking prescribed medications with a significant amount of alcohol and was later treated in hospital for likely aspiration pneumonia. She subsequently vomited, suffered cardiopulmonary arrest, and died shortly after midnight on 14 May 2025; the inquest concluded that her death was contributed to by neglect. The principal concern was that latching on Emergency Department monitoring equipment may contribute to alarm fatigue and hinder recognition of new alarms, with its use in other hospitals in England and Wales unknown.
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× 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Failure of alarm monitoring equipment to allow new or different alarms to be distinguished audibly
Wider context from the report “While in the resuscitation bay within the Emergency Department at the Alexandra Hospital, Redditch, Ms. Phelan was attached to equipment which monitored her physical observations. These observations are visible on a screen at the patient’s bedside and on a screen at the main nursing station. If a patient’s observations rise or fall outside acceptable parameters, the equipment generates notes both on audible alarm and a visual alarm ( red - higher priority; yellow – lower priority ) on each monitor.
The monitoring equipment has a facility known as “latching” which, if activated, means:
(a) an alarm will continue to be displayed and sounded even after the conditions which generated it have ended, until it is acknowledged on the monitor, meaning that any alarm for a new or different indication cannot be distinguished audibly ; and
(b) if the alarm is not acknowledged on the monitor, and the same alarm condition occurs again, this new alarm is not listed in the alarm review or audit log as a new alarm.
The inquest heard evidence that “alarm fatigue” is a recognized phenomenon, and that in a busy environment like a hospital’s Emergency Department, particularly when patient numbers are high, staff find it increasingly difficult to react and respond to the many different types of alarm in use. The use of the “latching” facility on monitoring equipment is likely to contribute to this phenomenon ; this has been recognized by the equipment manufacturer which no longer recommends its use on Emergency Department monitors, and by Worcestershire Acute Hospitals NHS Trust who have switched it off on monitors in its Emergency Departments.
It is not known whether, and to what extent, the “latching” facility remains in use in Emergency Departments in other hospitals in England and Wales.
” 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Failure of alarm monitoring equipment to record recurrent alarm conditions as new alarms
Wider context from the report “While in the resuscitation bay within the Emergency Department at the Alexandra Hospital, Redditch, Ms. Phelan was attached to equipment which monitored her physical observations. These observations are visible on a screen at the patient’s bedside and on a screen at the main nursing station. If a patient’s observations rise or fall outside acceptable parameters, the equipment generates notes both on audible alarm and a visual alarm ( red - higher priority; yellow – lower priority ) on each monitor.
The monitoring equipment has a facility known as “latching” which, if activated, means:
(a) an alarm will continue to be displayed and sounded even after the conditions which generated it have ended, until it is acknowledged on the monitor, meaning that any alarm for a new or different indication cannot be distinguished audibly; and
(b) if the alarm is not acknowledged on the monitor, and the same alarm condition occurs again, this new alarm is not listed in the alarm review or audit log as a new alarm .
The inquest heard evidence that “alarm fatigue” is a recognized phenomenon, and that in a busy environment like a hospital’s Emergency Department, particularly when patient numbers are high, staff find it increasingly difficult to react and respond to the many different types of alarm in use. The use of the “latching” facility on monitoring equipment is likely to contribute to this phenomenon ; this has been recognized by the equipment manufacturer which no longer recommends its use on Emergency Department monitors, and by Worcestershire Acute Hospitals NHS Trust who have switched it off on monitors in its Emergency Departments.
It is not known whether, and to what extent, the “latching” facility remains in use in Emergency Departments in other hospitals in England and Wales.
” Open source report
Concerns raised 2 Lack of provision on the Accident & Emergency Record Card to record medication prescription and administration View source Failure of the Medication Record to record medication prescription times 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
Susan Margaret Williams · 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 Margaret Williams was admitted to hospital on 14 July 2019 with suspected sepsis and abdominal pain, later deteriorating and dying from cardiorespiratory failure due to lung fibrosis and cor pulmonale. The principal concerns were the lack of recorded medication prescription times, a potential delay in administering antibiotics, and the absence of equivalent medication timing records on the Accident & Emergency Record Card.
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× 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Lack of provision on the Accident & Emergency Record Card to record medication prescription and administration
Wider context from the report “2. In the course of the evidence, it also became apparent that the Accident & Emergency Record Card (known as the “Cas Card”) has no similar provision to record medication prescription and administration within its content . This would have been a separate point of reference for this purpose.
Both of the documents referenced are understood to be used across the NHS in Wales and not confined to the Health Board in whose care Mrs Susan Margaret Williams was at the time.
” 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Failure of the Medication Record to record medication prescription times
Wider context from the report “1. The Medication Record shows the time that the medications are administered, but not the time that they were prescribed. In this case the evidence showed that the antibiotics were administered later than the other medications and there was a conflict between the prescribing clinician and the nurse administering the medications as to whether all of the medications had been prescribed at the same time.
The concern in this case related to a potential delay in the administration of the antibiotic medication (considered to be a significant sepsis treatment), there being a period of some 90 minutes between the times entered on the Record for the administration of the analgesia and the anti-emetic.
I consider this to be a concern as the lack of a recorded time of prescription highlights the possibility that there is no immediate means of referencing whether a prescribed medication has been administered within a reasonable time of it being prescribed .
Although the factual findings in this inquest did not show a causative connection between the delays in the administration of the antibiotics, I consider this to be a concern that may result in a potential future death.
” Open source report
Concerns raised 7 Failure to conduct timely and sufficiently wide patient safety investigations View source Failure to conduct robust, transparent and timely formal complaint investigations View source Insufficient staff training in risk assessment on Ward F View source Requirement for consent before assertive outreach to mentally unwell people in the community View source Failure to gather sufficient collateral information for MHA 83 assessments View source Failure to record s.12 doctors’ assessment outcomes when patients are not admitted View source Unavailability of relevant medical records to s.12 doctors before MHA 83 assessments View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Nicholas Kim Harrison · 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 Kim Harrison died on 9 April 2022 from injuries sustained when he was seriously assaulted by his son at the family home on 12 March 2022. The report identifies concerns about failures in mental health assessment, information-sharing, community engagement, patient risk assessment, Ward F security and staff training, and the scope and timeliness of investigations and complaints handling.
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× 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct timely and sufficiently wide patient safety investigations
Wider context from the report “I am concerned that if there is a reluctance within SBUHB to conduct robust, transparent and timely investigations into complaints in line with the formal complaints process and if there is a reluctance within SBUHB to ensure that a formal patient safety investigation following a death and / or patient safety incident is conducted in a timely manner and is sufficiently wide in scope, including reflecting on and incorporating the concerns from the affected family member , then SBUHB will not learn lessons from patient safety incidents and that this creates a risk that deaths will continue to occur.
” 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct robust, transparent and timely formal complaint investigations
Wider context from the report “I am concerned that if there is a reluctance within SBUHB to conduct robust, transparent and timely investigations into complaints in line with the formal complaints process and if there is a reluctance within SBUHB to ensure that a formal patient safety investigation following a death and / or patient safety incident is conducted in a timely manner and is sufficiently wide in scope, including reflecting on and incorporating the concerns from the affected family member, then SBUHB will not learn lessons from patient safety incidents and that this creates a risk that deaths will continue to occur.
” 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff training in risk assessment on Ward F
Wider context from the report “I heard evidence that Ward F of Neath and Port Talbot hospital is being used as the Single Point of Admission (‘SPOA’) for all adults requiring hospital admission in the locality for assessment of their mental illness. I heard that Ward F is a 21 bedded unit and that the move to using just Ward F as the SPOA (as opposed to three units which had been the practice) was brought in during the Covid-19 pandemic to manage the spread of the Covid-19 virus but that this change had been under consideration in SBUHB prior to the Covid-19 pandemic. I heard that this has resulted in a significantly increased level of acuity on Ward F with a significant increase in pressure on staff, a higher turnover of mentally unwell patients, and an increased pressure on staff from, for example, the need to prepare paperwork for the Mental Health Review Tribunal for Wales in a short period of time after admission. During the inquest I heard evidence (and SBUHB accepted) that the risk assessment conducted on ████████ during his time in Ward F was not adequate and that there was no assessment of ████████ risk of absconding. I found that the pressure on staff in Ward F due to its use as the SPOA impacted on ████████ care whilst he was on Ward F. I heard evidence from SBUHB that at the time there was insufficient training on risk assessments in Ward F . I heard from SBUHB that the current target is to ensure that 75% of staff on Ward F are trained in risk assessment by the end of 2024. I am concerned that only having 75% of staff trained in assessing risk means that risks may not be adequately assessed in respect of all patients on Ward F which raises a concern that risk to self and / or others and / or the risk of absconding will not be properly identified thus creating a risk that other deaths will occur. This is particularly so given the increased rates of acuity in the patients on Ward F due to it being used as the SPOA.
” 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Requirement for consent before assertive outreach to mentally unwell people in the community
Wider context from the report “I am concerned that if consent is required before a mentally unwell person in the community is able to receive assertive outreach then there may be a gap in the mental health services within SBUHB that creates a risk that mentally unwell people will remain in the community without access to mental health services in circumstances where they may pose a risk to their own life or the lives of others. This is because whilst they may need access to mental health services, they may be too unwell to consent to that access. I am concerned that if there is such a systemic deficiency within SBUHB in relation to how to engage mentally unwell people in the community then this creates a risk that deaths will continue to occur.
” 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to gather sufficient collateral information for MHA 83 assessments
Wider context from the report “I am concerned that an inadequate understanding within the CCOS AMPH service of the duty to gather sufficient collateral information in the context of any assessment under the MHA 83 and / or inadequate systems being employed within CCOS in relation to this issue creates a risk that information may not be captured and / or may be lost in relation to mentally unwell individuals in the community where they may pose a risk to their own lives and / or the lives of others and that this creates a risk that other deaths will occur.
” 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to record s.12 doctors’ assessment outcomes when patients are not admitted
Wider context from the report “It is a mandatory requirement of the MHACOP Wales that a medical examination by a doctor of a patient in a formal assessment under the MHA 83 where they are considering admission to hospital must involve consideration by that doctor of all available relevant clinical information. I heard evidence in the inquest that doctors approved under s.12 MHA 83, and used by SBUHB to conduct assessments under the MHA 83, only have access to a patient’s medical records if they are employed by SBUHB. I heard that SBUHB rely heavily on s.12 doctors who are not directly employed by them and / or are locum doctors. I also heard that there is no system within SBUHB to ensure s.12 doctors are required to record the outcome of their assessment when there is a decision not to admit a patient to hospital . I heard evidence that there is no single digital record system / platform for Mental Health Services and associated access for practitioners across Wales. I am concerned that there is a system in place (or a lack of a system) in SBUHB and more widely across the NHS in Wales which is placing s.12 doctors at risk of acting contrary to the MHACOP Wales where they are unable to view a patient’s medical records prior to an assessment under the MHA 83. I am concerned that this creates a risk that assessments may be flawed and / or may not detect that a person requires admission to hospital in circumstances where that patient may pose a risk to their own life and / or to the lives of others and that this creates a risk that other deaths will occur. In addition, if a s.12 doctor is unable to record their assessment in a patient’s medical records there is a risk that important information may not be documented which may be relevant to an understanding of the risk a patient may pose to themselves or others thus creating a risk that other deaths will occur.
” 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Unavailability of relevant medical records to s.12 doctors before MHA 83 assessments
Wider context from the report “It is a mandatory requirement of the MHACOP Wales that a medical examination by a doctor of a patient in a formal assessment under the MHA 83 where they are considering admission to hospital must involve consideration by that doctor of all available relevant clinical information. I heard evidence in the inquest that doctors approved under s.12 MHA 83, and used by SBUHB to conduct assessments under the MHA 83, only have access to a patient’s medical records if they are employed by SBUHB. I heard that SBUHB rely heavily on s.12 doctors who are not directly employed by them and / or are locum doctors. I also heard that there is no system within SBUHB to ensure s.12 doctors are required to record the outcome of their assessment when there is a decision not to admit a patient to hospital. I heard evidence that there is no single digital record system / platform for Mental Health Services and associated access for practitioners across Wales. I am concerned that there is a system in place (or a lack of a system) in SBUHB and more widely across the NHS in Wales which is placing s.12 doctors at risk of acting contrary to the MHACOP Wales where they are unable to view a patient’s medical records prior to an assessment under the MHA 83 . I am concerned that this creates a risk that assessments may be flawed and / or may not detect that a person requires admission to hospital in circumstances where that patient may pose a risk to their own life and / or to the lives of others and that this creates a risk that other deaths will occur. In addition, if a s.12 doctor is unable to record their assessment in a patient’s medical records there is a risk that important information may not be documented which may be relevant to an understanding of the risk a patient may pose to themselves or others thus creating a risk that other deaths will occur.
” Open source report
23 Jul 2019 Barbara Humphreys · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 10 Failure to fully involve families in palliative care or DNAR decision-making View source Delays in completing care plans and best interests assessments View source Failure to provide families with sufficient information about palliative care or DNAR decisions View source Use of mattresses unsuitable for particular beds or unable to maintain patient limbs within the mattress area View source Failure to include willing patient family members in bed rail risk assessments View source Lack of adequate staff training in bed rail and accompanying bedding arrangements View source Failure to complete full and frank bed rail risk assessments View source Lack of an implemented full bed rail policy governing regulatory compliance View source Failure to inform family and next of kin about medically trained professional attendance or review View source Failure to review bed rail risk assessments regularly View source See 7 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
Barbara Humphreys · 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
Barbara Humphreys was admitted to Crosfield House in July 2018 and later experienced repeated entrapment of her leg and foot between bed rails and the mattress. She underwent a right lower-leg amputation and died in hospital on 28 November 2018; the reported medical cause was thrombosis and the inquest conclusion was natural causes. The principal concerns included the lack of a bed-rail risk assessment, unsuitable mattresses, staff training, bed-rail policies, care planning, and communication with family about medical attendance, palliative care and DNAR decisions.
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× 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to fully involve families in palliative care or DNAR decision-making
Wider context from the report “7. The seventh issue is directed to National Health Service Wales who should consider and if so appropriate draft and implement a policy to ensure that families of those assigned to palliative care and/or made subject to DNAR orders are provided sufficient information about how that decision has been made, that they as a family have been fully involved in the decision-making process and upon what information it has been made such as the limits of patient confidentiality may allow in the circumstances.
” 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Delays in completing care plans and best interests assessments
Wider context from the report “5. The fifth issue is directed to Crosfield house Ltd and Care Inn limited which is there was evidence that the completion of care plans and best interests assessments was required to be fitted round other duties and as such may not be completed in a timely fashion . The group and the care home shall consider whether assigning a set or allotted period of time for a RGN to complete the care plan and assessment in the working day would help ensure that the care plan is most accurate and appropriately detailed.
” 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to provide families with sufficient information about palliative care or DNAR decisions
Wider context from the report “7. The seventh issue is directed to National Health Service Wales who should consider and if so appropriate draft and implement a policy to ensure that families of those assigned to palliative care and/or made subject to DNAR orders are provided sufficient information about how that decision has been made , that they as a family have been fully involved in the decision-making process and upon what information it has been made such as the limits of patient confidentiality may allow in the circumstances.
” 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Use of mattresses unsuitable for particular beds or unable to maintain patient limbs within the mattress area
Wider context from the report “1. The first issue is directed to Crosfield house Ltd and Care Inn limited and Care Inspectorate Wales. It relates to the use of mattresses which are either not designed for use on particular beds or when used on particular beds are not constructed or designed to maintain a level when a patient is placed in the centre of said mattress. Upon placing of a patient in the centre of said mattress certain mattresses can fold at the edge and otherwise become displaced such that a patient’s limbs will not be maintained within the mattress area . The correct mattress for the correct bed is considered de minimus in terms of a standard
” 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to include willing patient family members in bed rail risk assessments
Wider context from the report “3. The third issue is also directed to Crosfield house Ltd and Care Inn limited. The staff and care homes in general under your control should complete a full and frank risk assessment in relation to any and all issues with regards to bed rails. This should be conducted with the input and knowledge of a patient’s family members, if they so wish and the risk assessment should be reviewed regularly.
” 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate staff training in bed rail and accompanying bedding arrangements
Wider context from the report “2. The second issue is also directed to Crosfield house Ltd and Care Inn limited and requires adequate training to be provided to all employees in the homes operated by your respective companies. The training should include the selection, fitting, management and review of bed rails and accompanying bedding arrangements .
” 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to complete full and frank bed rail risk assessments
Wider context from the report “3. The third issue is also directed to Crosfield house Ltd and Care Inn limited. The staff and care homes in general under your control should complete a full and frank risk assessment in relation to any and all issues with regards to bed rails . This should be conducted with the input and knowledge of a patient’s family members, if they so wish and the risk assessment should be reviewed regularly.
” 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Lack of an implemented full bed rail policy governing regulatory compliance
Wider context from the report “4. The fourth issue is directed to Crosfield house Ltd and Care Inn limited. The company should produce and implement a full bed rail policy which is either group wide or relevant specific only to Crosfield house Ltd. This should detail how the company intends to ensure their employees are following the letter and spirit of the regulations .
” 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to inform family and next of kin about medically trained professional attendance or review
Wider context from the report “6. The sixth issue is directed to Care Inspectorate Wales and National Health Service Wales. They shall consider and if so appropriate, draft and implement a policy which requires a care home or care provider to inform the family and next of kin of events in which are medically trained professional has attended to or seen the patient particularly in cases where there is no or varying capacity .
” 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to review bed rail risk assessments regularly
Wider context from the report “3. The third issue is also directed to Crosfield house Ltd and Care Inn limited. The staff and care homes in general under your control should complete a full and frank risk assessment in relation to any and all issues with regards to bed rails. This should be conducted with the input and knowledge of a patient’s family members, if they so wish and the risk assessment should be reviewed regularly .
” Open source report
Concerns raised 2 Failure to ensure experienced mental health professional assessment of older people who self-harm View source Lack of healthcare professional access to detainees’ medical and mental health records 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 Nigel Phillips · 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 Nigel Phillips, who had a history of mental illness, previous suicide attempts, alcohol-related issues and type 2 diabetes, was found drowned in a rock pool near Mumbles Pier on 4 January 2015. He had been arrested the previous day after being found intoxicated in his parked car and had told police he had been attempting to take his own life. The principal concerns were that an experienced mental health professional should have assessed him and that the healthcare professional lacked access to his medical records, including mental health records, to review his medication and risks accurately.
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 Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure experienced mental health professional assessment of older people who self-harm
Wider context from the report “My concerns are that:-
(1) An experienced mental health doctor or nurse should have been called to carry out the assessment rather than a nurse . The quality of the assessment is critical rather than a box ticking exercise .
(2) The Health Care Professional did not have access to detainee’s medical records to accurately identify reasons as to why and how medications are changed or as to when this may or may not have occurred.
An ability to review medication and if necessary prescribe medication would be helpful and access to medical records is critical. Access to electronic Individual Health Records to include mental health 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Lack of healthcare professional access to detainees’ medical and mental health records
Wider context from the report “My concerns are that:-
(1) An experienced mental health doctor or nurse should have been called to carry out the assessment rather than a nurse. The quality of the assessment is critical rather than a box ticking exercise.
(2) The Health Care Professional did not have access to detainee’s medical records to accurately identify reasons as to why and how medications are changed or as to when this may or may not have occurred .
An ability to review medication and if necessary prescribe medication would be helpful and access to medical records is critical . Access to electronic Individual Health Records to include mental health records
” Open source report
27 Jul 2016 James Michael HEDGE · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 2 Inadequate education on managing hyperglycaemia and its life-threatening progression View source Inadequate advice and guidance on insulin pump misuse dangers 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 Michael HEDGE · 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 Michael HEDGE, an 18-year-old type 1 insulin-dependent diabetic, was found deceased in his room at Cardiff University with an insulin pump connected to him. The pump’s insulin cartridge had been fitted incorrectly and leaked, and the inquest recorded diabetic ketoacidosis as the medical cause of death. Concerns included inadequate guidance about the dangers of insulin-pump misuse and insufficient education about the potentially rapid, life-threatening consequences of hyperglycaemia.
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 Wales; that does not assign responsibility.
PFD Monitor interpretation Inadequate education on managing hyperglycaemia and its life-threatening progression
Wider context from the report “(2) The evidence showed that the education of diabetic patients does not adequately focus upon the potential consequences of failing to properly manage a hyperglycaemic state and in particular, how quickly such a state can become life threatening .
” 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Inadequate advice and guidance on insulin pump misuse dangers
Wider context from the report “(1) The evidence showed that the advice and guidance in relation to the use of the insulin pump, which is one of several on the market, does not adequately highlight the dangers of misuse and the potential consequences which may follow if the device is not used correctly – in this case, the incorrect insertion of the insulin cartridge leading to a leak and loss of insulin at a time when blood sugars were high.
” Open source report
Concerns raised 3 Potential for Miconazole Gel and Warfarin interaction causing increased blood clotting time and INR View source Lack of knowledge of the Miconazole Gel and Warfarin interaction among health professionals View source Unclear or difficult-to-locate resources for checking the Miconazole Gel and Warfarin interaction 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
Patricia Margaret Thomas · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Patricia Margaret Thomas died at Morriston Hospital on 30 October 2013 after suffering an intracerebral haemorrhage, following an episode of unresponsiveness and left-sided weakness. The report identified a potential interaction between Miconazole Gel and Warfarin, a lack of awareness of this interaction among health professionals, and possible difficulties locating clear interaction-checking resources.
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 Wales; that does not assign responsibility.
PFD Monitor interpretation Potential for Miconazole Gel and Warfarin interaction causing increased blood clotting time and INR
Wider context from the report “It became apparent in the course of the evidence that
(1) There is a potential for Miconazole Gel to have an interaction with Warfarin such as to increase the blood clotting time and hence a higher INR reading than should be expected. This could lead to significant uncontrolled bleeding.
(2) There is a significant lack of knowledge of the interaction among health professionals and/or
(3) The resources available to check the interaction may not be entirely clear on this issue or readily straight forward to locate.
” 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of the Miconazole Gel and Warfarin interaction among health professionals
Wider context from the report “It became apparent in the course of the evidence that
(1) There is a potential for Miconazole Gel to have an interaction with Warfarin such as to increase the blood clotting time and hence a higher INR reading than should be expected. This could lead to significant uncontrolled bleeding.
(2) There is a significant lack of knowledge of the interaction among health professionals and/or
(3) The resources available to check the interaction may not be entirely clear on this issue or readily straight forward to locate.
” 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Unclear or difficult-to-locate resources for checking the Miconazole Gel and Warfarin interaction
Wider context from the report “It became apparent in the course of the evidence that
(1) There is a potential for Miconazole Gel to have an interaction with Warfarin such as to increase the blood clotting time and hence a higher INR reading than should be expected. This could lead to significant uncontrolled bleeding.
(2) There is a significant lack of knowledge of the interaction among health professionals and/or
(3) The resources available to check the interaction may not be entirely clear on this issue or readily straight forward to locate.
” Open source report
Concerns raised 2 Absence of a medication reconciliation policy at the University Hospital of Wales View source Lack of medication reconciliation policies at other Health Boards across Wales 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
Kathleen Ludmila Neville · 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
Kathleen Ludmila Neville was admitted to hospital after an accidental fall that fractured her femur and later died following complications after surgery and a prolonged hospital stay. Her regular thyroid medication was omitted for five weeks because it was not recorded on the drug chart and the hospital lacked a Medication Reconciliation Policy; this contributed to lassitude and confusion but not to her death. The principal concern was that the absence of such a policy could allow medication errors to persist and potentially contribute to future deaths, particularly with medicines whose omission could be fatal.
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 Wales; that does not assign responsibility.
PFD Monitor interpretation Absence of a medication reconciliation policy at the University Hospital of Wales
Wider context from the report “(1) The absence of a Medication Reconciliation Policy at the University Hospital of Wales over the relevant period made it much harder for the individual failures of the admitting doctor and initial pharmacist to be picked up. As a consequence Kathleen Neville was deprived of her medication for a much longer period than would otherwise have been the case.
(2) While the Coroner found in this inquest that the omission of Levothyroxine did not contribute to the eventual outcome, the position would have been far different in the case of other drugs where omission of medication might lead directly to death (e.g. in insulin). In such cases the absence of a Medication Reconciliation Policy assist in picking up individual failures could lead to future deaths . The Coroner found that any system that relies solely on individual human excellence without a supporting policy is eventually bound to fail through individual human error.
” 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Lack of medication reconciliation policies at other Health Boards across Wales
Wider context from the report “(4) The Coroner is concerned that there may be other Health Boards across Wales that have still not adopted a Medication Reconciliation Policy as recommended by NICE . Future lives may be lost if a Health Board does not have such a policy and similar prescription errors are made. The Coroner is concerned that all Health Boards across Wales should learn the lessons of this inquest and have a Medication Reconciliation Policy in place to prevent future deaths in similar circumstances.
” Open source report
Concerns raised 2 Failure of software programs to provide interruptive alerts for important diagnosed conditions View source Lack of adequate training on the use of electronic software systems 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
Alan Vaughan Jones · 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
Alan Vaughan Jones had Addison’s disease and became unable to take his steroid medication after developing gastroenteritis. His condition deteriorated, and he died at 08.50 hours on 8 April 2011; the inquest concluded that Addison’s Disease resulted from neglect. Concerns included inadequate training in the use of electronic patient-record software and failures of the software to highlight important diagnosed conditions as alerts.
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 Wales; that does not assign responsibility.
PFD Monitor interpretation Failure of software programs to provide interruptive alerts for important diagnosed conditions
Wider context from the report “(2) An apparent failure in the software programs themselves to highlight important diagnosed conditions as an alert, when the patient record is opened and to prevent any further steps being taken to navigate the program (and make any entries) without consciously closing the “alert” first .
” 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate training on the use of electronic software systems
Wider context from the report “(1) An apparent lack of adequate training on the use of the software systems . This meant that important clinical information could not be made available easily . The expert GP gave evidence that this training deficit was not uncommon . He had the experience of using 4 different software programs in his career and had identical issues over lack of training .
” Open source report
Concerns raised 2 Lack of GP awareness of NICE head-injury guidelines for patients treated with warfarin View source Failure to admit patients with head injuries treated with warfarin to hospital forthwith 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
Phyllis Eleanor Barlow · 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
Phyllis Eleanor Barlow, who was taking warfarin, fell and struck her head in a GP surgery car park on 29 September 2014 but was not admitted to hospital. She fell again at home the following day, sustaining a subdural haemorrhage and hip fracture, and died on 8 November 2014; the concern was that GP surgeries were not sufficiently aware of NICE guidance requiring hospital admission and CT scanning after a head injury in a person taking warfarin.
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 Wales; that does not assign responsibility.
PFD Monitor interpretation Lack of GP awareness of NICE head-injury guidelines for patients treated with warfarin
Wider context from the report “(1) At the time of her fall in the GP car park on 29th September 2014 NICE guidelines (on head injuries) were in place to the effect that anyone suffering a head injury who was on warfarin should be admitted to hospital forthwith and undergo a CT scan. ████████ who appeared at the inquest on behalf of the GP practice testified that these NICE guidelines were not known or appreciated by her GP practice at the time even though they were in force . Mrs Barlow was not admitted to hospital as she should have been on 29th September 2014. ████████ subsequent enquiries have revealed that there is widespread ignorance of these NICE guidelines among GP colleagues , although they are appreciated by the ambulance service, and A&E departments.
The Coroner is concerned that steps should be taken to make GP surgeries in Wales aware of the importance of these NICE guidelines, and that anyone who suffers a head injury while being treated with Warfarin should be admitted to hospital forthwith and a CT scan undertaken on them..
” 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 Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to admit patients with head injuries treated with warfarin to hospital forthwith
Wider context from the report “(1) At the time of her fall in the GP car park on 29th September 2014 NICE guidelines (on head injuries) were in place to the effect that anyone suffering a head injury who was on warfarin should be admitted to hospital forthwith and undergo a CT scan. ████████ who appeared at the inquest on behalf of the GP practice testified that these NICE guidelines were not known or appreciated by her GP practice at the time even though they were in force. Mrs Barlow was not admitted to hospital as she should have been on 29th September 2014 . ████████ subsequent enquiries have revealed that there is widespread ignorance of these NICE guidelines among GP colleagues, although they are appreciated by the ambulance service, and A&E departments.
The Coroner is concerned that steps should be taken to make GP surgeries in Wales aware of the importance of these NICE guidelines, and that anyone who suffers a head injury while being treated with Warfarin should be admitted to hospital forthwith and a CT scan undertaken on them..
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations