Concerns raised 2 Failure to assess patients’ ability to use a call bell and provide suitable alternatives when they cannot View source Lack of pre-placement side-room risk assessment of patients’ ability to communicate their needs in an emergency 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
Jeanine Maria HUGGINS · 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
Jeanine Maria Huggins, who was being treated for diffuse large B-cell lymphoma, was admitted with neutropenic sepsis, dehydration and acute kidney injury and initially showed clinical improvement. She was found not breathing during the night of 9 May 2022 and could not be resuscitated; the inquest concluded that she died from natural causes, with coronary artery atheroma and lymphoma on treatment recorded as the medical cause of death. Concerns included the absence of a formal risk assessment for patients placed in side rooms, including assessment of their ability to use a call bell or suitable alternatives, and failures to escalate raised NEWS scores in accordance with guidance.
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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to assess patients’ ability to use a call bell and provide suitable alternatives when they cannot
Wider context from the report “2. There is no formal requirement to ensure that a patient is risk assessed with regard to ability to use a call bell and, if they are unable, to consider suitable alternatives , especially when in a side room and there is no other way to attract staff attention .
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of pre-placement side-room risk assessment of patients’ ability to communicate their needs in an emergency
Wider context from the report “1. There is no requirement for a risk assessment to be carried out before a patient is placed in a side room (other than for risk of falls), so as to identify if they will have any risks and difficulties associated with communicating their needs to staff in an emergency situation .
” Open source report
Concerns raised 6 Unavailability of an appointed Falls Lead View source Failure to complete the Falls Risk Assessment View source Failure of the Falls Policy to comply with NICE Guidelines View source Lack of a developed falls training package View source Failure to complete the Falls Policy View source Failure to progress assisted technology for alerting staff to patient movements and needs 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
Irene Muriel FITCHES · 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
Irene Muriel Fitches was admitted to hospital on 17 July 2021 with dizziness, nausea and general illness, and was diagnosed with Benign Positional Paroxysmal Vertigo. On 21 July 2021 she had an unwitnessed fall, suffered a head injury, deteriorated and became unresponsive; she died on 22 July 2021. The substantive concerns included a Falls Policy that did not comply with NICE Guidelines, no appointed Falls Lead, undeveloped staff training, and limited progress on assisted technology.
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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Unavailability of an appointed Falls Lead
Wider context from the report “3. There is no person appointed as Falls Lead. The job application has not yet been advertised , although it is recognised that someone is required to lead the Falls process.
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to complete the Falls Risk Assessment
Wider context from the report “2. Evidence was heard that a Falls Policy was drafted, and a Risk Assessment trialled at the beginning of 2020 , the Covid-19 pandemic intervened and delayed its completion .
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of the Falls Policy to comply with NICE Guidelines
Wider context from the report “1. The Falls Policy does not comply with NICE Guidelines.
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of a developed falls training package
Wider context from the report “4. Staff will need training and the training package has not yet been developed .
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to complete the Falls Policy
Wider context from the report “2. Evidence was heard that a Falls Policy was drafted , and a Risk Assessment trialled at the beginning of 2020, the Covid-19 pandemic intervened and delayed its completion .
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to progress assisted technology for alerting staff to patient movements and needs
Wider context from the report “5. Assisted Technology is being considered to alert staff to movements and the needs of patients. This has not been progressed since October 2021 and is still at an early stage.
” Open source report
20 Jul 2021 Ben Buster KING · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 20 Failure to address weight gain and set weight-loss goals in multidisciplinary reviews View source Failure to contact the respiratory on-call consultant on repeat presentation View source Failure to implement substantive safety changes in residential care homes View source Reduction of dietician-led staff training View source Failure of internal investigations to capture identified care concerns View source Failure to provide timely responses to care staff seeking clarification of discharge and escalation plans View source Failure of staff to follow basic dietary advice and guidance View source Failure to notify the respiratory team of emergency department attendances View source Failure to carry out one-to-one observations in accordance with policy View source Failure of the care recording system to support accessible and complete food and fluid intake records View source Failure to record pertinent medication history on discharge documentation View source Failure to hold multidisciplinary team meetings at required intervals View source Reliance on outdated weight measurements in multidisciplinary reviews View source Failure of the care software system to provide accessible and usable policies and documents View source Failure to provide clear, accurate and complete discharge advice View source Failure to communicate prior emergency department attendance to the respiratory consultant View source Failure of staff to complete important care records View source Failure to ensure regular exercise provision View source Unavailability of CCTV in residential care homes View source Failure to document risk-benefit analysis for pertinent respiratory-affecting medication View source See 17 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
Ben Buster KING · 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
Ben Buster KING was detained under the Mental Health Act at Jeesal Cawston Park and died in hospital on 29 July 2020 after becoming unwell following respiratory problems and receiving sedative medication. The inquest identified concerns including failure to diagnose obesity hypoventilation syndrome, inadequate consideration of promethazine, failure to recognise the seriousness of a life-threatening situation, and wider care, observation, record-keeping and hospital communication issues.
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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to address weight gain and set weight-loss goals in multidisciplinary reviews
Wider context from the report “7. Multi-Disciplinary Team (MDT) Meetings were not held every 4 to 6 weeks as required. At MDT meetings which did take place, out of date weight measurements were recorded and relied upon for Ben. His increasing weight gain was not discussed at these meetings and weight loss was not set as a desirable or essential goal
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to contact the respiratory on-call consultant on repeat presentation
Wider context from the report “1. Guidance was sought by Emergency Department (ED) when Ben King attended on 10 July 2020 from a Respiratory Consultant, who was not made aware that Ben King had attended some 6 hours earlier with the same symptoms.
2. The Respiratory on call consultant was not contacted when Mr King returned to NNUH two days later on the 12 July 2020 with the same symptoms.
3. At the time of Ben King’s attendance at NNUH, Ben King was under the Respiratory Team and had been seen a few days earlier, on the 3 July 2020. The Respiratory Team was not made aware of Ben King’s attendances at ED on 9, 10 or 12 July 2020 with respiratory problems
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to implement substantive safety changes in residential care homes
Wider context from the report “9. The internal investigation carried out following Mr Ben King’s death did not capture the concerns raised at inquest
10. Evidence was heard that no substantive changes have been made at the residential homes owned by JHL and JRCSL following the death of Ben King and the closure of JCP to deal with these concerns
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Reduction of dietician-led staff training
Wider context from the report “3. Basic dietary advice and guidance provided was not followed by staff.
4. The use of the Dietician in training of staff was reduced in 2017 from one day’s training to an hour’s power point presentation
5. Important records were not completed by staff, eg Food intake, Exercise, Weight and vital observations
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of internal investigations to capture identified care concerns
Wider context from the report “9. The internal investigation carried out following Mr Ben King’s death did not capture the concerns raised at inquest
10. Evidence was heard that no substantive changes have been made at the residential homes owned by JHL and JRCSL following the death of Ben King and the closure of JCP to deal with these concerns
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely responses to care staff seeking clarification of discharge and escalation plans
Wider context from the report “4. Advice given on discharge appears to be unclear and contradictory. The expert Respiratory Consultant referred to the advice as being “inadequate, unclear and inaccurate”. On the Discharge Form provided on 9 July 2020 it is noted “Plan – home as Ben is back to normal, self, red flags and safety netting covered, to return in the event of any difficulty.”
On discharge from ED on 10 July 2020 (second occasion) the hospital record states that Ben King is to return home, encouraged to lose weight, fluids are to be encouraged and “with no need to monitor his sats unless clinically unwell with sats in 60s%”. Not all of this information was included in the Discharge Form on 10 July 2020. The Discharge Form provided “Other” – “seen by respiratory team, they are happy to send him home, they have clerked their advice on the paper. Cpap and O2”
On 12 July 2020 the Discharge Plan provided “Home”.
The advice from the Respiratory Consultant seen on 3 July 2020 was for CPAP to stop.
Evidence was heard from the Care staff at JCP that they were unclear as to what the plan was with regard to Ben and specifically as to when Ben was to be returned to Hospital. One of the Doctors at JCP contacted the ED, NNUH to try to ascertain what the advice was and was unable to get any substantive response . Email contact was made with the Respiratory Team but no response was received until after Ben King’s death on 28 July 2020.
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to follow basic dietary advice and guidance
Wider context from the report “3. Basic dietary advice and guidance provided was not followed by staff.
4. The use of the Dietician in training of staff was reduced in 2017 from one day’s training to an hour’s power point presentation
5. Important records were not completed by staff, eg Food intake, Exercise, Weight and vital observations
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the respiratory team of emergency department attendances
Wider context from the report “1. Guidance was sought by Emergency Department (ED) when Ben King attended on 10 July 2020 from a Respiratory Consultant, who was not made aware that Ben King had attended some 6 hours earlier with the same symptoms.
2. The Respiratory on call consultant was not contacted when Mr King returned to NNUH two days later on the 12 July 2020 with the same symptoms.
3. At the time of Ben King’s attendance at NNUH, Ben King was under the Respiratory Team and had been seen a few days earlier, on the 3 July 2020. The Respiratory Team was not made aware of Ben King’s attendances at ED on 9, 10 or 12 July 2020 with respiratory problems
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out one-to-one observations in accordance with policy
Wider context from the report “2. CCTV was shown at the inquest which revealed Ben King had been assaulted in the hours prior to his death and also that 1 to 1 observation was not carried out in accordance with the Observations Policy. CCTV is a reliable means of ensuring that staff comply with Policies and residents are treated with dignity. CCTV is not available in many if not all of the residential homes owned by JHL and JRCSL.
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of the care recording system to support accessible and complete food and fluid intake records
Wider context from the report “8. JCP used the Pandora software system, (company Directors for Pandora are the same as for JHL and JRCSL) which is still used at the residential homes owned by JHL and JRCSL.
Concerns were raised at the inquest in respect of this software system in that not all policies and documents were available to staff on the IPads provided, some of the documents were unwieldy and difficult to read (eg Personal Healthcare Plan), the Dietician recommended use of paper records in respect of Food and Fluid intake as these would be more accessible to staff and encourage the documents to be completed or in the alternative providing for the records on Ipads to be more easy to access and complete
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to record pertinent medication history on discharge documentation
Wider context from the report “5. The section headed “Drug History” was not completed on the Discharge Form on Ben King’s attendances on 9 or 12 July 2020. On 10 July, it states “nil significant”. This is despite Ben King being prescribed Promethazine, a sedative medication, affecting the respiratory system. Evidence was heard that not all prescribed medications could be expected to be included in “the small space” provided. That this is a medication where consideration would have been given to a risk vs benefit analysis but there was no evidence of any such analysis. Regulation 28 evidence was that not all medication can be listed; only “pertinent” medication.
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to hold multidisciplinary team meetings at required intervals
Wider context from the report “7. Multi-Disciplinary Team (MDT) Meetings were not held every 4 to 6 weeks as required. At MDT meetings which did take place, out of date weight measurements were recorded and relied upon for Ben. His increasing weight gain was not discussed at these meetings and weight loss was not set as a desirable or essential goal
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Reliance on outdated weight measurements in multidisciplinary reviews
Wider context from the report “7. Multi-Disciplinary Team (MDT) Meetings were not held every 4 to 6 weeks as required. At MDT meetings which did take place, out of date weight measurements were recorded and relied upon for Ben. His increasing weight gain was not discussed at these meetings and weight loss was not set as a desirable or essential goal
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of the care software system to provide accessible and usable policies and documents
Wider context from the report “8. JCP used the Pandora software system, (company Directors for Pandora are the same as for JHL and JRCSL) which is still used at the residential homes owned by JHL and JRCSL.
Concerns were raised at the inquest in respect of this software system in that not all policies and documents were available to staff on the IPads provided , some of the documents were unwieldy and difficult to read (eg Personal Healthcare Plan), the Dietician recommended use of paper records in respect of Food and Fluid intake as these would be more accessible to staff and encourage the documents to be completed or in the alternative providing for the records on Ipads to be more easy to access and complete
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear, accurate and complete discharge advice
Wider context from the report “4. Advice given on discharge appears to be unclear and contradictory. The expert Respiratory Consultant referred to the advice as being “inadequate, unclear and inaccurate” . On the Discharge Form provided on 9 July 2020 it is noted “Plan – home as Ben is back to normal, self, red flags and safety netting covered, to return in the event of any difficulty.”
On discharge from ED on 10 July 2020 (second occasion) the hospital record states that Ben King is to return home, encouraged to lose weight, fluids are to be encouraged and “with no need to monitor his sats unless clinically unwell with sats in 60s%”. Not all of this information was included in the Discharge Form on 10 July 2020. The Discharge Form provided “Other” – “seen by respiratory team, they are happy to send him home, they have clerked their advice on the paper. Cpap and O2”
On 12 July 2020 the Discharge Plan provided “Home”.
The advice from the Respiratory Consultant seen on 3 July 2020 was for CPAP to stop.
Evidence was heard from the Care staff at JCP that they were unclear as to what the plan was with regard to Ben and specifically as to when Ben was to be returned to Hospital. One of the Doctors at JCP contacted the ED, NNUH to try to ascertain what the advice was and was unable to get any substantive response. Email contact was made with the Respiratory Team but no response was received until after Ben King’s death on 28 July 2020.
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate prior emergency department attendance to the respiratory consultant
Wider context from the report “1. Guidance was sought by Emergency Department (ED) when Ben King attended on 10 July 2020 from a Respiratory Consultant, who was not made aware that Ben King had attended some 6 hours earlier with the same symptoms.
2. The Respiratory on call consultant was not contacted when Mr King returned to NNUH two days later on the 12 July 2020 with the same symptoms.
3. At the time of Ben King’s attendance at NNUH, Ben King was under the Respiratory Team and had been seen a few days earlier, on the 3 July 2020. The Respiratory Team was not made aware of Ben King’s attendances at ED on 9, 10 or 12 July 2020 with respiratory problems
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to complete important care records
Wider context from the report “3. Basic dietary advice and guidance provided was not followed by staff.
4. The use of the Dietician in training of staff was reduced in 2017 from one day’s training to an hour’s power point presentation
5. Important records were not completed by staff, eg Food intake, Exercise, Weight and vital observations
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure regular exercise provision
Wider context from the report “6. Evidence was heard that exercise was not regularly offered to Ben King and when the Sports Instructor was absent for lengthy periods of time, there was no replacement
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Unavailability of CCTV in residential care homes
Wider context from the report “2. CCTV was shown at the inquest which revealed Ben King had been assaulted in the hours prior to his death and also that 1 to 1 observation was not carried out in accordance with the Observations Policy. CCTV is a reliable means of ensuring that staff comply with Policies and residents are treated with dignity. CCTV is not available in many if not all of the residential homes owned by JHL and JRCSL.
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to document risk-benefit analysis for pertinent respiratory-affecting medication
Wider context from the report “5. The section headed “Drug History” was not completed on the Discharge Form on Ben King’s attendances on 9 or 12 July 2020. On 10 July, it states “nil significant”. This is despite Ben King being prescribed Promethazine, a sedative medication, affecting the respiratory system. Evidence was heard that not all prescribed medications could be expected to be included in “the small space” provided. That this is a medication where consideration would have been given to a risk vs benefit analysis but there was no evidence of any such analysis . Regulation 28 evidence was that not all medication can be listed; only “pertinent” medication.
” Open source report
Concerns raised 5 Failure to coordinate hospital discharge with the receiving care home View source Placement of people in unsuitable and unsafe residential settings View source Failure to provide appropriate falls prevention for patients in cohorted hospital bays View source Failure to respond to requests for help finding suitable placements View source Discharge of patients with medicines that the receiving care home cannot administer View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Michael Yemm · 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
Michael Yemm had dementia and complex medical needs and was placed in a residential care home despite concerns that it was unsuitable and unsafe. He experienced several falls, including an in-patient fall that fractured his hip and required surgery, and later died in hospital. The principal concerns were the care-home placement, his discharge back to a home that had said it could not meet his needs, and the management of falls and dementia patients in 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate hospital discharge with the receiving care home
Wider context from the report “The hospital dropped Mr Yemm off back at the care home without any warning after being informed that they could not have him back . He was also discharged on insulin which the home could not administer as they do not have trained nursing staff.
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Placement of people in unsuitable and unsafe residential settings
Wider context from the report “That Mr Yemm was placed into a totally unsuitable and unsafe residential setting . Shortly after his arrival, the next day, the manager contacted Mr Yemm's social worker and told them they couldn't look after him properly . Despite this he was left in this care home . ████████ wrote to the Director of Adult Social Services asking for help in finding a suitable placement and did not receive the courtesy of a reply. She was also told that after his falls that he had hairline fractures of his left hip before the fall in hospital.
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate falls prevention for patients in cohorted hospital bays
Wider context from the report “That he was able, in a cohorted patient bay, to climb past raised bedrails , he did not have a lowered bed , whilst staff were present. A cohorted bay has extra staff to deal with challenging patients and fell fracturing his hip , necessitating surgery. For the whole of his stay Mr Yemm was agitated, confused anxious and distressed, he had to move wards because of the need for surgery which further exacerbated his 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to respond to requests for help finding suitable placements
Wider context from the report “That Mr Yemm was placed into a totally unsuitable and unsafe residential setting. Shortly after his arrival, the next day, the manager contacted Mr Yemm's social worker and told them they couldn't look after him properly. Despite this he was left in this care home. ████████ wrote to the Director of Adult Social Services asking for help in finding a suitable placement and did not receive the courtesy of a reply . She was also told that after his falls that he had hairline fractures of his left hip before the fall in hospital.
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Discharge of patients with medicines that the receiving care home cannot administer
Wider context from the report “The hospital dropped Mr Yemm off back at the care home without any warning after being informed that they could not have him back. He was also discharged on insulin which the home could not administer as they do not have trained nursing staff .
” Open source report
29 Oct 2020 Sarah Nadine Louise GIBBS · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 2 Failure to establish use of the SBARD communication tool View source Failure to ensure effective communication and information handover between teams 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
Sarah Nadine Louise GIBBS · 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
Sarah Gibbs died shortly after returning home following a PEG operation and discharge on 17 April 2019; she became unresponsive later that day and was pronounced dead at the scene. The medical cause of death included aspiration of gastric contents, vomiting, and acute peritonitis following recent insertion of the PEG tube. Concerns were raised about communication between teams, particularly the handover of information to night staff, and whether the SBARD communication tool was in use.
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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to establish use of the SBARD communication tool
Wider context from the report “Concerns were raised during the inquest with regard to communication between teams, particularly to the staff on duty at night as to what information was handed over. Evidence was heard of an easy to use form of communication tool which enables information to be transferred accurately, especially at handover time, between nurses and clinicians, known as SBARD. This helps in reducing the likelihood of errors in communication information.
It was not known whether this tool is in use although it was “hoped” it is being used . This is some eighteen months following Miss Gibb’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure effective communication and information handover between teams
Wider context from the report “Concerns were raised during the inquest with regard to communication between teams, particularly to the staff on duty at night as to what information was handed over . Evidence was heard of an easy to use form of communication tool which enables information to be transferred accurately, especially at handover time, between nurses and clinicians, known as SBARD. This helps in reducing the likelihood of errors in communication information.
It was not known whether this tool is in use although it was “hoped” it is being used. This is some eighteen months following Miss Gibb’s death.
” Open source report
26 Nov 2019 David Michael Potts · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 4 Failure to establish why prescribed medication was not given as ordered View source Delays in giving prescribed Beriplex View source Failure to check administration of prescribed medication after an extension of bleeding View source Failure to establish the patient's whereabouts View source See 1 more concern
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 Michael Potts · 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 Michael Potts fell at home while prescribed apixaban and was admitted with an acute subdural haematoma. Beriplex was prescribed to reverse the apixaban but was not given in a timely manner, and staff did not confirm that it had been administered or establish where he was. His bleed extended; after transfer to a local unit, he declined and died seven days later.
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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to establish why prescribed medication was not given as ordered
Wider context from the report “(3) That no-one seemed to know why it was not given as ordered or where Mr Potts was on the day in question.
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in giving prescribed Beriplex
Wider context from the report “(1) That the prescription of Beriplex was not given in a timely manner .
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to check administration of prescribed medication after an extension of bleeding
Wider context from the report “(2) That no-one checked that it had been given despite an extension of the bleed .
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to establish the patient's whereabouts
Wider context from the report “(3) That no-one seemed to know why it was not given as ordered or where Mr Potts was on the day in question .
” Open source report
22 Mar 2019 Brian Robert HAVARD · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 6 Failure to exercise professional curiosity in high-risk discharge decisions View source Failure of senior clinicians to review patients referred for advice View source Failure to routinely include or read ambulance notes in clinical records View source Lack of a system ensuring senior review of cases referred by junior doctors View source Failure to obtain and review ambulance electronic records View source Poor clinical record keeping 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
Brian Robert HAVARD · 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
Brian Robert Havard attended the Emergency Department with chest pain and vomiting, was discharged with a diagnosis of musculoskeletal pain, then collapsed in the car and died while being taken back to hospital. The concerns included failure to review ambulance records, inadequate senior review arrangements, and poor record keeping.
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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to exercise professional curiosity in high-risk discharge decisions
Wider context from the report “1. The doctor had not read the ambulance electronic records and was not aware of a system in place to obtain these notes prior to his seeing the patient. These notes contained information about Mr Havard having hematemesis and two doses of morphine given to Mr Havard by the crew. He did examine Mr Havard and had differential diagnoses and went to speak to the locum consultant who was just coming on shift for advice. The consultant did not ask to see the notes from the crew or the hospital notes and was just shown the ECG. He evinced no professional curiosity about a patient needing three doses of morphine and being considered for discharge. The locum consultant did not seem to be aware of any system in place to access the ambulance electronic records. He did not give any convincing explanation for not seeing this patient or his apparent ignorance regarding obtaining ambulance notes. He did not give a convincing explanation for not reviewing the patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of senior clinicians to review patients referred for advice
Wider context from the report “1. The doctor had not read the ambulance electronic records and was not aware of a system in place to obtain these notes prior to his seeing the patient. These notes contained information about Mr Havard having hematemesis and two doses of morphine given to Mr Havard by the crew. He did examine Mr Havard and had differential diagnoses and went to speak to the locum consultant who was just coming on shift for advice. The consultant did not ask to see the notes from the crew or the hospital notes and was just shown the ECG. He evinced no professional curiosity about a patient needing three doses of morphine and being considered for discharge. The locum consultant did not seem to be aware of any system in place to access the ambulance electronic records. He did not give any convincing explanation for not seeing this patient or his apparent ignorance regarding obtaining ambulance notes. He did not give a convincing explanation for not reviewing the patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely include or read ambulance notes in clinical records
Wider context from the report “3. Record keeping generally appeared to be poor and thus the doctors who attended at inquest had little documentation with which to refresh their memories and the ambulance notes do not appear to be routinely included in these notes and or read.
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of a system ensuring senior review of cases referred by junior doctors
Wider context from the report “2. There did not appear to be a system in place for junior doctors who have approached a senior to have their case reviewed with the responsibility for this being on the senior doctor.
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and review ambulance electronic records
Wider context from the report “1. The doctor had not read the ambulance electronic records and was not aware of a system in place to obtain these notes prior to his seeing the patient. These notes contained information about Mr Havard having hematemesis and two doses of morphine given to Mr Havard by the crew. He did examine Mr Havard and had differential diagnoses and went to speak to the locum consultant who was just coming on shift for advice. The consultant did not ask to see the notes from the crew or the hospital notes and was just shown the ECG. He evinced no professional curiosity about a patient needing three doses of morphine and being considered for discharge. The locum consultant did not seem to be aware of any system in place to access the ambulance electronic records. He did not give any convincing explanation for not seeing this patient or his apparent ignorance regarding obtaining ambulance notes. He did not give a convincing explanation for not reviewing the patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Poor clinical record keeping
Wider context from the report “3. Record keeping generally appeared to be poor and thus the doctors who attended at inquest had little documentation with which to refresh their memories and the ambulance notes do not appear to be routinely included in these notes and or read.
” Open source report
Concerns raised 5 Failure to risk assess and make safe the physical environment before patient access View source Failure of staff to understand required patient-observation practices View source Lack of an agreed pathway for detained patients requiring assessment and treatment at A & E View source Failure to record information gained from patient observations correctly View source Failure of escort policy and planning to address inter-service patient transfers View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
CHRISTOPHER JONATHAN HIGGINS · 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
Christopher Jonathan Higgins died on 2 July 2013 after sustaining a head injury when he dived over railings while being taken outside for a cigarette at the Fermoy Unit. The report identified concerns about staff understanding of patient observations, patient transfers involving other services, risk assessment of the environment, and arrangements for detained patients requiring assessment and treatment at 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to risk assess and make safe the physical environment before patient access
Wider context from the report “(3) The safety of the environment where the incident took place, namely a disabled ramp with a railing along the edge and a concrete floor, had not been risk assessed prior to taking Mr Higgins outside for a cigarette . It is understood that since Mr Higgins' death the railing has been heightened. There was no evidence of a formal Risk Assessment having been undertaken since his death . Other ways of making the area safe are still under consideration .
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to understand required patient-observation practices
Wider context from the report “(1) It became clear during evidence, that members of staff are not aware of what is required of them when they carry out Observations on a patient . This was particularly evident with regard to Observations to be carried out on a "two members of staff to one patient" basis. Areas of confusion include how staff are to engage with a patient, how close they are required to be with regard to the patient, i.e. at arm's length or within eyesight and how to record the information gained from the Observation.
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of an agreed pathway for detained patients requiring assessment and treatment at A & E
Wider context from the report “(4) There is no agreement in place between the NSFT and the Acute Hospital as to the best way to deal with patients subject to detention under the Mental Health Act who require assessment and treatment at A & E , as a result of which Mr Higgins, was required to wait over 2 hours in a busy, public area , having already self-harmed and shown signs of paranoia.
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to record information gained from patient observations correctly
Wider context from the report “(1) It became clear during evidence, that members of staff are not aware of what is required of them when they carry out Observations on a patient. This was particularly evident with regard to Observations to be carried out on a "two members of staff to one patient" basis. Areas of confusion include how staff are to engage with a patient, how close they are required to be with regard to the patient, i.e. at arm's length or within eyesight and how to record the information gained from the Observation .
” 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 Norfolk and Norwich University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of escort policy and planning to address inter-service patient transfers
Wider context from the report “(2) The Escort Policy does not include information relating to the transfer of patients from one place to another (in this case from an Acute Hospital to the Fermoy Unit) when other services are involved, for instance the Police . In particular, Mr Higgins who had been acting in an unpredictable, and paranoid manner, was put into a cage at the rear of the Police van with three Police Officers, with no Mental Health staff to accompany him . The evidence did not reveal that this had been considered by the Mental Health staff previously attending to Mr Higgins;
” 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