14 Apr 2026 James Patrick · Prevention of Future Deaths report Cumbria
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Concerns raised 1 Failure to provide Flow Coordinators with information about patient vulnerabilities when arranging discharge View source
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James Patrick · 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 Stewart, aged 52, died on 27 December 2024 after leaving hospital during alcohol withdrawal and placing a ligature around his neck at a nearby hotel, sustaining catastrophic injuries. The report describes concerns that he was discharged prematurely, without reassessment by the Psychiatric Liaison Team or intervention when safety concerns were raised, and that Flow Coordinators might not receive information about patient vulnerabilities when arranging discharge.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Flow Coordinators with information about patient vulnerabilities when arranging discharge
Wider context from the report “(1) I heard evidence from a Flow Coordinator who was responsible for taking the practical steps to arrange a patient's discharge after the treating clinicians had determined that the patient was medically fit. I understand that the Flow Coordinator is to make the necessary logistical arrangements for discharge, not to decide whether discharge is appropriate. However, the evidence was that the Flow Coordinator would not necessarily be briefed on any particular vulnerabilities that a patient had . For instance, in this instance Mr Stewart had made repeated threats to harm himself, including on the railway, which the Flow Coordinator did not know of. She considered making arrangements for him to travel home by train, which might have been especially risky. Whilst these matters did not eventuate in this inquest, I consider that not giving Flow Coordinators information about patient vulnerability risks them making unsuitable arrangements .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement clinical-risk information sharing during discharge coordination and multidisciplinary discharge processes, including updated documentation and mental-health referral prompts.
Verbatim wording from the response “1 | Implement process for sharing clinical risk information during discharge coordination and ensure MDT-led discharge for all patients. This includes mental health services. | Collaborative Lead Nurse Emergency Care | 31/08/2026 | Update discharge documentation to include:
- Mental health section. Has the patient had any involvement in mental health services during their admission or inpatient stay.
- If patient has been involved in mental health services – consider a referral to PLT prior to discharge. | Emergency Care Collaborative Workforce Group” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
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PFD Monitor interpretation Review the Band 4 Flow Coordinator role and associated discharge processes, including responsibilities, risk-information flow, escalation and multidisciplinary clinical leadership.
Verbatim wording from the response “1. Flow Coordinator Role and Discharge Processes” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
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PFD Monitor interpretation Contemporaneous staff accounts did not indicate that explicit hanging suicide intent was escalated immediately before discharge.
Verbatim wording from the response “For completeness, I would note that the Trust’s learning response completed in January 2025 was based on the contemporaneous evidence available at the time, including accounts from staff directly involved in Mr Stewart’s care. These accounts did not indicate that an explicit expression of intent to end his life by hanging had been escalated immediately prior to discharge. Notwithstanding this, I acknowledge your careful consideration of the evidence and accept the seriousness of your findings. The Trust has undertaken extensive reflection on the circumstances of Mr Stewart’s care, and is fully committed to ensuring that the learning identified is embedded into clinical practice and operational delivery.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
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26 May 2025 Sarah Kathleen Hill · Prevention of Future Deaths report Cumbria
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Concerns raised 7 Lack of documentation about the use of cot sides View source Insufficient ward nursing capacity for safe patient allocation View source Failure to undertake and evidence appropriate falls risk assessments View source Failure to ensure call bells are within patients' reach View source Failure to provide additional monitoring for patients in side rooms that are not easily observed View source Failure to report falls or collapses on the ward View source Lack of frequent recorded observations for deteriorating patients View source See 4 more concerns
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AI-generated summary
Sarah Kathleen Hill · 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 Kathleen Hill was admitted for an elective ERCP to remove gallstones and developed worsening pancreatitis, perforation, multi-organ failure and cardiac arrest before dying in the early hours of 8 November 2024. Concerns included inadequate falls-risk assessment and reporting, insufficient documentation and monitoring, poor observability in a side room, and understaffing despite escalation.
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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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of documentation about the use of cot sides
Wider context from the report “(2) There was a lack of documentation about the use of cot sides and the placement of the call bell within Mrs Hill's reach .
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient ward nursing capacity for safe patient allocation
Wider context from the report “(5) I was advised that the ward was understaffed and under pressure . I was told that despite this being appropriately escalated nurses were caring for 10 patients when the expected allocation would be 6 patients for each nurse on duty .No further help was provided to the ward following escalation . The evidence presented to me was that this was not an unusual situation on the ward .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake and evidence appropriate falls risk assessments
Wider context from the report “(1) There was a lack of evidence suggested appropriate falls risk assessments had been undertaken and a failure to report falls / collapses on the ward .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure call bells are within patients' reach
Wider context from the report “(2) There was a lack of documentation about the use of cot sides and the placement of the call bell within Mrs Hill's reach .
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide additional monitoring for patients in side rooms that are not easily observed
Wider context from the report “(4) Mrs Hill was placed in a side room where she was not easily observed without consideration given for the need for additional monitoring which led to her being left alone for extended periods of 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to report falls or collapses on the ward
Wider context from the report “(1) There was a lack of evidence suggested appropriate falls risk assessments had been undertaken and a failure to report falls / collapses on the ward .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of frequent recorded observations for deteriorating patients
Wider context from the report “(3) There was a lack of frequent recorded observations necessitated by Mrs Hill's deteriorating condition.
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit to the approved AMU establishment of eight qualified day nurses and seven night nurses.
Verbatim wording from the response “Concern 5: Staffing Levels and Escalation Response
Response:
The AMU have experienced nurse staffing difficulties with temporary escalation beds being open indefinitely. This has significantly impacted the ability to staff the ward in line with the recommended safe nurse staffing ratio of 1:6. This was acknowledged by the Trust in 2025 and an increased funded establishment was awarded in April 2025. The AMU is now ensuring that staffing levels are maintained at a minimum of six qualified nurses 24 hours per day to maintain a maximum nurse-to-patient ratio of 1:7.8 (nurse in charge plus 5 nurses for 39 patients). Furthermore, a new safe staffing establishment was approved in April 2025 for the ward, increasing staffing levels to eight qualified nurses during the day and seven at night.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and implement a Trust-wide documented risk-benefit protocol for placing deteriorating patients in isolation.
Verbatim wording from the response “Side Room Risk Assessment: Working with the infection prevention team, using the hierarchy of risks alongside professional judgement, develop and implement a Trust wide documented risk-” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a cohort-based care model for admission-ward patients with elevated NEWS2 scores and assess it for wider rollout.
Verbatim wording from the response “Cohort Monitoring: A pilot of a cohort-based care model for patients on the admission ward with elevated NEW2 scores is under development and if successful will be rolled out to other acute admission wards. This will allow greater visibility of patient’s with a dedicated nurse for the area/room. Prioritise use of rooms 1-6 which are closer to the front of the ward and doctor hub room.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise and implement the Safe Staffing Escalation SOP, including 30-minute action triggers and nurse-to-patient ratio review.
Verbatim wording from the response “Staffing Escalation SOP Review: The Trust’s Safe Staffing Escalation SOP will be revised and implemented to ensure that unmet staffing thresholds trigger action within 30 minutes, including redeployment. This will include a review of nurse-to-patient ratios.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver refresher incident-reporting training to AMU nursing staff covering falls, collapses, unwitnessed incidents and reporting thresholds.
Verbatim wording from the response “Incident Reporting Training: Refresher training is being delivered to all AMU nursing staff to clarify expectations around reporting collapses, falls, and unwitnessed incidents with an emphasis on always reporting even if there is doubt. Clarity will be included on borderline definitions and thresholds for reporting. This training will be expanded based upon the findings of the compliance review audit.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and pilot a two-zone ward layout with two registered nurses to improve visibility and responsiveness.
Verbatim wording from the response “Ward Layout Improvements: A proposal to split the corridor where the single rooms are, into two zones with two registered nurses is being developed and will be piloted to improve nurse-patient ratios in this part of the ward.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete an urgent assurance check of falls documentation and current AMU patient monitoring.
Verbatim wording from the response “Immediate Assurance Check: An urgent assurance check on falls documentation and current patient monitoring on AMU is being completed to confirm improved compliance post-incident. Additionally, the ward has an established programme of work to undertake thematic reviews of falls related incidents (including collapses) on a quarterly basis to determine quality improvement plans and identify any new themes that ought to be shared with other teams or added to our Falls Trust Wide Improvement Plan.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce at least hourly intentional rounding for patients receiving necessary side-room care through visual prompts.
Verbatim wording from the response “Intentional Rounding: Where side room care is necessary, intentional rounding will be re-enforced at least hourly, and staff are reminded of this through visual prompts.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the Nurse-in-Charge checklist to include bed rails, call bells and environmental safety.
Verbatim wording from the response “Daily Spot Checks: The daily Nurse-in-Charge quality checklist will be revised to include specific items on bed rails, call bells and environmental safety.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the FRAMP policy to mandate reassessment after sedation, deterioration or procedures and reinforce prompt documentation.
Verbatim wording from the response “Protocol Update: The FRAMP policy will be revised to mandate reassessment following sedation, clinical deterioration, or medical procedures. This will include reinforcement of prompt documentation.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore mandatory electronic fields for bed-rail status and call-bell placement, including with the replacement-record supplier.
Verbatim wording from the response “Electronic Documentation Enhancement: The Web V electronic record system is under review to explore the options to introduce mandatory (cannot be bypassed) fields for bed rails status and call bell placement. NB: WebV will be replaced as part of the implementation of a new electronic patient record in 2026 and this feature will be explored with the supplier to ensure any progress made with WebV is not lost.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore electronic-health-record dashboard options for real-time observation flagging and escalation alerts.
Verbatim wording from the response “• Deteriorating Patient Dashboard: Options are to be explored to enhance real-time flagging systems within the electronic health record, including escalation alerts visible to nurses and medical clinicians if observations fall below safe thresholds.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review ward falls assurance evidence against the Trust-wide Falls Improvement Plan and ward SMART plans.
Verbatim wording from the response “Compliance Review: The trust is reviewing the falls assurance evidence being captured by those wards undertaking Quality Accreditation to ensure that results are aligned with the Trust-wide Falls Improvement Plan and are linked to individual ward SMART improvement plans.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation FRAMP falls assessments were completed and updated appropriately; the identified failure concerned documenting and applying mitigating controls.
Verbatim wording from the response “Concern 1: Inadequate Falls Risk Assessment and Incident Reporting
Response:
The Trust acknowledges the failure to evidence appropriate falls risk assessment and timely incident reporting in Mrs Hill’s care.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Four-hourly observations initially complied with NEWS2 policy because the recorded scores did not trigger increased monitoring, despite later missed observations and escalation failures.
Verbatim wording from the response “Following Mrs Hill’s ERCP procedure on 5 November 2024, she was admitted to the AMU at 19:00 hours with a diagnosis of post-ERCP pancreatitis based on a significantly raised amylase level. Mrs Hill’s condition initially appeared stable, with a planned 4-hourly National Early Warning Score (NEWS 2) in response to the score of 0-1 due to temperature 38.2°C on 6 November 2024. In line with the Trust policy (4-6 hourly observations for the first 48 hours unless NEWS2 triggers a change/escalation), the vital signs monitoring remained at 4 hourly.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
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13 Aug 2024 Daphne Gillian AUSTIN · Prevention of Future Deaths report Cumbria
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Concerns raised 1 Failure of industrial-action contingency planning to provide safe levels of clinical cover View source
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Daphne Gillian AUSTIN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Daphne Gillian Austin, who was 71 and had diabetes, was admitted to hospital after a stroke. Her glucose levels were poorly controlled, she became dehydrated, and her fluid balance was not effectively monitored; blood testing was not carried out on 15 or 16 June 2023. She developed an acute kidney injury and then sepsis, and died on 18 June 2023. The principal concern was that planning for safe staffing during industrial action was insufficient, creating a risk of future deaths.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of industrial-action contingency planning to provide safe levels of clinical cover
Wider context from the report “(1) I received evidence of the planning that had gone into preparing the trust for strikes. However, there was evidence from one of the Trust's consultants that on the day of the strike she had to "look after nearly 25 patients" and that "due to the junior doctor’s strike on 14/06/2023, Mrs Austin did not receive any medical input that day". Another consultant gave evidence that despite being listed as one of the consultants covering the unit (in the contingency planning evidence) he was probably dealing with other duties on that day. In the circumstances I am concerned that the planning that seeks to ensure safe levels of cover during periods of industrial action was insufficient to meet need and that this gave rise to a risk of future deaths.
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain the existing industrial-action planning process and staffing plans for safe levels of medical cover during future industrial action.
Verbatim wording from the response “The Trust has reviewed the planning process and staffing plans and is satisfied that it ensures safe levels of cover during periods of industrial action to meet need, and that this does not give rise to a risk of future deaths. The process and plans will therefore be maintained during any future periods of industrial action. However, despite the Trust’s robust framework in ensuring appropriate medical cover during periods of industrial action, the Trust has identified areas of learning which could contribute to the Trust’s resilience:” Source location Response from North Cumbria Integrated Care NHS Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing industrial-action staffing processes and plans are considered sufficient to provide safe cover and will be maintained during future industrial action.
Verbatim wording from the response “The Trust has reviewed the planning process and staffing plans and is satisfied that it ensures safe levels of cover during periods of industrial action to meet need, and that this does not give rise to a risk of future deaths. The process and plans will therefore be maintained during any future periods of industrial action. However, despite the Trust’s robust framework in ensuring appropriate medical cover during periods of industrial action, the Trust has identified areas of learning which could contribute to the Trust’s resilience:” Source location Response from North Cumbria Integrated Care NHS Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust considers that staffing levels during industrial action did not cause or contribute to missed opportunities in the patient’s care.
Verbatim wording from the response “In view of the Trust’s assurance that there is safe levels of cover during periods of industrial action to meet patient needs, the Trust is satisfied that this did not cause or contribute to any missed opportunities within Ms Austin’s care. However, the Trust unreservedly acknowledges that there is a need to establish what the causal and/or contributory factors were in Ms Austin not receiving medical input and basic, fundamental observations and interventions during her hospital admission. The Trust will therefore carry out a review into this to identify any learning and take immediate action to embed the learning to prevent recurrence and ensure that the care we provide is safe, effective, and of a high quality.” Source location Response from North Cumbria Integrated Care NHS Trust
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2 May 2024 Karen THOMASON · Prevention of Future Deaths report Cumbria
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Concerns raised 3 Failure to notify support services of vulnerable patients' discharge View source Failure to distinguish mental capacity from vulnerability in safeguarding decisions View source Failure to complete safeguarding questions accurately and meaningfully View source
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Karen THOMASON · 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
Karen Thomason, aged 52, collapsed at home on 31 October 2023, was discharged from hospital without Cumbria Housing staff being notified, and was found unresponsive at home the following day. Her death was confirmed on 1 November 2023 after she had consumed a substantial amount of alcohol. The concerns included errors in safeguarding documentation, failures to notify housing staff about discharge, and the risk of conflating capacity with an absence of vulnerability or safeguarding concerns.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to notify support services of vulnerable patients' discharge
Wider context from the report “(2) There is evidence that Cumbria Housing staff had asked to be notified of the discharge of a vulnerable patient so that they could provide support to her but that they received no communications on several occasions. I am concerned that this may mean that other patients are discharged without appropriate support being alerted to their needs .
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to distinguish mental capacity from vulnerability in safeguarding decisions
Wider context from the report “(3)The evidence I received places an emphasis on the fact that Ms Thomason had capacity and indicated that she felt safe. It is certainly correct that this meant that there could be no question of her being held in hospital. It is also correct that her view of her situation was of relevance. However, it does not mean that obvious vulnerability or safeguarding concerns could not be addressed. Regardless of what Ms Thomason said, her vulnerability was obvious. I am concerned that the concepts of 'having capacity' and 'not being vulnerable' are being elided.
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete safeguarding questions accurately and meaningfully
Wider context from the report “(1) There were errors in the completion of the hospital's safeguarding questions. The clinician answered 'no' to the question 'Is there a safeguarding concern?'. The clinician's evidence was that, in fact, she did have a safeguarding concern and explored it with Ms Thomason, but that she completed the electronic form in error. I am concerned that the form is regarded as a 'tick box' exercise rather than a vital safeguarding tool.
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure relevant staff attend mandated safeguarding training at the appropriate level and review attendance through governance meetings.
Verbatim wording from the response “Currently our mandatory Safeguarding Adults Level 3 Training for all clinicians is completed every 3 years and stands at 80% completion across our Emergency Care Collaborative (88% for the organisation overall and 80.5% for our individual EDs). This needs to improve in order that all our staff have an understanding of vulnerability and how to recognise it and act accordingly. We also recognise that while this training is important, there needs to be some additional supplementary means of ensuring that staff are continually learning and using safeguarding best practice.” Source location Response from North Cumbria Integrated Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider changing Symphony’s safeguarding question to distinguish new concerns from existing concerns under control.
Verbatim wording from the response “RECOMMENDATION 1: change the symphony safeguarding question. Consider “are there any new safeguarding concerns?” “Is there an existing safeguarding concern that is under control?” Is there something new today that needs action today to deal with something different or unusual today?” Source location Response from North Cumbria Integrated Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update Symphony’s discharge screen to record discharge discussions and identify notifications or vulnerable-adult support needed before patients go home.
Verbatim wording from the response “RECOMMENDATION 2: Update Symphony to include discharge discussions for all patients. Include an ask “is there anything we can do or anyone we can notify before you go home?” Explore the “discharge screen” options on symphony to include a vulnerable adult question set.” Source location Response from North Cumbria Integrated Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop an Emergency Department safeguarding supervision programme for adult patients, supported by the Trust Safeguarding Team.
Verbatim wording from the response “Safeguarding supervision for staff working with children is mandated within the Intercollegiate Document. Staff working with children are offered Safeguarding Children’s supervision which is attended quarterly. Safeguarding adults supervision is not mandated or recommended as best practice. Safeguarding supervision sessions can help staff explore their own experiences as well as support colleagues to understand, change, and improve their approach collectively. The ED Team recognise that engaging with this approach for all ages of patients would ensure our staff regularly discuss this and debate patient vulnerability, options for managing them safely, improve professional understanding, provide peer to peer support through professional conversations, and potentially offer suggestions around improvements to systems and processes.” Source location Response from North Cumbria Integrated Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Emergency Department was not informed of any request or requirement to notify the Housing Officer about discharge.
Verbatim wording from the response “Unfortunately, the ED Team were not made aware at any stage during Ms Thomason’s ED attendance, of any ask or requirement to notify the Housing Officer of Ms Thomason discharge or that the Housing officer had any concerns, either by the Housing Officer themselves, the Ambulance Service, or Ms Thomason. This was not conveyed verbally nor was it documented in the Ambulance records that were shared with ED on Ms Thomason’s arrival into the department.” Source location Response from North Cumbria Integrated Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The safeguarding response was not a box-checking error; the clinician conducted a full safety and welfare discussion.
Verbatim wording from the response “The clinician’s statements coupled with the symphony record for this patient provides evidence that on this occasion the safeguarding of Ms Thomason was taken incredibly seriously. The ACP clinician has demonstrated that they had a full safety and welfare conversation with Ms Thomason. We do not believe the safeguarding box was checked in error on this occasion.” Source location Response from North Cumbria Integrated Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A capacitous adult’s liberty and choice limited the Trust’s ability to intervene despite risky behaviours or an unsafe lifestyle.
Verbatim wording from the response “We do recognise however that this case highlights how vulnerable adults such as Ms Thomason could be better supported and safeguarded in particular when leaving the department and even in the knowledge of them being known to support services. Notwithstanding that even if people have what we regard as risky behaviours or unsafe lifestyles they do have the capacity and choice (freedom of liberty) to do as they wish.” Source location Response from North Cumbria Integrated Care
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9 Jan 2024 Karena WICKINGS · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 2 Failure of surgical mortality reviews to consider the role of anticoagulation View source Failure of discharge planning to consider ongoing anticoagulant prophylaxis for patients with restricted mobility View source
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Karena WICKINGS · 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
Karena Wickings, aged 58, died at home in Brampton, Cumbria on 5 February 2023 from pulmonary embolism following a prolonged hospital admission for surgery and postoperative complications. Her mobility remained significantly restricted at discharge, when anticoagulant prophylaxis stopped. The report raises concern that discharge planning did not consider whether ongoing anticoagulant prophylaxis was indicated for patients who had not regained full mobility.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of surgical mortality reviews to consider the role of anticoagulation
Wider context from the report “(1) The surgical mortality review conducted after Karena's does not seem to have considered the role that anticoagulation may have played. I understand trust guidelines suggest it continues until 5-7 days or until the patient regains full mobility. I was told many surgeons will extend this to 28 days. Karena was past the 28 day period but still had significant restriction at the time of discharge. A few years ago I heard a very similar case which occurred at a different health trust. The purpose of this report is to suggest that discharge planning might have a prompt to consider possible ongoing anticoagulant prophylaxis in patients who leave the hospital but have not yet regained full mobility.
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of discharge planning to consider ongoing anticoagulant prophylaxis for patients with restricted mobility
Wider context from the report “(1) The surgical mortality review conducted after Karena's does not seem to have considered the role that anticoagulation may have played. I understand trust guidelines suggest it continues until 5-7 days or until the patient regains full mobility. I was told many surgeons will extend this to 28 days. Karena was past the 28 day period but still had significant restriction at the time of discharge. A few years ago I heard a very similar case which occurred at a different health trust. The purpose of this report is to suggest that discharge planning might have a prompt to consider possible ongoing anticoagulant prophylaxis in patients who leave the hospital but have not yet regained full mobility.
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review NICE guidance and update the Trust pharmacological VTE prophylaxis guideline, including discharge advice and VTE-risk documentation.
Verbatim wording from the response “Recommendation 2:
Update the Pharmacological VTE Prophylaxis in Adult Medical and Surgical Patients Guideline to include advice on discharge and documenting VTE risk.” Source location Response from Cumbria NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Progress training, discharge-summary amendments and ownership guidance for documenting VTE assessment and ongoing prophylaxis at discharge.
Verbatim wording from the response “Recommendation 4:
VTE assessment at the time of discharge to be documented on the electronic discharge summary, providing an update on actions taken to reduce this risk and any further actions required.” Source location Response from Cumbria NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit the nursing discharge checklist for compliance with VTE documentation requirements.
Verbatim wording from the response “Liaise with Digital Systems to update the system to include VTE on discharge in the nursing checklist.” Source location Response from Cumbria NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss implementation with Digital Systems to add VTE discharge documentation to the nursing checklist.
Verbatim wording from the response “Recommendation 3:
Amend the nursing discharge checklist to document the ongoing plan for VTE prophylaxis at the time of discharge, to ensure patient information advice and management plan for pharmacological VTE.” Source location Response from Cumbria NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the Regulation 28 recommendation with Matrons to raise awareness of discharge VTE documentation requirements.
Verbatim wording from the response “Recommendation 3:
Amend the nursing discharge checklist to document the ongoing plan for VTE prophylaxis at the time of discharge, to ensure patient information advice and management plan for pharmacological VTE.” Source location Response from Cumbria NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend the ward-round proforma to prompt daily VTE review and a discharge VTE-risk plan.
Verbatim wording from the response “Recommendation 5:
Amend the Ward round proforma to include daily review of VTE in place and plan for discharge with regards to VTE.” Source location Response from Cumbria NHS
Open published response
Concerns raised 5 Radiology triage arrangements failing to ensure reliable transfer of referral information to imaging clinicians View source Failure to communicate accurate clinically important information between clinicians and departments View source Lack of radiologist access to patients’ medical notes during imaging assessment View source Failure to complete required referral for surgical opinion View source Failure of telephone referrals and imaging summaries to provide accurate, consistent clinical information View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Brian David MORETON · 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 Moreton was admitted with diarrhoea, recurring fever and a distended abdomen; a toxic megacolon present on CT was not reported to those treating him. He was treated for severe colitis, later found to have a perforated bowel, and died from infections following surgery and immunosuppression. The principal concern was poor and misleading communication between clinicians, departments and hospital trusts, including deficiencies in the information provided to radiologists and assumptions about his clinical improvement and surgical referral.
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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Radiology triage arrangements failing to ensure reliable transfer of referral information to imaging clinicians
Wider context from the report “- Evidence was heard that at the time of the inquest radiologists do not have access to patient' medical notes and base their reporting on a summary document submitted by the department requiring imaging. The summary document in Mr MORETON’S case was seen to be deficient in that it omitted his symptom of fever. It was heard in evidence a radiologist would need to telephone the department in question or go there to inspect the notes. Their awareness of a patient's condition is based on a telephone call referral followed by a summary document which can be at odds with each.
- It is of concern that the use of telephone referral system and summary could contain errors and the radiologist must rely on this information, with no quick way to inspect a patient's notes.
- The evidence also dealt with radiologists working in 2 hour triage shifts in a hectic environment where those clinicians receiving the referral seldom were the clinicians who carried out the imaging . The inference was the arrangement was susceptible to error .
- Over the course of the inquest evidence was heard on a number of issues where information passed to and from clinicians involved in Mr MORETON’S care was inaccurate and misleading.
- Assumptions were made that, Mr MORETON was improving clinically when a surgical opinion was sought, this was incorrect.
- It was assumed Mr MORETON would be referred for a surgical opinion by ED department clinicians, when in fact none took place.
- Clinicians in Newcastle Upon Tyne when asked for advice were under the impression treatment was working as it was mentioned his discharge from hospital was contemplated - this was not the case.
- Overall I am concerned by the poor and misleading communications between clinicians, departments and Hospital Trusts on matters of vital importance to patient care.
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate accurate clinically important information between clinicians and departments
Wider context from the report “- Evidence was heard that at the time of the inquest radiologists do not have access to patient' medical notes and base their reporting on a summary document submitted by the department requiring imaging. The summary document in Mr MORETON’S case was seen to be deficient in that it omitted his symptom of fever. It was heard in evidence a radiologist would need to telephone the department in question or go there to inspect the notes. Their awareness of a patient's condition is based on a telephone call referral followed by a summary document which can be at odds with each.
- It is of concern that the use of telephone referral system and summary could contain errors and the radiologist must rely on this information, with no quick way to inspect a patient's notes.
- The evidence also dealt with radiologists working in 2 hour triage shifts in a hectic environment where those clinicians receiving the referral seldom were the clinicians who carried out the imaging. The inference was the arrangement was susceptible to error.
- Over the course of the inquest evidence was heard on a number of issues where information passed to and from clinicians involved in Mr MORETON’S care was inaccurate and misleading .
- Assumptions were made that, Mr MORETON was improving clinically when a surgical opinion was sought, this was incorrect.
- It was assumed Mr MORETON would be referred for a surgical opinion by ED department clinicians, when in fact none took place.
- Clinicians in Newcastle Upon Tyne when asked for advice were under the impression treatment was working as it was mentioned his discharge from hospital was contemplated - this was not the case.
- Overall I am concerned by the poor and misleading communications between clinicians, departments and Hospital Trusts on matters of vital importance to patient care.
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of radiologist access to patients’ medical notes during imaging assessment
Wider context from the report “- Evidence was heard that at the time of the inquest radiologists do not have access to patient' medical notes and base their reporting on a summary document submitted by the department requiring imaging . The summary document in Mr MORETON’S case was seen to be deficient in that it omitted his symptom of fever. It was heard in evidence a radiologist would need to telephone the department in question or go there to inspect the notes. Their awareness of a patient's condition is based on a telephone call referral followed by a summary document which can be at odds with each.
- It is of concern that the use of telephone referral system and summary could contain errors and the radiologist must rely on this information, with no quick way to inspect a patient's notes .
- The evidence also dealt with radiologists working in 2 hour triage shifts in a hectic environment where those clinicians receiving the referral seldom were the clinicians who carried out the imaging. The inference was the arrangement was susceptible to error.
- Over the course of the inquest evidence was heard on a number of issues where information passed to and from clinicians involved in Mr MORETON’S care was inaccurate and misleading.
- Assumptions were made that, Mr MORETON was improving clinically when a surgical opinion was sought, this was incorrect.
- It was assumed Mr MORETON would be referred for a surgical opinion by ED department clinicians, when in fact none took place.
- Clinicians in Newcastle Upon Tyne when asked for advice were under the impression treatment was working as it was mentioned his discharge from hospital was contemplated - this was not the case.
- Overall I am concerned by the poor and misleading communications between clinicians, departments and Hospital Trusts on matters of vital importance to patient care.
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete required referral for surgical opinion
Wider context from the report “- Evidence was heard that at the time of the inquest radiologists do not have access to patient' medical notes and base their reporting on a summary document submitted by the department requiring imaging. The summary document in Mr MORETON’S case was seen to be deficient in that it omitted his symptom of fever. It was heard in evidence a radiologist would need to telephone the department in question or go there to inspect the notes. Their awareness of a patient's condition is based on a telephone call referral followed by a summary document which can be at odds with each.
- It is of concern that the use of telephone referral system and summary could contain errors and the radiologist must rely on this information, with no quick way to inspect a patient's notes.
- The evidence also dealt with radiologists working in 2 hour triage shifts in a hectic environment where those clinicians receiving the referral seldom were the clinicians who carried out the imaging. The inference was the arrangement was susceptible to error.
- Over the course of the inquest evidence was heard on a number of issues where information passed to and from clinicians involved in Mr MORETON’S care was inaccurate and misleading.
- Assumptions were made that, Mr MORETON was improving clinically when a surgical opinion was sought, this was incorrect.
- It was assumed Mr MORETON would be referred for a surgical opinion by ED department clinicians, when in fact none took place.
- Clinicians in Newcastle Upon Tyne when asked for advice were under the impression treatment was working as it was mentioned his discharge from hospital was contemplated - this was not the case.
- Overall I am concerned by the poor and misleading communications between clinicians, departments and Hospital Trusts on matters of vital importance to patient care.
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of telephone referrals and imaging summaries to provide accurate, consistent clinical information
Wider context from the report “- Evidence was heard that at the time of the inquest radiologists do not have access to patient' medical notes and base their reporting on a summary document submitted by the department requiring imaging. The summary document in Mr MORETON’S case was seen to be deficient in that it omitted his symptom of fever . It was heard in evidence a radiologist would need to telephone the department in question or go there to inspect the notes. Their awareness of a patient's condition is based on a telephone call referral followed by a summary document which can be at odds with each .
- It is of concern that the use of telephone referral system and summary could contain errors and the radiologist must rely on this information, with no quick way to inspect a patient's notes.
- The evidence also dealt with radiologists working in 2 hour triage shifts in a hectic environment where those clinicians receiving the referral seldom were the clinicians who carried out the imaging. The inference was the arrangement was susceptible to error.
- Over the course of the inquest evidence was heard on a number of issues where information passed to and from clinicians involved in Mr MORETON’S care was inaccurate and misleading.
- Assumptions were made that, Mr MORETON was improving clinically when a surgical opinion was sought, this was incorrect.
- It was assumed Mr MORETON would be referred for a surgical opinion by ED department clinicians, when in fact none took place.
- Clinicians in Newcastle Upon Tyne when asked for advice were under the impression treatment was working as it was mentioned his discharge from hospital was contemplated - this was not the case.
- Overall I am concerned by the poor and misleading communications between clinicians, departments and Hospital Trusts on matters of vital importance to patient care.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Relaunch SBAR across the Trust, requiring documented email confirmation and record copies for telephone advice and escalation communications.
Verbatim wording from the response “Whilst staff are expected to utilise SBAR within handover and referrals, and is clearly referenced within various policies and SOPs, it would appear that this system has lost momentum within the Trust. SBAR is therefore being relaunched throughout the Trust and meetings are ongoing to determine how best to achieve this. Clinicians will be expected to utilise SBAR in any escalation of a clinical problem that requires attention, or to facilitate efficient handover, both internally and externally.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require ICE referrers to record clinical details and differential diagnoses in the renamed mandatory referral field.
Verbatim wording from the response “The purpose of diagnostic imaging is to assist in the process of identifying or determining the etiology of a disease or condition, alongside the evaluation of a patient’s history, physical examination, and review of laboratory data. Reaching a diagnosis provides a trajectory of treatment and an understanding of a patient’s prognosis, and in some cases, may be useful for preventative treatments. However, in order to justify diagnostic imaging (to provide assurance that the benefits outweigh the risks) it is necessary to provide a differential diagnosis, which the imaging seeks to evidence or rule out. A differential diagnosis of query obstruction was included within Mr Moreton’s ICE referral, but toxic megacolon was not considered as an explanation for his presentation during his admission.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the ratified CT imaging referral protocol requiring senior review, written ICE referrals and defined Radiographer authorisation pathways.
Verbatim wording from the response “In August 2022, the Trust ratified a protocol, which sets out a clear referral flow chart for the authorisation of CT imaging for adults. If a CT scan is indicated, the patient must be reviewed or discussed with a senior decision maker within the referring team, and the referrer must make a written referral on ICE (as is the process for all imaging), with reference to who the senior decision maker is within the referral. If the request falls within the Rapid Radiology Request Pathway (“RRRP”) criteria below, this can be discussed with a CT Radiographer without the requirement to discuss this with a Radiologist or the referrer:” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and ratify an inflammatory bowel disease SOP covering acute severe colitis red flags, toxic megacolon and specialist referrals.
Verbatim wording from the response “A standard operating procedure (SOP) is in the final stages of development for the management of inflammatory bowel disease (IBD), including the general management of acute severe colitis of all causes. The SOP includes red flag symptoms for acute severe colitis, and makes regular reference to the need for clinicians to be cognisant of high-risk features and devastating complications of severe colitis, such as toxic megacolon. The SOP provides education that toxic megacolon is characterised by radiographic distension of the colon often with fever, tachycardia, neutrophil leucocytosis and anaemia. Once ratified the SOP will be electronically accessible to all clinical teams via the Trust’s Clinical SOPs intranet page.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold joint internal and cross-Trust IBD multidisciplinary meetings at established biweekly and triweekly frequencies.
Verbatim wording from the response “The Trust now holds joint biweekly IBD multidisciplinary team meetings (MDTs) between the internal general surgery and gastroenterology teams. A triweekly joint specialist IBD MDT between the Trust and Newcastle upon Tyne Hospitals NHS Foundation Trust has also been established since February 2023. An MDT, made up of a variety of specialists within an interest in IBD or gastroenterology, approach to the management of a patient’s IBD, is recommended to provide optimised and personalised care, based on available professional expertise, infrastructure and funding, and helps to prevent errors in the delivery of care and avoid related harm to patients. The timing of MDT meetings happen on the aforementioned frequencies to ensure decision-making is not delayed, however, such discussions largely relate to complex, chronic IBD patients.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind Radiology staff to document relevant justification discussions in RIS for access by subsequent reporting Radiologists.
Verbatim wording from the response “The Trust however recognises that there may be occasions where referrers and the Radiology Department need to discuss a referral. As aforementioned, such discussions were not documented or recorded at the time of Mr Moreton’s admission. The Radiology Department utilises RIS (radiology information system) which has the ability to document any relevant information, and each Radiologist has access to the system. Following Mr Moreton’s death, Radiology staff have been reminded of situations where it might be appropriate to record information on RIS, particularly discussions during the justification process, which could be reviewed by the Reporting Radiologist, if the imaging was justified by another Radiologist.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and deliver diagnostic-referral education covering mandatory fields, clinical information and differential diagnoses for trained staff.
Verbatim wording from the response “The Trust recognises that if most requests for imaging are managed via written referral on ICE, there is a need to ensure that such referrals are robust. A robust referral should contain high-quality clinical information, which enables the Radiology Department to determine the most appropriate investigation or procedure to be selected, that takes into account patient safety, radiation exposure, and diagnostic value. It also provides a reason for the investigation through a clear diagnostic question that the referrer wants answering, to assist the Radiologist in the interpretation of results, minimising perceptual and interpretational diagnostic errors, and the subsequent completion of a pertinent and concise report.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement digital patient-record access by maintaining Radiology access to Clinica Portal and WebV and extending access to Symphony Paperlite and the new EPR.
Verbatim wording from the response “Whilst it would not be commonplace for Radiology staff to access records in the process of triage or whilst interpreting and reporting on imaging, the Trust recognises that in exceptional circumstances, it may be of benefit. Radiology staff have therefore already been granted access to the Clinica Portal, which is an EPR and contains primary care information and past medical history. Access has also been granted to WebV, which is an inpatient EPR and provides access to a patient’s pathology results, vitals/NEWS scoring and nursing assessments. The Trust is in the process of granting Radiology staff access to Symphony Paperlite, and access will also be granted to the new EPR once commissioned. A guideline needs to be produced on which records should be accessed in line with the Royal College of Radiologists.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Radiology departments cannot guarantee that the radiologist justifying imaging will also interpret and report it.
Verbatim wording from the response “Operationally NHS Radiology Departments cannot guarantee that Radiologists who may have been involved in the justification of a scan, be the Radiologist who interprets and reports on it. With the reduction in the telephone duty system and the introduction of Radiographers being able to justify certain CT images, it is likely most referrals will be limited to what is documented on ICE. With the intended improvements to the quality of referrals being made by the educational programme and introduction of the differential diagnosis box within the ICE system and the IBD SOP, that the overall quality of information gleaned within the referral process will improve, and the involvement of more than 1 Radiologist will not give rise to errors within the arrangement, particularly now that the reporting environment is more productive.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Timetabled multidisciplinary team meetings cannot determine acute or emergency care because those decisions cannot be delayed.
Verbatim wording from the response “Acute or emergency care decisions cannot not be delayed for timetabled MDTs, but should happen separately between relevant specialists. The introduction of the MDTs has improved working relationships and communication between the teams and Trusts, to ensure early referrals for specialist input in the management of a patient’s care is sought, for patients who are acutely unwell and/or where urgent advice is required. Had the MDTs been in place during Mr Moreton’s admission, he likely would have been listed for discussion in both MDTs and professional relationships would have been established to seek earlier input from surgical colleagues and specialists in Newcastle.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Radiologists could not routinely leave the department to review referring-department records because operational pressures made this infeasible.
Verbatim wording from the response “The inquest heard that Radiologists triaging and reporting on Mr Moreton’s imaging on 02/03/2022 did not have access to the relevant records. The Trust has a number of Electronic Patient Records (EPR) across its services. Inpatient, outpatient and community care also utilise paper records. On attendance to the ED on 02/03/2022, Mr Moreton’s records would initially have been in paper format, and later scanned to the ED’s EPR, Symphony. Within the Trust, post-holders are only granted access to systems relevant to their role/service in line with the Trust’s information governance policies. Furthermore, Radiology Departments are not an outlier and it is not common practice nationally within the NHS for Radiology staff to independently obtain information to assist them in the justification and reporting of imaging; the process is reliant on the information provided by the referrer.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Involvement of different radiologists in imaging justification and reporting is not expected to cause errors under the improved referral and reporting arrangements.
Verbatim wording from the response “Operationally NHS Radiology Departments cannot guarantee that Radiologists who may have been involved in the justification of a scan, be the Radiologist who interprets and reports on it. With the reduction in the telephone duty system and the introduction of Radiographers being able to justify certain CT images, it is likely most referrals will be limited to what is documented on ICE. With the intended improvements to the quality of referrals being made by the educational programme and introduction of the differential diagnosis box within the ICE system and the IBD SOP, that the overall quality of information gleaned within the referral process will improve, and the involvement of more than 1 Radiologist will not give rise to errors within the arrangement, particularly now that the reporting environment is more productive.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Written ICE referrals are generally sufficient to justify imaging without supplementary telephone discussion with a radiologist.
Verbatim wording from the response “Furthermore, there is no longer the expectation or requirement for referrers to discuss referrals for any imaging with a Radiologist. Whilst the duty line is still operational for referrers, Radiographers and Radiologists to discuss any requests being made, it is process for a robust ICE written referral to be made, and it is on that basis that the majority of imaging requests are justified or rejected, either by a Radiographer or Radiologist (depending on the above criteria), without the need for further discussion.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
Open published response
14 Jul 2022 Gordon Bernard Hendley · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 10 Failure of mortality and harm review to identify the need for a Serious Incident Review View source Failure to obtain dermatology advice for suspected Stevens-Johnson Syndrome View source Failure to act promptly on severe lactic acidosis and hyperkalaemia on the medical ward View source Delays in assessment of severely ill patients returning to A&E View source Failure to record recognition of the significance of critical blood-test results View source Delays in medical consultant review of patients referred to medicine View source Severely ill A&E patients without an advocate or support person View source Failure to use SCORTEN or ABCD-10 prognostic tools for Stevens-Johnson Syndrome View source Failure to escalate critical A&E blood-test abnormalities to the senior clinician View source Lack of a robust A&E intentional-rounding system 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
Gordon Bernard Hendley · 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
Gordon Bernard Hendley, who had lymphoma and recent lung infection and pulmonary embolism, developed a severe rash most likely caused by Stevens-Johnson Syndrome and died in hospital on 23 January 2022 after maximal treatment. The report identified concerns about delays in medical assessment and treatment, failure to escalate significant blood-test results, lack of specialist dermatology input and prognostic scoring, and the robustness of systems for monitoring and supporting severely ill patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of mortality and harm review to identify the need for a Serious Incident Review
Wider context from the report “7) I was shown a “Mortality and Harm Review Tool” completed in May which concluded that “care was good and decisions sound”, and that there was no need for a Serious Incident Review . I stated in court that I completely rejected this . I did however note and am pleased that ████████ is producing an educational programme and Standard operating procedure for SJS/TENS.
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain dermatology advice for suspected Stevens-Johnson Syndrome
Wider context from the report “1) Stevens-Johnson Syndrome is a dermatological emergency with a significant mortality rate (perhaps over 10% in a man of Gordon’s age and frailty), he was referred with this diagnosis by an experienced GP. While evidence suggests a medical consultant was contacted he did not see Gordon himself and I heard no evidence to suggest a dermatologist was consulted for advice . Also the SCORTEN or ABCD-10 prognostic tools were not used, they may have been helpful.
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act promptly on severe lactic acidosis and hyperkalaemia on the medical ward
Wider context from the report “5) On the medical ward there still seems to be no sense of urgency in Gordon’s treatment. A further blood test at 8.45pm showed severe lactic acidosis and hyperkalaemia but no action seems to have been taken . It was not until the ICU doctor happened upon Gordon just before 11pm, 24 hours after he arrived in the hospital that positive steps were taken.
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in assessment of severely ill patients returning to A&E
Wider context from the report “2) When Gordon returned to A&E late on 20th January there was an excessive delay in his assessment . His blood test revealed a significant lactic acidosis with marked anaemia and very low white blood counts. The A&E consultant who gave evidence said she would have expected this to be escalated to her -she was on call at home, but it was not. I have inputted the data in medical records to the scoring tools referred to above and mortality predictions have now risen to around 50%.
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record recognition of the significance of critical blood-test results
Wider context from the report “3) Gordon had a CT scan, he was referred to medicine but not seen by a medical consultant until 4.30 pm, he was to be admitted to a ward (this happened at 6.30pm) but there is no record in the notes of the significance of the earlier blood test being appreciated .
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in medical consultant review of patients referred to medicine
Wider context from the report “3) Gordon had a CT scan, he was referred to medicine but not seen by a medical consultant until 4.30 pm , he was to be admitted to a ward (this happened at 6.30pm) but there is no record in the notes of the significance of the earlier blood test being appreciated.
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Severely ill A&E patients without an advocate or support person
Wider context from the report “6) ████████, Gordon’s wife was not permitted to be with him in A&E due to Covid restrictions. Thus he had no advocate . I have no doubt that had she been there to speak for him care would have been expedited. It is my view that regardless of policy severely ill patients will benefit from support in similar 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use SCORTEN or ABCD-10 prognostic tools for Stevens-Johnson Syndrome
Wider context from the report “1) Stevens-Johnson Syndrome is a dermatological emergency with a significant mortality rate (perhaps over 10% in a man of Gordon’s age and frailty), he was referred with this diagnosis by an experienced GP. While evidence suggests a medical consultant was contacted he did not see Gordon himself and I heard no evidence to suggest a dermatologist was consulted for advice. Also the SCORTEN or ABCD-10 prognostic tools were not used , they may have been helpful.
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate critical A&E blood-test abnormalities to the senior clinician
Wider context from the report “2) When Gordon returned to A&E late on 20th January there was an excessive delay in his assessment. His blood test revealed a significant lactic acidosis with marked anaemia and very low white blood counts. The A&E consultant who gave evidence said she would have expected this to be escalated to her -she was on call at home, but it was not. I have inputted the data in medical records to the scoring tools referred to above and mortality predictions have now risen to around 50%.
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a robust A&E intentional-rounding system
Wider context from the report “4) At the inquest into the death of Nicholas Dietzold (who died in the A&E department) which I heard last September I was assured that a system of “Intentional Rounding” would take place in A&E when a senior doctor and nurse would go round the department to look at patients & assure themselves that appropriate actions were in hand (I am aware the design of the department is less than ideal). The consultant gave evidence assuring me that this did take place but there were no notes to confirm this and I question whether it is a robust system .
” Open source report
13 Jan 2022 Darran Busby · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 2 Failure of the result-filing function to prevent multiple-click filing of subsequent results without clinician review View source Lack of a failsafe for abnormal radiology results to prompt clinician review View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Darran Busby · 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
Darran Busby was at home with his family on 14 August 2021 and ended his life. Before his death, he had undergone an MRI scan after complaining of headaches, but the result was never reviewed by a clinician. The report raised concerns that weaknesses in the electronic systems could allow radiology results requiring urgent follow-up to be filed without clinical review, potentially creating a risk of future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the result-filing function to prevent multiple-click filing of subsequent results without clinician review
Wider context from the report “After it became apparent that the result of Mr Busby's MRI scan had not been reviewed by a clinician, a consultant employed by North Cumbria Integrated Care NHS Foundation Trust ('the Trust') undertook an investigation. He noted that the Trust use EMIS as an electronic patient record. He explained that the Trust used a separate system called ICE to gather the results of tests or scans. ICE is capable of linking to EMIS to input results into the EMIS system. Once a test result has been linked to a patient in EMIS the result enters the EMIS record as a provisional result pending review, and is placed on a work list. The consultant or a deputy then reviews the result, files it with or without comment and records any actions taken. EMIS provides two options: 'file no comment' and 'file and comment'. Results of blood tests which are undertaken to monitor treatment and which are normal may be filed without comment. If there is an abnormality flagged, however, EMIS will default to the file with comment dialogue box even if file no comment is selected. This acts as a safeguard against missing a significant finding. Unfortunately, there is no flag attached in the ICE system for abnormal radiology results, and so no failsafe exists for defaulting to a 'file and comment' if a significant positive or negative finding is reported.
In the course of investigating what occurred in relation to Mr Busby's MRI scan, it was determined that clicking more than once on the 'file no comment' button will result in the displayed result being filed, but will also result in filing of the next in the list if that result has no flag indicating the result is abnormal. Thus if a radiology result lies below a normal blood result and a clinician inadvertently double clicks to file the first result, the radiology result is also filed without comment and without the result being displayed. Furthermore, multiple clicks up to 6 (and perhaps even beyond) will lead to multiple filings. In the result it is possible that a clinician inadvertently clicking 'file no comment' more than once on one result would cause results which require urgent follow up being filed without a clinician being involved.
I am concerned that this might lead to lost opportunities to treat patients whose scans reveal, for instance, early malignancies. It might also mean that scans which reveal the need for urgent action will be overlooked. I am therefore concerned that future deaths will occur.
I was impressed by the candour of the report provided to me and the efforts that the Trust have already taken to resolve this issue. However I noted that the evidence I received was that "In order to fix this issue it is likely it will require action by the publishers of EMIS to prevent accidental filing of results. To attempt to mitigate this issue whilst a permanent fix is sought I have worked with colleagues from Pathology and Radiology to attempt to have all radiology results (where the greatest risk lies) flagged within the ICE system as abnormal, so that any attempt to file the result prompts via the file and comment dialogue box. Unfortunately at the time of writing this letter the flag, which is triggered in ICE for any radiology report originating within Cumbria Neuroscience, does not carry through to EMIS
and we continue to seek a local solution to mitigate this newly identified risk."
In the circumstances I have concluded that it is necessary for action to be taken to prevent future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a failsafe for abnormal radiology results to prompt clinician review
Wider context from the report “After it became apparent that the result of Mr Busby's MRI scan had not been reviewed by a clinician, a consultant employed by North Cumbria Integrated Care NHS Foundation Trust ('the Trust') undertook an investigation. He noted that the Trust use EMIS as an electronic patient record. He explained that the Trust used a separate system called ICE to gather the results of tests or scans. ICE is capable of linking to EMIS to input results into the EMIS system. Once a test result has been linked to a patient in EMIS the result enters the EMIS record as a provisional result pending review, and is placed on a work list. The consultant or a deputy then reviews the result, files it with or without comment and records any actions taken. EMIS provides two options: 'file no comment' and 'file and comment'. Results of blood tests which are undertaken to monitor treatment and which are normal may be filed without comment. If there is an abnormality flagged, however, EMIS will default to the file with comment dialogue box even if file no comment is selected. This acts as a safeguard against missing a significant finding. Unfortunately, there is no flag attached in the ICE system for abnormal radiology results, and so no failsafe exists for defaulting to a 'file and comment' if a significant positive or negative finding is reported.
In the course of investigating what occurred in relation to Mr Busby's MRI scan, it was determined that clicking more than once on the 'file no comment' button will result in the displayed result being filed, but will also result in filing of the next in the list if that result has no flag indicating the result is abnormal. Thus if a radiology result lies below a normal blood result and a clinician inadvertently double clicks to file the first result, the radiology result is also filed without comment and without the result being displayed. Furthermore, multiple clicks up to 6 (and perhaps even beyond) will lead to multiple filings. In the result it is possible that a clinician inadvertently clicking 'file no comment' more than once on one result would cause results which require urgent follow up being filed without a clinician being involved.
I am concerned that this might lead to lost opportunities to treat patients whose scans reveal, for instance, early malignancies. It might also mean that scans which reveal the need for urgent action will be overlooked. I am therefore concerned that future deaths will occur.
I was impressed by the candour of the report provided to me and the efforts that the Trust have already taken to resolve this issue. However I noted that the evidence I received was that "In order to fix this issue it is likely it will require action by the publishers of EMIS to prevent accidental filing of results. To attempt to mitigate this issue whilst a permanent fix is sought I have worked with colleagues from Pathology and Radiology to attempt to have all radiology results (where the greatest risk lies) flagged within the ICE system as abnormal, so that any attempt to file the result prompts via the file and comment dialogue box. Unfortunately at the time of writing this letter the flag, which is triggered in ICE for any radiology report originating within Cumbria Neuroscience, does not carry through to EMIS
and we continue to seek a local solution to mitigate this newly identified risk."
In the circumstances I have concluded that it is necessary for action to be taken to prevent future deaths.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Test a workable EMIS solution and continue collaborating with EMIS on system fixes, user communication and escalation of identified risks.
Verbatim wording from the response “The Trust’s Digital Services has since engaged with EMIS in support of testing a workable solution, and have made available all resources necessary to support the work on this issue.” Source location 2022-0011-Response-from-North-Cumbria-Integrated-Care_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase Neurology team vigilance when reviewing results and stop using “file no comment” in favour of “File and Comment” to require clinician review.
Verbatim wording from the response “In the interim Dr ████████ and the Neurology team have increased vigilance when reviewing results, and have accepted the key recommendation from the Digital Services to stop using the “file no Comment” button in favour of the “File and Comment” button. This approach will introduce a direct action by the clinician that means a result cannot be filed inadvertently as a pop box always appears. This introduces extra mouse clicks and is therefore more time consuming but does provide the assurance that the results cannot be filed without appropriate review until a more robust system based solution is in place.” Source location 2022-0011-Response-from-North-Cumbria-Integrated-Care_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Notify Primary Care colleagues using EMIS about the risk and required precautions through the CCG Chief Clinical Information Officer.
Verbatim wording from the response “The Trust has notified colleagues in Primary Care as users of EMIS through discussion with the CCG Chief Clinical Information Officer, to minimise any similar adverse action within GP provision.” Source location 2022-0011-Response-from-North-Cumbria-Integrated-Care_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Return the Cockermouth Hospital community ward to the ICE Order Comms system after assessing the affected functionality.
Verbatim wording from the response “The ward at Cockermouth Hospital reverted back to using the ICE Order Comms system (ICE was outlined in the Trust’s evidence to the inquest), following an initial assessment of the functionality. Whilst this option” Source location 2022-0011-Response-from-North-Cumbria-Integrated-Care_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a separate Rad Alert system that emails referrers about significant radiology findings and escalates unacknowledged alerts to alternative clinicians.
Verbatim wording from the response “Whilst this information has been shared with EMIS to inform their consideration of solutions to this issue the Trust has sought other appropriate remedies. The Trust is implementing a Rad Alert system, which will operate separately, though alongside ICE and upon recognising an alert code in a radiology report it will email the referring consultant/GP to advise them of a significant radiology finding. In the event the email is not acknowledged within a given time period (variable according to the severity of the alert) the system will alert the rad alert admin in order that alternate clinicians can be emailed. This should prevent a recurrence of this incident regardless of whether the report is being reviewed on EMIS or on ICE as it is a separate way of highlighting the significance of the report to the referrer. It is anticipated that the RAD system will be implemented in April 2022.” Source location 2022-0011-Response-from-North-Cumbria-Integrated-Care_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Neurology Service cannot revert to ICE because transferring data from ICE to EMIS could introduce transcription errors and other risks.
Verbatim wording from the response “was explored for the Neurology Service it not a feasible solution for the service due to the potential of introducing other risks such as transcription error when transferring data from ICE to EMIS.” Source location 2022-0011-Response-from-North-Cumbria-Integrated-Care_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adding flagging codes to ICE cannot affect results because source systems bypass ICE and interface directly with EMIS Web.
Verbatim wording from the response “The Trust has looked at ways of using codes to flag results via the ICE system but when the interface is linked to EMIS, the data comes directly from the source system (in this case, this would be either the Telepath Laboratory Information Management System or the GE (recently replaced by Philips) Radiology Information system). Both these systems bypass the ICE Order Comms system and interface directly with EMIS Web. Therefore, adding codes to ICE would not impact on any functionality for flagging.” Source location 2022-0011-Response-from-North-Cumbria-Integrated-Care_Published
Open published response
3 Jun 2020 Allan Arthur Watt · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 2 Delays in doctor-led admission clerking View source Delays in initiating prescribed intravenous fluids and antibiotic treatment 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
Allan Arthur Watt · 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
Allan Arthur Watt became increasingly unwell over several months and was ultimately admitted with an inoperable ischaemic bowel; he died on 20 September 2019. Concerns included delays in medical assessment after admission and a further delay before he received intravenous fluids and antibiotics. The report states that these delays may have denied him any chance of survival, although he may already have been too ill to survive on arrival.
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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in doctor-led admission clerking
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) Mr Watt arrived at A&E at 8pm, he was seen within an hour by a nurse practitioner and admission arranged. However after he got onto the ward at 2am he did not see a doctor to be clerked in until 10.30 . Both Allan’s family and I as coroner felt this delay was unacceptable .
(2)After Allan had been clerked in and IV fluid and antibiotic advised he did not receive an IV line or a first dose of antibiotic until 3pm –it was now 19 hours after he had arrived in A&E and in that period he had received no fluid or drug treatment.
(3)Allan died at 18.45, evidence suggested that he may have been too ill to survive even at the time he arrived in the A&E department but I have no doubt that the want of timely assessment and treatment denied him any chance at all. It is my hope that attention to these concerns will indeed prevent future deaths at your 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in initiating prescribed intravenous fluids and antibiotic treatment
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) Mr Watt arrived at A&E at 8pm, he was seen within an hour by a nurse practitioner and admission arranged. However after he got onto the ward at 2am he did not see a doctor to be clerked in until 10.30. Both Allan’s family and I as coroner felt this delay was unacceptable.
(2)After Allan had been clerked in and IV fluid and antibiotic advised he did not receive an IV line or a first dose of antibiotic until 3pm –it was now 19 hours after he had arrived in A&E and in that period he had received no fluid or drug treatment .
(3)Allan died at 18.45, evidence suggested that he may have been too ill to survive even at the time he arrived in the A&E department but I have no doubt that the want of timely assessment and treatment denied him any chance at all. It is my hope that attention to these concerns will indeed prevent future deaths at your hospital.
” Open source report
Concerns raised 1 Failure to consider and recommend blood-level monitoring for powerful antipsychotics in older, frail patients receiving long-term high-dose treatment 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
Liane Davenport · 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
Liane Davenport had chronic schizophrenia treated with high doses of two antipsychotic medicines, alongside significant coronary artery disease and left ventricular dysfunction, and died at home in Cumbria on 4 December 2019. The principal concern was whether blood-level monitoring should be considered for patients receiving long-term high-dose antipsychotic treatment, particularly as they become older and more frail.
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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider and recommend blood-level monitoring for powerful antipsychotics in older, frail patients receiving long-term high-dose treatment
Wider context from the report “(1) Should monitoring of blood levels of powerful antipsychotics be considered and recommended for patients on long term high dose treatment, particularly as they become older & more frail?
” Open source report
16 Apr 2018 Karen Jane Edgar · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 2 Delays in obtaining mental health treatment for children and young people in Cumbria View source Underfunding of mental health services for children and young people in Cumbria 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
Karen Jane Edgar · 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
Karen Jane Edgar had emotional and behavioural difficulties and was referred to CAMHS in October 2015, aged 15. She received delayed and limited mental health support, including gaps in family therapy, individual therapy, risk reassessment and care planning, before she died after hanging herself on 8 April 2017. The report raised concerns about underfunded child and adolescent mental health services, delays in treatment and inadequate resources and care.
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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining mental health treatment for children and young people in Cumbria
Wider context from the report “(1) The provision of mental health services for children and young people in Cumbria is underfunded.
(2) There are long delays in getting treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Underfunding of mental health services for children and young people in Cumbria
Wider context from the report “(1) The provision of mental health services for children and young people in Cumbria is underfunded.
(2) There are long delays in getting treatment.
” Open source report
Concerns raised 4 Lack of co-ordination View source Insufficient crisis-situation experience and maintenance of senior staff skills View source Lack of situational awareness View source Lack of understanding of capnography interpretation during CPR View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sharon Rose Grierson · 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
Sharon Rose Grierson, aged 44, underwent elective surgery to remove a benign vocal cord polyp and developed laryngospasm during extubation. Endotracheal tubes were twice placed in the oesophagus rather than the trachea, leading to oxygen deprivation, hypoxic brain injury and her death. Concerns included failure to appreciate capnography readings, lack of coordination and situational awareness, and limited experience of senior staff in crisis situations.
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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of co-ordination
Wider context from the report “(2)There was a lack of co-ordination and situational awareness.
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient crisis-situation experience and maintenance of senior staff skills
Wider context from the report “(3)It became apparent that senior staff often have little experience of crisis situations and there is a danger that they become ‘de-skilled’ to some extent as a result .
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of situational awareness
Wider context from the report “(2)There was a lack of co-ordination and situational awareness .
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of capnography interpretation during CPR
Wider context from the report “(1) There was a lack of appreciation of what the capnography was indicating and some lack of understanding of the trace one might expect to see during CPR .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Appoint a Simulation Trainer and Consultant Lead, with allocated time to oversee postgraduate simulation training.
Verbatim wording from the response “In light of that, a business case has been developed and approved in principle by the Trust to invest in equipment and a team to deliver simulation training for critical incident scenarios to whole teams within their clinical areas. The training would be provided by the Trust to full teams, and this training would complement that provided by Medical Education for undergraduates with the opportunity for sharing of resources. It is envisaged that further equipment including two manikins would be procured and a dedicated teaching area and storage developed. In addition, a Simulation Trainer will be appointed to specifically oversee post-graduate simulation training and will work alongside the current Simulation Trainer Lead. A Consultant Lead will also be appointed and have time allocated within their job plan to oversee this.” Source location 2018-0034-Response-by-North-Cumbria-University-Hospitals-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Procure additional simulation equipment and develop a dedicated teaching area and storage facility.
Verbatim wording from the response “In light of that, a business case has been developed and approved in principle by the Trust to invest in equipment and a team to deliver simulation training for critical incident scenarios to whole teams within their clinical areas. The training would be provided by the Trust to full teams, and this training would complement that provided by Medical Education for undergraduates with the opportunity for sharing of resources. It is envisaged that further equipment including two manikins would be procured and a dedicated teaching area and storage developed. In addition, a Simulation Trainer will be appointed to specifically oversee post-graduate simulation training and will work alongside the current Simulation Trainer Lead. A Consultant Lead will also be appointed and have time allocated within their job plan to oversee this.” Source location 2018-0034-Response-by-North-Cumbria-University-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver multidisciplinary difficult-airway simulation training, including emergency airway scenarios and front-of-neck access skills.
Verbatim wording from the response “As you are aware, the Serious Incident investigation into this matter identified that all relevant staff should undergo emergency scenario training and simulation including human factors training for difficult airway management in emergency situations. The investigation also recommended that there should be opportunities for multi-disciplinary teams to train together within simulated scenarios to practice technical and non-technical skills. This was with a view to team training scenarios reinforcing local clinical guidelines. Work has therefore already been underway prior to the inquest to implement this recommendation from the action plan.” Source location 2018-0034-Response-by-North-Cumbria-University-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and obtain in-principle approval for investment in equipment and a team to deliver postgraduate critical-incident simulation training.
Verbatim wording from the response “The Trust recognises that simulation based training is a powerful educational tool that allows the acquisition of knowledge, skills and attitudes at both individual and team-based levels in a safe and educational environment. Further, the Trust acknowledges that improved patient care can be achieved through the promotion of efficient, co-ordinated dissemination of learning across specialities and professions.” Source location 2018-0034-Response-by-North-Cumbria-University-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commence critical-incident simulation training for whole clinical teams, initially targeting theatres and then rolling out across the Trust.
Verbatim wording from the response “In light of that, a business case has been developed and approved in principle by the Trust to invest in equipment and a team to deliver simulation training for critical incident scenarios to whole teams within their clinical areas. The training would be provided by the Trust to full teams, and this training would complement that provided by Medical Education for undergraduates with the opportunity for sharing of resources. It is envisaged that further equipment including two manikins would be procured and a dedicated teaching area and storage developed. In addition, a Simulation Trainer will be appointed to specifically oversee post-graduate simulation training and will work alongside the current Simulation Trainer Lead. A Consultant Lead will also be appointed and have time allocated within their job plan to oversee this.” Source location 2018-0034-Response-by-North-Cumbria-University-Hospitals-NHS-Trust
Open published response
Concerns raised 12 Lack of corporate memory for nasogastric tube risks View source Failure of the policy to remain sufficiently usable for busy practitioners View source Failure to learn from deaths and incidents View source Failure of staff to apply the policy and follow good practice View source Lack of ward-based systems to ensure compliance View source Delays in fully implementing the 2011 NPSA Alert View source Lack of staff awareness of the policy View source Failure to roll out training to all staff who need it View source Failure to maintain accurate policy cross-references View source Failure to ensure compliance with the policy View source Failure of staff to read the policy View source Lack of checks and audits of competence and policy adherence View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Parke · 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 Parke, who had chronic liver disease, was admitted to West Cumberland Hospital and had a nasogastric tube inserted. The tube was misplaced into his left lung, an x-ray showing this was misinterpreted, and feeding and medication were administered through the tube before he developed aspiration pneumonia and died. The concerns included staff not following nasogastric-tube policy and systemic failures in policy implementation, training, competency checks, auditing and organisational learning.
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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of corporate memory for nasogastric tube risks
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register ).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the policy to remain sufficiently usable for busy practitioners
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years , making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to learn from deaths and incidents
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to apply the policy and follow good practice
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of ward-based systems to ensure compliance
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in fully implementing the 2011 NPSA Alert
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death .
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff awareness of the policy
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to roll out training to all staff who need it
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate policy cross-references
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions , and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure compliance with the policy
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to read the policy
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of checks and audits of competence and policy adherence
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include delivery-plan progress and compliance with the updated Nasogastric Tube Policy in the 2017/18 Internal Audit Plan for independent Board assurance.
Verbatim wording from the response “Attached to this letter is a report summarising the action we have taken against the five specific actions in your Regulation 28 Notice. We have also summarised additional actions that we have identified and will implement over the next 12 months. Progress against the delivery of this plan and compliance with the updated Nasogastric Tube Policy will be included in the Trust’s Internal Audit Plan for 2017/18. This is to ensure that independent assurance on the delivery of the plan and implementation of the policy can be provided to the Trust Board.” Source location 2017-0025-Response-by-North-Cumbria-University-Hospitals-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold organisational briefings in April 2017 to share learning from the Never Events.
Verbatim wording from the response “I will be reporting this action plan to the public Board meeting in March 2017, please do let me know if you have any concerns regarding this. In addition to this, we are in the process of contacting the families of Michale Parke and Amanda Coulthard in order to include a personal comment from them in the organisational briefings which will be holding in April 2017 to share the learning from these tragic Never Events.” Source location 2017-0025-Response-by-North-Cumbria-University-Hospitals-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Contact the deceased patients’ families to obtain personal comments for organisational learning briefings.
Verbatim wording from the response “I will be reporting this action plan to the public Board meeting in March 2017, please do let me know if you have any concerns regarding this. In addition to this, we are in the process of contacting the families of Michale Parke and Amanda Coulthard in order to include a personal comment from them in the organisational briefings which will be holding in April 2017 to share the learning from these tragic Never Events.” Source location 2017-0025-Response-by-North-Cumbria-University-Hospitals-Trust
Open published response
Concerns raised 12 Lack of corporate memory for nasogastric tube safety risks View source Failure of staff to apply the nasogastric tube policy View source Failure of staff to follow good practice for nasogastric tube use View source Failure to learn from a prior nasogastric tube death View source Failure of staff to read the nasogastric tube policy View source Lack of staff awareness of the nasogastric tube policy View source Failure to maintain accurate cross-references in the nasogastric tube policy View source Nasogastric tube policy becoming difficult for practitioners to absorb View source Failure to fully implement the 2011 NPSA Alert on nasogastric tubes View source Lack of ward-level systems to ensure compliance with the nasogastric tube policy View source Lack of checks and audits of staff competence and policy adherence View source Failure to provide nasogastric tube policy training to all required staff View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Amanda Coulthard · 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
Amanda Coulthard, who had multiple sclerosis, died on 26 April 2015 after a nasogastric tube entered her right lung and feed and medication were administered into it. She developed aspiration pneumonia. The concerns included failures to follow and implement nasogastric-tube policies and best practice, inadequate checking and training, and insufficient systems to ensure compliance and learn from previous deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of corporate memory for nasogastric tube safety risks
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register ).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to apply the nasogastric tube policy
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to follow good practice for nasogastric tube use
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to learn from a prior nasogastric tube death
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to read the nasogastric tube policy
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff awareness of the nasogastric tube policy
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate cross-references in the nasogastric tube policy
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions , and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Nasogastric tube policy becoming difficult for practitioners to absorb
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to fully implement the 2011 NPSA Alert on nasogastric tubes
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of ward-level systems to ensure compliance with the nasogastric tube policy
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of checks and audits of staff competence and policy adherence
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide nasogastric tube policy training to all required staff
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report
4 Jun 2015 Alice Anne McMeekin · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 4 Failure to obtain and verify critical information about reported threats View source Discharge without timely and adequate follow-up care for a person remaining at risk View source Failure to communicate significant risk information to ambulance and psychiatric staff View source Failure of psychiatric assessments to recognise mental disorder and suicide risk 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
Alice Anne McMeekin · 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
Alice Anne McMeekin was fatally attacked with a hatchet at an address in Newton Street, Millom, Cumbria, on 8 June 2013, sustaining fatal head injuries. The report raises concerns about police information not being fully shared with the ambulance and psychiatric teams, and about the assessment and discharge of the attacker despite information indicating significant risks and possible mental disorder.
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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and verify critical information about reported threats
Wider context from the report “1.The Police
The evidence revealed that on the 6th June 2013 the perpetrator made remarks to a member of the public to the effect that he “would not kill his mother”. This information was passed to the Officers who attended the area. Some 2 hours later the same officers attended a call about a man behaving strangely and covered in blood. An ambulance was called.
The officers had not spoken to the original caller , who subsequently gave evidence that the remarks were that the perpetrator said he “would kill his mother”.
“Common sense” told the officers that the person was one and the same and they did a welfare check on his mother.
At no stage did they question the perpetrator about his originally reported remarks . Also, citing confidentiality they did not pass those remarks onto the Ambulance Team. This meant that when later seen by psychiatric nurse the latter was in ignorance of this significant statement. It is possible that had the nurse been aware this may have altered the outcome of the perpetrator’s initial assessment and how he was dealt with.
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Discharge without timely and adequate follow-up care for a person remaining at risk
Wider context from the report “2.The Partnership Trust
The Coroner concluded that the evidence at the inquest showed that the perpetrator was suffering from a mental disorder when he tried to kill himself on the 6th June 2013. Whilst the psychiatric nurse that day did not have all the information which was available at the inquest he had information to show that perpetrator had a history of self-harm, unemployment, family stressors, multiple and complex drug misuse, quasi-incestuous sexual feelings, past sex abuse, hopelessness, low mood and serious suicide attempt that day.
3.Not withstanding the above the nurse decided that the perpetrator was of zero risk and was not suffering from a mental disorder. He was discharged with the only potential follow up being talking therapy which would not commence, if it ever did, some weeks hence . The evidence at inquest shows that this was a very disturbed young man having intended to kill himself 6 hours earlier and who remained a risk to himself. Whilst the information known to the nurse at the time the tragic outcome could not have been anticipated, there was an opportunity to render care , which could, as a consequence have made a difference.
It is a concern that the two assessments after the killings also concluded the perpetrator was not suffering from a mental disorder.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate significant risk information to ambulance and psychiatric staff
Wider context from the report “1.The Police
The evidence revealed that on the 6th June 2013 the perpetrator made remarks to a member of the public to the effect that he “would not kill his mother”. This information was passed to the Officers who attended the area. Some 2 hours later the same officers attended a call about a man behaving strangely and covered in blood. An ambulance was called.
The officers had not spoken to the original caller, who subsequently gave evidence that the remarks were that the perpetrator said he “would kill his mother”.
“Common sense” told the officers that the person was one and the same and they did a welfare check on his mother.
At no stage did they question the perpetrator about his originally reported remarks. Also, citing confidentiality they did not pass those remarks onto the Ambulance Team . This meant that when later seen by psychiatric nurse the latter was in ignorance of this significant statement . It is possible that had the nurse been aware this may have altered the outcome of the perpetrator’s initial assessment and how he was dealt with.
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of psychiatric assessments to recognise mental disorder and suicide risk
Wider context from the report “2.The Partnership Trust
The Coroner concluded that the evidence at the inquest showed that the perpetrator was suffering from a mental disorder when he tried to kill himself on the 6th June 2013. Whilst the psychiatric nurse that day did not have all the information which was available at the inquest he had information to show that perpetrator had a history of self-harm, unemployment, family stressors, multiple and complex drug misuse, quasi-incestuous sexual feelings, past sex abuse, hopelessness, low mood and serious suicide attempt that day.
3.Not withstanding the above the nurse decided that the perpetrator was of zero risk and was not suffering from a mental disorder . He was discharged with the only potential follow up being talking therapy which would not commence, if it ever did, some weeks hence. The evidence at inquest shows that this was a very disturbed young man having intended to kill himself 6 hours earlier and who remained a risk to himself. Whilst the information known to the nurse at the time the tragic outcome could not have been anticipated, there was an opportunity to render care, which could, as a consequence have made a difference.
It is a concern that the two assessments after the killings also concluded the perpetrator was not suffering from a mental disorder .
” Open source report
19 Feb 2015 Alexander George Ball · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 2 Lack of communication between the Partnership Trust and other agencies View source Absence of a dedicated Care Co-ordinator View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alexander George Ball · 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
Alexander George Ball was found unresponsive at home on the night of 20 February 2014 and died following ingestion of prescription and illicit drugs. The substantive concerns were a lack of communication between the Partnership Trust and other agencies, and the absence of a dedicated Care Co-ordinator.
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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of communication between the Partnership Trust and other agencies
Wider context from the report “There was a lack of communication between the Partnership Trust and other agencies. The position was exacerbated by the absence of a dedicated Care Co-ordinator.
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a dedicated Care Co-ordinator
Wider context from the report “There was a lack of communication between the Partnership Trust and other agencies. The position was exacerbated by the absence of a dedicated Care Co-ordinator .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Set a maximum waiting-time measure for allocating care coordinators to patients.
Verbatim wording from the response “With regards to the second concern you raise in respect of the lack of a permanent care coordinator, the Trust has set an internal measure relating to the maximum waiting times patients should expect for the allocation of a care co-ordinator.” Source location 2015-0069-Response-by-Cumbria-Partnership
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Actively manage the care-coordinator waiting list and undertake robust caseload reviews and supervision through clinical leads.
Verbatim wording from the response “At the time of Mr Ball’s death there were 74 patients on the waiting list to be allocated a care co-ordinator within our Adult community mental health service in Copeland. The internal measures to address this area are being supported by clinical leads within the service including responsibility for the active management of the waiting list and undertaking robust caseload reviews and supervision.” Source location 2015-0069-Response-by-Cumbria-Partnership
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out the Copeland care-coordinator capacity measures across the Trust during 2015.
Verbatim wording from the response “At the time of Mr Ball’s death there were 74 patients on the waiting list to be allocated a care co-ordinator within our Adult community mental health service in Copeland. The internal measures to address this area are being supported by clinical leads within the service including responsibility for the active management of the waiting list and undertaking robust caseload reviews and supervision.” Source location 2015-0069-Response-by-Cumbria-Partnership
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use timely discharges and transfers to release capacity for allocating new cases.
Verbatim wording from the response “At the time of Mr Ball’s death there were 74 patients on the waiting list to be allocated a care co-ordinator within our Adult community mental health service in Copeland. The internal measures to address this area are being supported by clinical leads within the service including responsibility for the active management of the waiting list and undertaking robust caseload reviews and supervision.” Source location 2015-0069-Response-by-Cumbria-Partnership
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Facilitate a multi-agency Oxford Learning Event to clarify and address communication pathways for people with mental health and substance misuse needs.
Verbatim wording from the response “As detailed in the Serious Untoward Incident action plan, the Trust will facilitate an Oxford Learning Event with the identified partner agencies. The purpose of this event is to identify and address the issues of communication ensuring clarity over the pathway for clients presenting with both mental health problems and substance misuse problems across the various care groups. We plan to hold this event during June 2015 subject to agreement with partner agencies.” Source location 2015-0069-Response-by-Cumbria-Partnership
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a quarterly county-wide liaison forum and report its feedback to the Clinical Governance group.
Verbatim wording from the response “Prior to the Oxford Learning Event, I have requested that a range of immediate actions are introduced by the Trust’s Mental Health Care Group in order to improve communication arrangements with partners. These improvements include:-” Source location 2015-0069-Response-by-Cumbria-Partnership
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold monthly locality meetings between Mental Health Care Group staff and local UNITY team members to provide direct communication.
Verbatim wording from the response “Prior to the Oxford Learning Event, I have requested that a range of immediate actions are introduced by the Trust’s Mental Health Care Group in order to improve communication arrangements with partners. These improvements include:-” Source location 2015-0069-Response-by-Cumbria-Partnership
Open published response
3 Jul 2014 Helena Kathleen Farrell · Prevention of Future Deaths report South and East Cumbria
View report summary
Concerns raised 8 Unrealistic school nurse service workload expectations View source Failure to recognise escalating incident seriousness and frequency View source Inadequate CAMHS staffing numbers View source Failure to verify school counsellor updating, training and professional registration View source Failure to verify school counsellor qualifications and competence View source Failure to follow up urgent CAMHS referrals after triage View source Failure of the CAMHS referral system to function adequately View source Insufficient CAMHS staff experience and training in working with teenagers View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Helena Kathleen Farrell · 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
Helena Kathleen Farrell had bulimia, had been sexually assaulted, took an overdose, self-harmed, and wrote letters that appeared to be suicide letters after her death. She died from hanging following a period in which she was not seen by CAMHS until the day before her death, and those dealing with her did not recognise her suicidal feelings and intentions. The concerns included failures in the CAMHS referral and follow-up system, inadequate staffing and training, failure to recognise escalating seriousness, unrealistic demands on the school nurse, and insufficient checking of the school counsellor’s credentials.
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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unrealistic school nurse service workload expectations
Wider context from the report “(4) As far as Cumbria County Council is concerned, they are involved because I understand they are responsible for provision of the school nurse service although they contract this out to the Partnership Trust but nonetheless the responsibility lies with Cumbria County Council. I thought that the expectations of the school nurse in this particular case were totally unrealistic. I heard in evidence that she was responsible for 5 senior schools and 20 or more feeder schools to those 5 senior schools and although the total number of pupils involved was not clear, it is obviously thousands rather than hundreds. She worked a 26 hour week, had 40 current cases at Kirkbie Kendal School alone. The provision of service at this level is totally unfair on the school nurse concerned , unrealistic in the sense that she seems to have expectations of a school nurse which one part time provider cannot meet .
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise escalating incident seriousness and frequency
Wider context from the report “(3) Those dealing with Helena failed to recognise the escalation of the incidents in which she was involved in terms of their seriousness and their increasing frequency .
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate CAMHS staffing numbers
Wider context from the report “(2) Staffing levels at CAMHS were inadequate in terms of pure numbers and also in terms of experience and training in connection with teenagers.
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to verify school counsellor updating, training and professional registration
Wider context from the report “(5) The school’s counsellor had been in post for many years and there was no proof of her qualifications or her competence nor of update and training or registration with any professional body . The County Council needs to be more thorough with checking credentials.
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to verify school counsellor qualifications and competence
Wider context from the report “(5) The school’s counsellor had been in post for many years and there was no proof of her qualifications or her competence nor of update and training or registration with any professional body. The County Council needs to be more thorough with checking credentials.
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up urgent CAMHS referrals after triage
Wider context from the report “(1) As for CAMHS (part of the Foundation Trust) the referral system was not working adequately and the referral was not followed up after triage even though it was classified as urgent .
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the CAMHS referral system to function adequately
Wider context from the report “(1) As for CAMHS (part of the Foundation Trust) the referral system was not working adequately and the referral was not followed up after triage even though it was classified as urgent.
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient CAMHS staff experience and training in working with teenagers
Wider context from the report “(2) Staffing levels at CAMHS were inadequate in terms of pure numbers and also in terms of experience and training in connection with teenagers .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the identified CAMHS staff training programme, including prioritised suicide-prevention training.
Verbatim wording from the response “The Trust, with commissioners, has fully implemented the recommendations of the independent, external review of CAMHS in 2012 which has resulted in the staffing levels across the service increasing from 45 to 63, with improved skill mixes and clear development plans. Significant training has been identified, planned and delivery has commenced. Suicide prevention training was prioritised and delivered as shown in the action plan, point 10.” Source location 2014-0309-Response-by-Cumbria-NHS-Foundation-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce recognition and action following incident escalation through training and supervision processes.
Verbatim wording from the response “This is covered within the training provided and re-enforced through the supervision processes in the action plan.” Source location 2014-0309-Response-by-Cumbria-NHS-Foundation-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Redesign the CAMHS referral system with a 48-hour urgent-response target and electronic breach flagging and investigation.
Verbatim wording from the response “The referral system has been significantly redesigned, as evidenced in the internal action plan at Appendix 1 (enclosed), points 5 and 6. The timescales for response to referrals deemed urgent is now 48 hours and any breaches are electronically flagged and investigated. Achievement of this demand target has been consistently high.” Source location 2014-0309-Response-by-Cumbria-NHS-Foundation-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase CAMHS staffing from 45 to 63 and improve skill mix through development plans.
Verbatim wording from the response “The Trust, with commissioners, has fully implemented the recommendations of the independent, external review of CAMHS in 2012 which has resulted in the staffing levels across the service increasing from 45 to 63, with improved skill mixes and clear development plans. Significant training has been identified, planned and delivery has commenced. Suicide prevention training was prioritised and delivered as shown in the action plan, point 10.” Source location 2014-0309-Response-by-Cumbria-NHS-Foundation-Trust
Open published response
6 Jun 2014 James Edward Boylan · Prevention of Future Deaths report South and East Cumbria
View report summary
Concerns raised 6 Failure to remove removable bathroom rails except when required View source Failure to disseminate GRIST assessment information to staff View source Failure to rigorously complete GRIST assessments View source Failure to keep ligature-capable cords centrally so that patients cannot directly access them View source Failure to maintain an overall view of escalating patient risk View source Insufficient searching of patients’ property for concealed dangerous items 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
James Edward Boylan · 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 Edward Boylan, who had a history of anxiety and was admitted to a mental health unit, died by hanging using a phone charger cord and a bathroom rail. The concerns included removable bathroom rails creating a ligature point, insufficient searching of patients’ property, access to a cord, and failures in recognising and communicating the escalation of his condition.
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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to remove removable bathroom rails except when required
Wider context from the report “(1) Removable rails in a bathroom designed for use by disabled people had been left inadvertently ever since the unit was opened. No one seemed to be aware that these rails were removable and certainly nobody had removed them. This provided a ligature point which would otherwise have been absent in a unit which was specifically designed to have as few ligature points as possible. The Coroner is concerned that this same situation may apply in other units and people need to be aware that ligature points in mental health units should be limited as far as humanly possible, and specifically that removable rails should be removed except when actually required .
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to disseminate GRIST assessment information to staff
Wider context from the report “(4) GRIST: Assessments should be more rigorously completed and disseminated so that staff are aware of their contents , because in relation to Mr Boylan this did not appear to have taken place so that an opportunity for communication of information was lost .
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to rigorously complete GRIST assessments
Wider context from the report “(4) GRIST: Assessments should be more rigorously completed and disseminated so that staff are aware of their contents, because in relation to Mr Boylan this did not appear to have taken place so that an opportunity for communication of information was lost.
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to keep ligature-capable cords centrally so that patients cannot directly access them
Wider context from the report “(2) Mr Boylan appears to have brought onto the ward a stanley knife blade. This was not discovered for several days. Mr Boylan only left the unit on one occasion and so could only have brought the blade onto the unit either 7 days before his death or 3 days before his death. The Coroner asks that thought be given to more robust searching of patients’ property. The origin of the cord which Mr Boylan used is not clear. It may have been his own, but the policy of having these kept centrally so that patients do not have access direct to them was not adhered to on this occasion , and so again Mr Boylan had access to something which he could use to hang himself with .
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an overall view of escalating patient risk
Wider context from the report “(3) There were numerous events over the 7 days during which Mr Boylan was present on the ward for someone with an overall view to realise that his condition was escalating and that he might become a danger to himself, but because no one person had such knowledge of all the facts, this was not recognised . It is suggested that communication be improved in any way in which the Trust thinks possible.
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient searching of patients’ property for concealed dangerous items
Wider context from the report “(2) Mr Boylan appears to have brought onto the ward a stanley knife blade. This was not discovered for several days. Mr Boylan only left the unit on one occasion and so could only have brought the blade onto the unit either 7 days before his death or 3 days before his death. The Coroner asks that thought be given to more robust searching of patients’ property. The origin of the cord which Mr Boylan used is not clear. It may have been his own, but the policy of having these kept centrally so that patients do not have access direct to them was not adhered to on this occasion, and so again Mr Boylan had access to something which he could use to hang himself with.
” Open source report
Concerns raised 3 Failure to ensure timely summons of on-call clinicians for seriously injured trauma patients View source Delays between presentation and theatre when surgery is indicated View source Failure to account for contraindications to CT scanning in seriously injured trauma patients 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
Keith Thomas Graham · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Keith Thomas Graham was involved in a road traffic collision after colliding with a bullock while travelling by motorcycle and later died from multiple injuries on 28 May 2012. Concerns included the timing of summoning on-call clinicians, the use of CT scanning for seriously injured trauma patients, and the time between presentation and theatre, as well as a misplaced chest drain that damaged the liver.
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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure timely summons of on-call clinicians for seriously injured trauma patients
Wider context from the report “To review the procedures to deal with seriously injured trauma patients on arrival at A & E to include the timing of the summons to the on call Clinicians , the contra-indications for the use of CT Scanning, and where surgery is indicated, minimising the time between presentation and theatre.
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays between presentation and theatre when surgery is indicated
Wider context from the report “To review the procedures to deal with seriously injured trauma patients on arrival at A & E to include the timing of the summons to the on call Clinicians, the contra-indications for the use of CT Scanning, and where surgery is indicated, minimising the time between presentation and theatre .
” 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 North Cumbria Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to account for contraindications to CT scanning in seriously injured trauma patients
Wider context from the report “To review the procedures to deal with seriously injured trauma patients on arrival at A & E to include the timing of the summons to the on call Clinicians, the contra-indications for the use of CT Scanning , and where surgery is indicated, minimising the time between presentation and theatre.
” Open source report
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Addressed to North Cumbria University Hospitals NHS Trust, now represented here by North Cumbria Integrated Care NHS Foundation Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations