8 Apr 2026 Jonathan Mark Thornton · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 6 Unavailability of NOMIS/DPS alerts to Healthcare Staff View source Lack of a formal mechanism for sharing prisoners’ mental health risks and triggers with operational prison staff View source Failure to equip operational prison staff to identify and report behavioural deterioration View source Failure to communicate monitoring plans to the healthcare team View source Insufficiently detailed and visible NOMIS/DPS risk-alert categorisation for operational prison staff View source Lack of formal information sharing and reliable handover between the CFT and Prison Healthcare View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 7
Action
Conduct quarterly audits of information-sharing timeliness, documentation completeness, and escalation, and report findings to relevant quality and accountability groups.
Stated plannedThe respondent said that this action was planned when they made their response on 13 April 2026. View source
Action
Share and agree the information-sharing guidance with CFT staff, Prison Healthcare providers, and HMP Lincoln to establish consistent cross-organisational expectations.
Stated completedThe respondent said that this action was complete when they made their response on 13 April 2026. View source
Action
Embed the information-sharing guidance through team briefings, clinical supervision, and induction for new staff.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 April 2026. View source
Action
Implement a formal information-sharing procedure requiring prompt, secure, documented handover of clinical and risk information, standard documents, and escalation when contact fails.
Stated completedThe respondent said that this action was complete when they made their response on 13 April 2026. View source
Action
Establish bimonthly interface meetings with HMP Nottingham Prison Healthcare teams to review cases, address communication issues, monitor guidance adherence, and escalate risks.
Stated plannedThe respondent said that this action was planned when they made their response on 13 April 2026. View source
Action
Work jointly with Northamptonshire Healthcare NHS Foundation Trust to clarify responsibilities, availability expectations, responsiveness, and escalation pathways.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 April 2026. View source
Action
Maintain a dedicated CFT Link Worker as a consistent Prison Healthcare contact with oversight of information sharing, timely responses, continuity, and service liaison.
Stated completedThe respondent said that this action was complete when they made their response on 13 April 2026. View source See 4 more actions
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AI-generated summary
Jonathan Mark Thornton · 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
Jonathan Mark Thornton died at Queens Medical Centre in Nottingham on 12 July 2024 after sustaining a severe head injury in an attack by a fellow inmate at HMP Nottingham on 28 June 2024. The report raises concerns about inadequate information sharing between community forensic, prison healthcare and operational prison staff, and about the categorisation and visibility of risk alerts on NOMIS/DPS, 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of NOMIS/DPS alerts to Healthcare Staff
Wider context from the report “3. Categorisation and visibility of alerts on NOMIS/DPS
I heard that NOMIS/DPS has preset categorisation of alerts. The categories are limited and broad. This means that ‘violent’ prisoners – regardless of the particulars of that violence – will all be categorised together. This case illustrated quite clearly that there are certain categories of offender who require better particularisation of their risk. In this case, that was those prisoners with a history of assaulting fellow inmates. I was told that unless a prisoner has assaulted a cellmate, which would be subject to its own assessment, the operational prison staff would not necessarily know whether their violent behaviour was aimed at prison officers, other prisoners or simply a genera violent behaviour linked to their offending. Clearly, each of these categories gives rise to a particular risk within a prison setting. I am concerned that if more detailed categorisation and/or information is not provided to the operational prison staff within NOMIS/DPS alerts, with clear visibility, this gives rise to a risk of future death. I understand that this is controlled nationally.
Moreover, I understand that the Healthcare Staff are unable to view NOMIS/DPS alerts . This gives rise to the same risk .
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal mechanism for sharing prisoners’ mental health risks and triggers with operational prison staff
Wider context from the report “2. Information sharing between Prison Healthcare and Operational Prison Staff.
This case illustrated a lack of communication and information sharing between Prison Healthcare and the Operational Prison Staff which was concerning to me. I heard evidence that Prison Healthcare had in place a quasi ‘watch and wait’ plan for monitoring a potentially high-risk inmate. Not only was this plan not communicated to all of the healthcare team, but it relied upon reporting of deterioration in behaviours from operational prison staff who were completely unaware that (i) they were being tasked with this role; and (ii) what to look for. Furthermore, the operational prison staff told me that having a broad understanding (within the confines of confidentiality) of a prisoner’s mental health risks and triggers would improve the safety and security of the prison for the officers and prisoners . It would enable them to properly assess and manage risk, but that there was no effective mechanism in place by which to achieve this . I am concerned that the lack of formal information sharing between the two departments gives rise to a risk of future death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to equip operational prison staff to identify and report behavioural deterioration
Wider context from the report “2. Information sharing between Prison Healthcare and Operational Prison Staff.
This case illustrated a lack of communication and information sharing between Prison Healthcare and the Operational Prison Staff which was concerning to me. I heard evidence that Prison Healthcare had in place a quasi ‘watch and wait’ plan for monitoring a potentially high-risk inmate. Not only was this plan not communicated to all of the healthcare team, but it relied upon reporting of deterioration in behaviours from operational prison staff who were completely unaware that (i) they were being tasked with this role; and (ii) what to look for . Furthermore, the operational prison staff told me that having a broad understanding (within the confines of confidentiality) of a prisoner’s mental health risks and triggers would improve the safety and security of the prison for the officers and prisoners. It would enable them to properly assess and manage risk, but that there was no effective mechanism in place by which to achieve this. I am concerned that the lack of formal information sharing between the two departments gives rise to a risk of future death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate monitoring plans to the healthcare team
Wider context from the report “2. Information sharing between Prison Healthcare and Operational Prison Staff.
This case illustrated a lack of communication and information sharing between Prison Healthcare and the Operational Prison Staff which was concerning to me. I heard evidence that Prison Healthcare had in place a quasi ‘watch and wait’ plan for monitoring a potentially high-risk inmate. Not only was this plan not communicated to all of the healthcare team , but it relied upon reporting of deterioration in behaviours from operational prison staff who were completely unaware that (i) they were being tasked with this role; and (ii) what to look for. Furthermore, the operational prison staff told me that having a broad understanding (within the confines of confidentiality) of a prisoner’s mental health risks and triggers would improve the safety and security of the prison for the officers and prisoners. It would enable them to properly assess and manage risk, but that there was no effective mechanism in place by which to achieve this. I am concerned that the lack of formal information sharing between the two departments gives rise to a risk of future death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficiently detailed and visible NOMIS/DPS risk-alert categorisation for operational prison staff
Wider context from the report “3. Categorisation and visibility of alerts on NOMIS/DPS
I heard that NOMIS/DPS has preset categorisation of alerts. The categories are limited and broad . This means that ‘violent’ prisoners – regardless of the particulars of that violence – will all be categorised together. This case illustrated quite clearly that there are certain categories of offender who require better particularisation of their risk. In this case, that was those prisoners with a history of assaulting fellow inmates. I was told that unless a prisoner has assaulted a cellmate, which would be subject to its own assessment, the operational prison staff would not necessarily know whether their violent behaviour was aimed at prison officers, other prisoners or simply a genera violent behaviour linked to their offending. Clearly, each of these categories gives rise to a particular risk within a prison setting. I am concerned that if more detailed categorisation and/or information is not provided to the operational prison staff within NOMIS/DPS alerts, with clear visibility , this gives rise to a risk of future death. I understand that this is controlled nationally.
Moreover, I understand that the Healthcare Staff are unable to view NOMIS/DPS alerts. This gives rise to the same risk.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of formal information sharing and reliable handover between the CFT and Prison Healthcare
Wider context from the report “1. Information sharing between the CFT and Prison Healthcare.
During the course of the inquest, I heard that there had been various barriers to information sharing between the community forensic team and prison healthcare. There was no formal system in place for the handover of information between these teams at the time of Jonathan’s death or at the conclusion of the inquest. Prison Healthcare staff were often unavailable or uncontactable for handover meetings . The handover of information between CFT and Prison Healthcare is vital for the risk assessment and management of prisoners who are known to the CFT (often some of the most complex and high-risk prisoners). I am concerned that the lack of formal information sharing between the two departments gives rise to a risk of future death.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct quarterly audits of information-sharing timeliness, documentation completeness, and escalation, and report findings to relevant quality and accountability groups.
Verbatim wording from the response “4. Quarterly Audit and Reporting” Source location Response from Nottingham Healthcare 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 Share and agree the information-sharing guidance with CFT staff, Prison Healthcare providers, and HMP Lincoln to establish consistent cross-organisational expectations.
Verbatim wording from the response “3. Guidance Shared with all CFT Staff” Source location Response from Nottingham Healthcare 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 Embed the information-sharing guidance through team briefings, clinical supervision, and induction for new staff.
Verbatim wording from the response “2. Embedding the Guidance Through Training and Supervision” Source location Response from Nottingham Healthcare 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 Implement a formal information-sharing procedure requiring prompt, secure, documented handover of clinical and risk information, standard documents, and escalation when contact fails.
Verbatim wording from the response “1. Introduction of a Formal Information-Sharing Guidance Document (December 2025)” Source location Response from Nottingham Healthcare 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 Establish bimonthly interface meetings with HMP Nottingham Prison Healthcare teams to review cases, address communication issues, monitor guidance adherence, and escalate risks.
Verbatim wording from the response “The Link Worker will also arrange and chair a bimonthly interface meeting with Prison Healthcare teams at HMP Nottingham. These meetings will:” Source location Response from Nottingham Healthcare 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 Work jointly with Northamptonshire Healthcare NHS Foundation Trust to clarify responsibilities, availability expectations, responsiveness, and escalation pathways.
Verbatim wording from the response “3. Joint Working with Prison Healthcare Providers” Source location Response from Nottingham Healthcare 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 Maintain a dedicated CFT Link Worker as a consistent Prison Healthcare contact with oversight of information sharing, timely responses, continuity, and service liaison.
Verbatim wording from the response “1. Appointment of a Dedicated CFT Link Worker” Source location Response from Nottingham Healthcare NHS Foundation Trust
Open published response
30 Oct 2025 Mr Gunaratnam Kannan · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Lack of joint-agency definition of roles and remits for Mental Capacity Act and Mental Health Act assessments View source Lack of training of service providers on the process for referrals for Mental Health Act assessments View source Lack of training of service providers on Mental Capacity Act assessments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mr Gunaratnam Kannan · 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
Mr Gunaratnam Kannan took an overdose of Metformin and Indapamide tablets on 18 March 2025 and initially refused hospital treatment after being assessed as having mental capacity. He was later found confused, with limited consciousness and lacking mental capacity, was taken to hospital, suffered a cardiac arrest and was pronounced deceased on 19 March 2025. The concerns identified were a lack of joint-agency policy and training on Mental Capacity Act and Mental Health Act assessments, including uncertainty about which service should request or undertake a Mental Health Act assessment.
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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of joint-agency definition of roles and remits for Mental Capacity Act and Mental Health Act assessments
Wider context from the report “• Lack of joint agency working/policy work on the Mental Capacity Act Assessments and Mental Health Act Assessments setting out the roles and remit of service providers.
• Lack of training of service providers on the Mental Capacity Act assessments and the process for referrals for Mental Health Act assessments.
I heard evidence at the inquest from EMAS that it would be for the NHCT crisis team to attend for a MHA assessment if the patient was deemed to have capacity and that EMAS do not make referrals for mental health act assessments. I heard evidence from NHCT that it would be for either the family, GP or the attending medical practitioner , in this case EMAS, to request a MHA assessment. There is a clear lack of understanding between these service providers as to what actions should be taken and by who.
In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training of service providers on the process for referrals for Mental Health Act assessments
Wider context from the report “• Lack of joint agency working/policy work on the Mental Capacity Act Assessments and Mental Health Act Assessments setting out the roles and remit of service providers.
• Lack of training of service providers on the Mental Capacity Act assessments and the process for referrals for Mental Health Act assessments.
I heard evidence at the inquest from EMAS that it would be for the NHCT crisis team to attend for a MHA assessment if the patient was deemed to have capacity and that EMAS do not make referrals for mental health act assessments. I heard evidence from NHCT that it would be for either the family, GP or the attending medical practitioner , in this case EMAS, to request a MHA assessment. There is a clear lack of understanding between these service providers as to what actions should be taken and by who.
In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training of service providers on Mental Capacity Act assessments
Wider context from the report “• Lack of joint agency working/policy work on the Mental Capacity Act Assessments and Mental Health Act Assessments setting out the roles and remit of service providers.
• Lack of training of service providers on the Mental Capacity Act assessments and the process for referrals for Mental Health Act assessments.
I heard evidence at the inquest from EMAS that it would be for the NHCT crisis team to attend for a MHA assessment if the patient was deemed to have capacity and that EMAS do not make referrals for mental health act assessments. I heard evidence from NHCT that it would be for either the family, GP or the attending medical practitioner , in this case EMAS, to request a MHA assessment. There is a clear lack of understanding between these service providers as to what actions should be taken and by who.
In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action.
” 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 Develop and disseminate two flow charts supporting capacity considerations and referral decisions, including display in team offices.
Verbatim wording from the response “Two flow charts were also developed (Appendix A and B) to help support staff in what considerations need to be given regarding mental capacity upon receipt of a call such as that in the case of Mr. Kannan. This includes when liaising with EMAS to ensure that there is significant consideration on how a person’s mental health and consumption of substances may alter their thinking and capacity. These have been shared with all staff and are displayed in team offices for quick reference.” Source location Response from Nottinghamshire Healthcare
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 Participate in a multi-agency workstream to develop a joint mechanism or protocol clarifying roles and remits for capacity assessments.
Verbatim wording from the response “In addition, prior to the commencement of the inquest, Nottinghamshire Healthcare NHS Foundation Trust contacted the Safeguarding Adults Board (SAB) to make them aware of the concerns that the coroner had made organisations aware of when gathering the evidence of the case. The request was for SAB to facilitate a workstream forum involving all key agencies within the Nottingham area, with the aim to come together and agree a joint working mechanism / protocol setting out the roles and remits of service providers in the context of assessments via both the Mental Capacity and Mental Health Acts. The first meeting took place on 3 December 2025, with the plan to meet again on 7 January 2026. The initial meeting provided opportunity to discuss the case of Mr. Kannan and the current practices being followed by each agency in attendance.” Source location Response from Nottinghamshire Healthcare
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Mental Capacity training to confirm it covers required topics and maintain compliance monitoring across clinical teams.
Verbatim wording from the response “All clinical staff members must attend the Trust Mental Capacity Training on a three yearly basis. Key topics covered as part of this training are:” Source location Response from Nottinghamshire Healthcare
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 Deliver bespoke Mental Capacity Act training to Clinical Access Line and Crisis Resolution Home Treatment staff.
Verbatim wording from the response “Lack of training of service providers on the Mental Capacity Act assessments and the process for referrals for Mental Health Act assessments.” Source location Response from Nottinghamshire Healthcare
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the Trust’s local internal pathways and protocols at the next multi-agency workstream meeting.
Verbatim wording from the response “waiting for the outcome of the national discussion. The plan from this first meeting was then for all agencies to share their local internal pathway and protocol in terms of response and remit and EMAS to provide an update on the national forum at the next meeting in January 2026.” Source location Response from Nottinghamshire Healthcare
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 An established process and pathway for requesting Mental Health Act assessments is already in place across Nottingham City and County.
Verbatim wording from the response “The process for referring for Mental Health Act assessments is held by the Approved Mental Health Practitioners (AMHP) who are part of the Local Authority. There is a clear process and pathway already in place (Appendix C).” Source location Response from Nottinghamshire Healthcare
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 Mental Health Act assessment referrals are the responsibility of Approved Mental Health Practitioners within the Local Authority.
Verbatim wording from the response “The process for referring for Mental Health Act assessments is held by the Approved Mental Health Practitioners (AMHP) who are part of the Local Authority. There is a clear process and pathway already in place (Appendix C).” Source location Response from Nottinghamshire Healthcare
Open published response
24 Oct 2025 Sophie Louise TOWLE · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 12 Lack of policy prompts for cross-sector consultation in foreign-body cases View source Lack of clarity about the current personality disorder service and level of provision View source Lack of staff working knowledge of the current local VTE policy View source Absence of a specialised central personality disorder service View source Failure of the foreign-object insertion policy to require mental health consultation View source Insufficient staffing capacity on mental health wards View source Insufficient experience across the mental health ward staff pool View source Ineffective communication of foreign-object insertion policy and guidance to staff View source Insufficient or ineffective training on the VTE policy View source Lack of an embedded mechanism for cross-sector MDT meetings and liaison in foreign-body cases View source Failure of the local VTE policy to provide clear, robust and consistent assessment requirements View source Lack of specific, clear and robust policy guidance for managing foreign-object insertion View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 14
Action
Pilot an electronic VTE policy link and competency assessment with reporting for oversight before full rollout.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 October 2025. View source
Action
Review the Mentalisation-Based Therapy service’s location, form and function to support integration into the wider clinical pathway.
Stated plannedThe respondent said that this action was planned when they made their response on 31 October 2025. View source
Action
Ensure preceptorship nurses are not the sole registered nurse on a ward by rostering an experienced nurse alongside them.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2025. View source
Action
Integrate Personality Disorder pathway key workers, mental health practitioners, community support workers and peer workers into local mental health teams.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2025. View source
Action
Provide bespoke mandatory VTE e-learning for medical staff and monitor compliance.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2025. View source
Action
Review and update the Trust VTE policy to clarify reassessment requirements and training expectations.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2025. View source
Action
Agree a stepped-care pathway covering brief, moderate and intensive treatment with clarity about complexity and pathway navigation.
Stated plannedThe respondent said that this action was planned when they made their response on 31 October 2025. View source
Action
Deliver and disseminate reflective VTE learning to the involved medical team, Resident Doctors Forum and physical health forum.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2025. View source
Action
Embed VTE reassessment prompts into daily inpatient board reviews and weekly multidisciplinary team templates.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2025. View source
Action
Add a local inpatient-practice appendix to the VTE policy within three months.
Stated plannedThe respondent said that this action was planned when they made their response on 31 October 2025. View source
Action
Trial a joint physical and mental health policy for managing patients who insert foreign bodies, including joint meetings and impact review.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 October 2025. View source
Action
Streamline Matron attendance at Safe Care and Sit-Rep meetings while maintaining ward staffing and clinical-quality oversight.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2025. View source
Action
Maintain Practice Development Nurses on wards to mentor, coach and train staff supporting preceptorship nurses.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2025. View source
Action
Update the RiO electronic patient record to require inpatient VTE assessment, record risk-factor actions and activate risk alerts.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2025. View source See 11 more actions
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AI-generated summary
Sophie Louise TOWLE · 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
Sophie Louise TOWLE died at Kings Mill Hospital on 27 May 2024 after suffering a large pulmonary embolus originating from a deep vein thrombosis in her left leg. The report describes concerns about the management of an inserted foreign object, VTE risk assessment and related policy and training, mental health services for patients with personality disorders, staffing levels, and cross-sector communication and working.
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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of policy prompts for cross-sector consultation in foreign-body cases
Wider context from the report “1. Lack of joint agency policy/cross-sector working between physical and mental health trusts in relation to the insertion of foreign bodies
I heard evidence that it would have been beneficial in Sophie’s case for there to have been an MDT between Sophie’s psychiatric team (NHCT) and her physical health team (Orthopaedics and Anaesthesia at SFH). The reason that this would have been of assistance is due to the complexity of cases where there are physical and mental health considerations in play for decisions around the management of a foreign body.
There is no embedded mechanism for arranging MDT meetings, or indeed for any liaison or contact between these teams, in such cases. Similarly, there is no policy or procedure which prompts clinicians from either team to consider an MDT in these cases or, at the very least, picking up the phone for a consult.
If this had happened in Sophie’s case, it seems likely that the outcome in relation to the management of the foreign body would have been different. Sophie’s psychiatric team were keen for removal and were satisfied that they could implement a robust policy to avoid re-insertion, which was one of the main concerns of the Orthopaedic team.
In my opinion there is a risk that future deaths could occur unless action is taken in relation to this issue.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about the current personality disorder service and level of provision
Wider context from the report “3. The disbanding of the Personality Disorder Hub at NHCT
I am told that as of mid-October 2025, the Personality Disorder Hub at NHCT has been disbanded. Neither the witness who worked within the disbanded service, nor the policy witness for NHCT was able to give me any particulars as to the arrangement of the new service, beyond a general statement that it was being absorbed into the LMHTs. I was told by the witness who had worked within the PDH that his understanding for his LMHT was that there would be a personality disorder service which would consist of him, as that was his specialist interest.
Given the current inquiry into Mental Health Services in Nottinghamshire, and particularly the care of those patients with personality disorders within the service, I am concerned about the lack of clarity within the Trust as to the current position and level of service available to patients with personality disorders.
I am concerned that an absence of a specialised and central service dealing with personality disorder patients, with care provided by specialists in personality disorder, causes a risk of future death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff working knowledge of the current local VTE policy
Wider context from the report “2. VTE risk assessment and associated policy and training at NHCT
During the course of Sophie’s inquest, I heard evidence which concerns me that there is a lack of clarity in relation to the current local VTE policy. I was provided with version of the policy that I have assured was current at the outset of the inquest. All witnesses who were directly asked about this policy recognised it as the current policy in its terms. On 22 October 2025, I was sent late disclose of the correct updated policy which was ratified in April 2025 (available to view from May 2025), some 6 months before the inquest hearing began. The updated policy was materially different in its terms on the frequency and circumstances in which VTE risk assessments should be undertaken. This gives rise to a number of specific concerns:
A) The staff do not have a proper working knowledge of the current local VTE policy.
B) The knock-on concern from this is that the training around the VTE policy is not robust in its content or is otherwise not being properly engaged with by staff.
C) The current policy has been weakened in its terms, in particular at paragraph 1.6 where the requirement for an updated assessment of risk on at least a weekly basis has been removed. I understand from the evidence that, notwithstanding the wording changes to the policy, prompts are given on VTE risk assessment at the weekly MDTs. I am concerned that the policy is not reflective of the encouraged practice on the Wards. I am also concerned that, whilst this happens on Fir Ward, it is important that guidance is consistent across all wards within the Trust. The common document across the wards is the local policy and therefore I am concerned about the clarity and robustness of its terms.
In my opinion there is a risk that future deaths could occur unless action is taken in relation to this issue.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a specialised central personality disorder service
Wider context from the report “3. The disbanding of the Personality Disorder Hub at NHCT
I am told that as of mid-October 2025, the Personality Disorder Hub at NHCT has been disbanded. Neither the witness who worked within the disbanded service, nor the policy witness for NHCT was able to give me any particulars as to the arrangement of the new service, beyond a general statement that it was being absorbed into the LMHTs. I was told by the witness who had worked within the PDH that his understanding for his LMHT was that there would be a personality disorder service which would consist of him, as that was his specialist interest.
Given the current inquiry into Mental Health Services in Nottinghamshire, and particularly the care of those patients with personality disorders within the service, I am concerned about the lack of clarity within the Trust as to the current position and level of service available to patients with personality disorders.
I am concerned that an absence of a specialised and central service dealing with personality disorder patients, with care provided by specialists in personality disorder , causes a risk of future death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the foreign-object insertion policy to require mental health consultation
Wider context from the report “4. The policy and procedures around the management of insertion of foreign objects for SFH
I have had sight of the newly ratified local policy for management of insertion of foreign objects at SFH. I am concerned that its content is lacking in specificity, the language used is vague and open to interpretation, and it does not provide clear advice for medical professionals accessing it for guidance. It is not a robust policy in its terms.
Further, I am concerned that it does not make any reference to consultation of mental health services, whether local or acute, at all. Given that the policy recognises that in the majority of cases where management of insertion of foreign objects the patient has a mental health condition, I find this particularly concerning.
Based on the evidence that I have heard, I am also concerned that there is no effective communication of the policy and guidance to Trust staff on this issue.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing capacity on mental health wards
Wider context from the report “5. Staffing on mental health wards
I have been told by numerous witnesses to this inquest that the staffing levels on Fir Ward both at the time of Sophie’s admission, and now, are insufficient. The result of that, I am told, is that the wards cannot run safely and patient care and safety negatively impacted. Staff simply do not have time to complete essential tasks on the ward (like physical observations, completing care plans and risk assessments etc.) or give the patients the 1:1 time they require. I saw a genuine concern and regret on the faces of the hardworking healthcare professionals who gave evidence in my court of the course of this inquest, some were brought to tears. The job is relentless, and they do not feel supported by virtue of a lack of staff numbers and experience. I am told that this remains the case notwithstanding that the minimum staffing levels as governed by the Department of Health and Social Care are being met. This is an issue of grave concern. It suggests that the minimum levels of staff are too low, the staff pool is not sufficiently experienced across the board, that the wards are not functioning safely and that patients are at risk of death 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient experience across the mental health ward staff pool
Wider context from the report “5. Staffing on mental health wards
I have been told by numerous witnesses to this inquest that the staffing levels on Fir Ward both at the time of Sophie’s admission, and now, are insufficient. The result of that, I am told, is that the wards cannot run safely and patient care and safety negatively impacted. Staff simply do not have time to complete essential tasks on the ward (like physical observations, completing care plans and risk assessments etc.) or give the patients the 1:1 time they require. I saw a genuine concern and regret on the faces of the hardworking healthcare professionals who gave evidence in my court of the course of this inquest, some were brought to tears. The job is relentless, and they do not feel supported by virtue of a lack of staff numbers and experience. I am told that this remains the case notwithstanding that the minimum staffing levels as governed by the Department of Health and Social Care are being met. This is an issue of grave concern. It suggests that the minimum levels of staff are too low, the staff pool is not sufficiently experienced across the board , that the wards are not functioning safely and that patients are at risk of death 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective communication of foreign-object insertion policy and guidance to staff
Wider context from the report “4. The policy and procedures around the management of insertion of foreign objects for SFH
I have had sight of the newly ratified local policy for management of insertion of foreign objects at SFH. I am concerned that its content is lacking in specificity, the language used is vague and open to interpretation, and it does not provide clear advice for medical professionals accessing it for guidance. It is not a robust policy in its terms.
Further, I am concerned that it does not make any reference to consultation of mental health services, whether local or acute, at all. Given that the policy recognises that in the majority of cases where management of insertion of foreign objects the patient has a mental health condition, I find this particularly concerning.
Based on the evidence that I have heard, I am also concerned that there is no effective communication of the policy and guidance to Trust staff on this issue.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient or ineffective training on the VTE policy
Wider context from the report “2. VTE risk assessment and associated policy and training at NHCT
During the course of Sophie’s inquest, I heard evidence which concerns me that there is a lack of clarity in relation to the current local VTE policy. I was provided with version of the policy that I have assured was current at the outset of the inquest. All witnesses who were directly asked about this policy recognised it as the current policy in its terms. On 22 October 2025, I was sent late disclose of the correct updated policy which was ratified in April 2025 (available to view from May 2025), some 6 months before the inquest hearing began. The updated policy was materially different in its terms on the frequency and circumstances in which VTE risk assessments should be undertaken. This gives rise to a number of specific concerns:
A) The staff do not have a proper working knowledge of the current local VTE policy.
B) The knock-on concern from this is that the training around the VTE policy is not robust in its content or is otherwise not being properly engaged with by staff.
C) The current policy has been weakened in its terms, in particular at paragraph 1.6 where the requirement for an updated assessment of risk on at least a weekly basis has been removed. I understand from the evidence that, notwithstanding the wording changes to the policy, prompts are given on VTE risk assessment at the weekly MDTs. I am concerned that the policy is not reflective of the encouraged practice on the Wards. I am also concerned that, whilst this happens on Fir Ward, it is important that guidance is consistent across all wards within the Trust. The common document across the wards is the local policy and therefore I am concerned about the clarity and robustness of its terms.
In my opinion there is a risk that future deaths could occur unless action is taken in relation to this issue.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an embedded mechanism for cross-sector MDT meetings and liaison in foreign-body cases
Wider context from the report “1. Lack of joint agency policy/cross-sector working between physical and mental health trusts in relation to the insertion of foreign bodies
I heard evidence that it would have been beneficial in Sophie’s case for there to have been an MDT between Sophie’s psychiatric team (NHCT) and her physical health team (Orthopaedics and Anaesthesia at SFH). The reason that this would have been of assistance is due to the complexity of cases where there are physical and mental health considerations in play for decisions around the management of a foreign body.
There is no embedded mechanism for arranging MDT meetings, or indeed for any liaison or contact between these teams, in such cases. Similarly, there is no policy or procedure which prompts clinicians from either team to consider an MDT in these cases or, at the very least, picking up the phone for a consult.
If this had happened in Sophie’s case, it seems likely that the outcome in relation to the management of the foreign body would have been different. Sophie’s psychiatric team were keen for removal and were satisfied that they could implement a robust policy to avoid re-insertion, which was one of the main concerns of the Orthopaedic team.
In my opinion there is a risk that future deaths could occur unless action is taken in relation to this issue.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the local VTE policy to provide clear, robust and consistent assessment requirements
Wider context from the report “2. VTE risk assessment and associated policy and training at NHCT
During the course of Sophie’s inquest, I heard evidence which concerns me that there is a lack of clarity in relation to the current local VTE policy. I was provided with version of the policy that I have assured was current at the outset of the inquest. All witnesses who were directly asked about this policy recognised it as the current policy in its terms. On 22 October 2025, I was sent late disclose of the correct updated policy which was ratified in April 2025 (available to view from May 2025), some 6 months before the inquest hearing began. The updated policy was materially different in its terms on the frequency and circumstances in which VTE risk assessments should be undertaken. This gives rise to a number of specific concerns:
A) The staff do not have a proper working knowledge of the current local VTE policy.
B) The knock-on concern from this is that the training around the VTE policy is not robust in its content or is otherwise not being properly engaged with by staff.
C) The current policy has been weakened in its terms, in particular at paragraph 1.6 where the requirement for an updated assessment of risk on at least a weekly basis has been removed. I understand from the evidence that, notwithstanding the wording changes to the policy, prompts are given on VTE risk assessment at the weekly MDTs. I am concerned that the policy is not reflective of the encouraged practice on the Wards. I am also concerned that, whilst this happens on Fir Ward, it is important that guidance is consistent across all wards within the Trust. The common document across the wards is the local policy and therefore I am concerned about the clarity and robustness of its terms.
In my opinion there is a risk that future deaths could occur unless action is taken in relation to this issue.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of specific, clear and robust policy guidance for managing foreign-object insertion
Wider context from the report “4. The policy and procedures around the management of insertion of foreign objects for SFH
I have had sight of the newly ratified local policy for management of insertion of foreign objects at SFH. I am concerned that its content is lacking in specificity, the language used is vague and open to interpretation, and it does not provide clear advice for medical professionals accessing it for guidance. It is not a robust policy in its terms.
Further, I am concerned that it does not make any reference to consultation of mental health services, whether local or acute, at all. Given that the policy recognises that in the majority of cases where management of insertion of foreign objects the patient has a mental health condition, I find this particularly concerning.
Based on the evidence that I have heard, I am also concerned that there is no effective communication of the policy and guidance to Trust staff on this issue.
” 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 Pilot an electronic VTE policy link and competency assessment with reporting for oversight before full rollout.
Verbatim wording from the response “We have worked with our E-learning department to create an electronic link to the policy and competency questions to ensure that people have both read and understand the implications of the policy to their practice. It will be reportable so that there is oversight and assurance that all who need to be aware of the policy have read it. This has been trialled as a pilot to ensure it is effective and functional prior to being fully rolled out and will report into the Urgent Improvement Group for ongoing oversight.” Source location Response from Nottingham Healthcare 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 Review the Mentalisation-Based Therapy service’s location, form and function to support integration into the wider clinical pathway.
Verbatim wording from the response “9. MBT service to be relocated to AMH Community Services. Wider work as part of this is to explore the form and function of this service to ensure fidelity.” Source location Response from Nottingham Healthcare 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 Ensure preceptorship nurses are not the sole registered nurse on a ward by rostering an experienced nurse alongside them.
Verbatim wording from the response “Within the inpatient environments, the Trust has a high percentage of newly qualified nurses in their preceptorship period. Due to recognising their experience is minimal at this point in their career, the preceptee is not left as the only registered nurse on a ward and will have a more experienced nurse working at the same time, leading the shift.” Source location Response from Nottingham Healthcare 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 Integrate Personality Disorder pathway key workers, mental health practitioners, community support workers and peer workers into local mental health teams.
Verbatim wording from the response “The change that was completed integrated key workers from within the PD pathway into core local mental health teams (LMHTs). This change constituted a change in line management, as it was clear from the review that the pathways were fractured, with an inequitable service offer based upon the geographical area.” Source location Response from Nottingham Healthcare 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 Provide bespoke mandatory VTE e-learning for medical staff and monitor compliance.
Verbatim wording from the response “E-learning training for medical staff members has recently gone live and uptake will now be monitored for compliance. The E-learning was created as a bespoke module recognising that the modules available on Learning for Healthcare were only relevant to physical acute hospitals and primary care. The locally developed Trust module also places significant focus on the risks of VTE associated with Psychiatry. The development of this module is aligned to the NICE guidance (Venous thromboembolism in over 16s) and the evidence base available through Thrombosis UK online source.” Source location Response from Nottingham Healthcare 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 Review and update the Trust VTE policy to clarify reassessment requirements and training expectations.
Verbatim wording from the response “To increase staff awareness a VTE poster has been developed and is displayed in ward offices and clinic rooms. The Trust VTE policy was reviewed and updated in April 2025 to amend the frequency of re-assessment of VTE risk, provide clarity on which patients require re-assessment of VTE risk and the training expectations of those performing VTE risk assessments.” Source location Response from Nottingham Healthcare 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 Agree a stepped-care pathway covering brief, moderate and intensive treatment with clarity about complexity and pathway navigation.
Verbatim wording from the response “13. Pathway development to be agreed in line with stepped care model considering brief, moderate and intensive treatment with clarity around complexity to aid clinical pathway navigation.” Source location Response from Nottingham Healthcare 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 Deliver and disseminate reflective VTE learning to the involved medical team, Resident Doctors Forum and physical health forum.
Verbatim wording from the response “A reflective learning session was facilitated on the 22 July 2024 with the medical team involved in Sophie’s care by a Trust GP and the Associate Director for Physical Health. This learning was also shared via presentation to the Resident Doctors Forum on the 16 July 2024 and shared through the physical health forum for wider consideration across services.” Source location Response from Nottingham Healthcare 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 Embed VTE reassessment prompts into daily inpatient board reviews and weekly multidisciplinary team templates.
Verbatim wording from the response “The policy expects that VTE reassessment is carried out at the time of a change in clinical condition or risk. This has been reflected within adult mental health services inpatient areas within the daily board review process which now includes prompts relating to VTE risks and reassessment. This is a daily process to adhere to the requirement to early identification of change rather than a previous focus on reassessment at least weekly which could have resulted in further missed opportunities. This process ensures timely identification and response to a change in risk factors.” Source location Response from Nottingham Healthcare 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 Add a local inpatient-practice appendix to the VTE policy within three months.
Verbatim wording from the response “The VTE policy reflects the expected standard across our Trust inpatient services. It is recognised that the local systems, processes and practice need to be included and reflected within the Trust policy. Within the next 3 months, an appendix will be added to the policy outlining the local approach across our inpatient services in delivering practice against this policy standard.” Source location Response from Nottingham Healthcare 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 Trial a joint physical and mental health policy for managing patients who insert foreign bodies, including joint meetings and impact review.
Verbatim wording from the response “Staff at Nottinghamshire Healthcare Foundation Trust (NHFT) and Sherwood Forest Hospital Trust (SFHT) have collaborated on creating a joint management policy that provides guidance to staff on the management of patients who have inserted a foreign body. This includes the recommendation of joint meetings to support joined up collaborative care for patients requiring support from both services. This is being trialled for three months, and the impact of its use will be reviewed.” Source location Response from Nottingham Healthcare 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 Streamline Matron attendance at Safe Care and Sit-Rep meetings while maintaining ward staffing and clinical-quality oversight.
Verbatim wording from the response “The attendance at the Safe Care and Sit-Rep meetings has been streamlined so that the 4 inpatient Matrons take it in turns to attend with the expectation that the other Matrons are attending the board reviews and, on the wards, to review firsthand the staffing levels on the wards and to oversee clinical quality on the ward. Any concerns will also be escalated to the Head of Nursing and Associate Director of Nursing.” Source location Response from Nottingham Healthcare 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 Maintain Practice Development Nurses on wards to mentor, coach and train staff supporting preceptorship nurses.
Verbatim wording from the response “To support preceptee nurses there are Practice Development Nurses in post who work on the wards to role model, mentor and coach staff and also deliver direct training. These are directly overseen by the Head of Nursing who also spends time on the wards and with Ward Managers to understand the current ward contexts and senior clinical nursing support.” Source location Response from Nottingham Healthcare 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 Update the RiO electronic patient record to require inpatient VTE assessment, record risk-factor actions and activate risk alerts.
Verbatim wording from the response “The Electronic Patient Record system RiO was updated in June 2024 to ensure clarity that all inpatients require VTE assessment with a mandatory field of actions to be taken if there are risk factors identified. This also includes a risk alert activation on the patient’s electronic record. Amendments were made to the VTE risk assessment template form within the Electronic Patient Record system RiO in June 2024 to ensure clarity that all inpatients require a VTE risk assessment on admission with the addition of a mandatory field of actions to be taken if there are risk factors identified. This also includes a risk alert activation on the patient’s electronic record.” Source location Response from Nottingham Healthcare 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 MHOST establishments, daily staffing reviews and escalation arrangements are considered sufficient to meet ward clinical demands and address staffing shortfalls.
Verbatim wording from the response “As discussed at the Inquest, the safe staffing tool identifies what staffing numbers are needed is set by NHS England via the Mental Health Optimal Staffing Tool, (MHOST). In October 2025, the Trust reviewed the staffing establishment tool (MHOST) which were agreed by the Ward Managers, Matrons and Nurse Directors to be sufficient to meet the clinical demands. This then reports to the board for oversight at the most senior level within the Trust.” Source location Response from Nottingham Healthcare 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 The Personality Disorder Hub was not disbanded; its senior clinical leads remain responsible for pathway oversight, development and evaluation.
Verbatim wording from the response “In line with wider community mental health service improvements, the Personality Disorder pathway has been reviewed and an associated improvement plan developed. The pathways consist of two parts: a hub, which is senior clinical leads, and the spoke part, which relates to the clinical staffing linked to each local mental health team. As part of the Improvement Plan, the Personality Disorder Hub has not been disbanded. Key clinical leads from within the Hub will remain in place to ensure ongoing oversight of the clinical interventions, development of the clinical pathway and oversee and evaluate clinical effectiveness. Changes to the spoke part of the pathway has been made which is in relation to the line management of the staff within the spoke part of the personality disorder pathway. Further details in relation to this are outlined below.” Source location Response from Nottingham Healthcare 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 Daily board reviews and weekly MDT prompts provide timely VTE reassessment when clinical condition or risk changes, making weekly reassessment unnecessary.
Verbatim wording from the response “The policy expects that VTE reassessment is carried out at the time of a change in clinical condition or risk. This has been reflected within adult mental health services inpatient areas within the daily board review process which now includes prompts relating to VTE risks and reassessment. This is a daily process to adhere to the requirement to early identification of change rather than a previous focus on reassessment at least weekly which could have resulted in further missed opportunities. This process ensures timely identification and response to a change in risk factors.” Source location Response from Nottingham Healthcare NHS Foundation Trust
Open published response
Concerns raised 11 Lack of police training for mental health-related incidents involving illicit substance use View source Lack of cross-sector working and joint agency policy for Acute Behavioural Disorder/Disturbance View source Delays and non-attendance in EMAS ambulance response to s.136 conveyance requests View source Unavailability of mental health management, monitoring and treatment for people with co-occurring substance misuse who cannot abstain View source Failure within EMAS to ratify, disseminate and implement the relevant s.136 joint agency policy View source Failure of police training on ambulance conveyance for s.136 detainees View source Lack of police training on communicating s.136 detention decisions and reasons View source Lack of an out-of-hours local protocol for police access to mental health advice View source Lack of joined-up agency policy for s.136 detention and conveyance View source Reliance on unrealistic self-referral for people requiring mental health and substance misuse support View source Failure to align Street Triage Team capacity with current demand View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Kaine Regan FLETCHER · 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
Kaine Regan FLETCHER, a 26-year-old man with paranoid personality disorder and a history of substance misuse, died on 3 July 2022 after restraint by police, developing rhabdomyolysis, multi-system organ failure and cardiac arrest. The report raises concerns about the lack of joined-up policies and cross-sector working on acute behavioural disturbance and section 136 detentions, police and ambulance conveyance practices and training, the availability of out-of-hours street triage, and gaps in services for people with combined mental health and substance misuse conditions.
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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of police training for mental health-related incidents involving illicit substance use
Wider context from the report “4. Police training on s.136 MHA 1983 detention and mental health
I heard evidence that there is no national training for police officers on the correct wording to communicate a decision and the reasons for a s.136 detention to the detainee. Further, that there is no specific training in relation to persons who are struggling with their mental health and who may be under the influence of illicit substances . I am concerned that training in the area of mental health generally is lacking , which is impacting upon the approach of the police officers dealing with mental health related incidents.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of cross-sector working and joint agency policy for Acute Behavioural Disorder/Disturbance
Wider context from the report “1. Lack of joint agency policy/cross-sector working on Acute Behavioural Disorder/Disturbance
In September 2022, the Royal College of Psychiatrists issued a position statement on Acute Behavioural Disturbance and Excited Delirium. The RCP recommend that:
• A cross-sector working group should be convened to develop an interim consensus on ‘ABD’, with active involvement of patients and carers, to agree terminology, key principles for professional guidance, and priorities for further research.
• This group should include representatives from police, custodial, ambulance, emergency medicine, mental health, and the judicial and coronial system. Support from relevant government departments would help ensure consistency across services.
• Further research should be urgently commissioned, including detailed investigation into how racial bias plays into the application of terminology such as ‘ABD’.
• Members of the cross-sector working group should collaborate on the development and delivery of training materials for staff working across public services
• All services should seek to improve standardised collection of disaggregated data on presentations and outcomes, and to conduct regular multi-disciplinary reviews to support high-quality research on this topic.
I have heard evidence that in Nottingham and Nottinghamshire, no such cross-sector working is in place or joint agency policy is in place . I have also heard evidence that there is no knowledge of such cross-sector working or joint agency policy in place within the East Midlands generally, or nationally. The consequence of this is that there is no joined up thinking, procedure or policy, between front-line services who are regularly dealing with cases of ABD . That lack of collaborative working between services gives rise to a risk of future death for persons who develop ABD both in the community or in custody. People at risk of developing ABD often also fall into categories of vulnerability, such as suffering with a mental health disorder or using illicit substances. To my mind, this increases the risk of future death in the absence of any collaboration. I am concerned that this appears to be a national issue.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays and non-attendance in EMAS ambulance response to s.136 conveyance requests
Wider context from the report “3. Police use of an ambulance as the mode of conveyance for s.136 detainees
I heard evidence that the correct mode of conveyance for persons detained under s.136 MHA 1983 is an ambulance, save in exceptional circumstances (e.g. where the detained person’s behaviour means it would be inappropriate, or where the wait for an ambulance would exceed 30 minutes).
I also heard evidence, that in the last 12 months an ambulance was called by the police in only 50% of s.136 detentions. Of that 50% in which an ambulance was called, an ambulance only attended on 50% of occasions (so 25% of the total detentions).
Of the nine police officers that gave evidence to me in this inquest on s.136 matters, none of them knew about the police policy on calling an ambulance to convey a s.136 detainee.
Two of the officers knew, anecdotally, that an ambulance was the preferred method of conveyance, but their evidence was that it was common for an ambulance to take well over 30 minutes or not turn up at all .
I am concerned that:
• There is a training issue within the police in relation to s.136 detentions and the correct mode of conveyance. Either officers do not know that they should call an ambulance, or they are ignoring their training/the instructions that they are given. This is born out in the statistics above.
• There is a response issue on the part of EMAS . This may, in part, be explained by the policy/service level agreement confusion within EMAS.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of mental health management, monitoring and treatment for people with co-occurring substance misuse who cannot abstain
Wider context from the report “6. Mental Health Services – ‘the gap’
I am concerned that there is a ‘gap’ in mental health services for those people who have a dual diagnosis of a recognised mental health condition, combined with a substance misuse diagnosis . Clinically, I understand that substance misuse can provide a barrier to effective treatment of any mental health condition. However, I have heard evidence that there is no service available to patients for management, monitoring and treatment in circumstances where they are unable to abstain from substances but require care for the residual mental health condition . In circumstances where it is clinically recognised that substance misuse can exacerbate the symptoms of many mental health conditions, this gives risk to a clear risk of future death. The evidence that I have heard is that once treatment or referral options for these patients have been exhausted, they are discharged from the Local Mental Health Team with signposting to other services e.g. substance misuse services/charities or CRISIS. These services often required self-referral, which is not realistic for many people in these circumstances. Kaine fell into this gap, and I am concerned that there is a risk of future death for other patients if this gap is not filled. Again, it seems to me that this is an issue of national concern.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure within EMAS to ratify, disseminate and implement the relevant s.136 joint agency policy
Wider context from the report “2. Lack of agreed joint agency policy between EMAS and the police on s.136 MHA 1983 detentions
I issued a PFD on 17 July 2025, part way through the final inquest hearing, to raise my concern over apparent confusion with both the police and EMAS as to the applicable joint agency policy dealing with s.136 MHA 1983 detention and conveyance.
Since that PFD was issued, the evidence has developed and the position at the end of the inquest was as follows:
• The police confirmed that the document titled “Nottingham and Nottinghamshire Multi-Agency Policy & Procedure Review Group Memorandum of Understanding: Joint Agency sections 135 and 136 Mental Health Act 1983 Procedures” has been ratified within their organisation and continues to remain the relevant joint-agency policy for s.136 detention and conveyance. This policy has been implemented for the police since its inception.
• EMAS cannot confirm whether the above policy has been ratified in its current version within the organisation . They have confirmed that an employee at EMAS signed off on the 2021 version, but that this information was never disseminated within the organisation because the finalised version of the policy remained within that employee’s email inbox. The consequence appears to be that EMAS has never implemented this policy , rather they have been working to an internal policy for Mental Health Conveyance that contains different working standards.
Acknowledging that there is no confusion for the police as to the relevant policy, and that they do consider that it has been implemented, I remain concerned. My concerns can now properly be formulated as follows:
• There is no joined up thinking between agencies on the local policy for s.136 MHA 1983 detention and conveyance. For a policy to be effective, all purported parties to that policy need to know it applies to them.
• Internal disorganisation within EMAS has culminated in a situation where, even after a period of investigation between 17 July – 25 July, they are unable to tell the Court which, if any, joint agency policy applies to them. They are unable to tell the Court whether they are still part of the relevant working group. EMAS have allowed a situation to perpetuate in which they appear, on the face of the policy documents, to be party to an agreement (which includes service level agreements for conveyance) when they simply do not know if this is correct. The upshot of this is that other agencies may be placing reliance on the conveyance terms within the policy when they are dealing with s.136 detention.
My concerns are supported by the guidance available at ss. 16.30 – 16.35 of the Mental Health Code of Practice, which highlights the importance of local policy for s.136 detention. It does not appear that there is compliance with this guidance, published by the Department of Health.
The lack of joined up thinking between agencies locally gives rise to a risk of future death for persons detained under s.136 MHA 1983.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of police training on ambulance conveyance for s.136 detainees
Wider context from the report “3. Police use of an ambulance as the mode of conveyance for s.136 detainees
I heard evidence that the correct mode of conveyance for persons detained under s.136 MHA 1983 is an ambulance, save in exceptional circumstances (e.g. where the detained person’s behaviour means it would be inappropriate, or where the wait for an ambulance would exceed 30 minutes).
I also heard evidence, that in the last 12 months an ambulance was called by the police in only 50% of s.136 detentions. Of that 50% in which an ambulance was called, an ambulance only attended on 50% of occasions (so 25% of the total detentions).
Of the nine police officers that gave evidence to me in this inquest on s.136 matters, none of them knew about the police policy on calling an ambulance to convey a s.136 detainee .
Two of the officers knew, anecdotally, that an ambulance was the preferred method of conveyance, but their evidence was that it was common for an ambulance to take well over 30 minutes or not turn up at all.
I am concerned that:
• There is a training issue within the police in relation to s.136 detentions and the correct mode of conveyance . Either officers do not know that they should call an ambulance, or they are ignoring their training/the instructions that they are given. This is born out in the statistics above.
• There is a response issue on the part of EMAS. This may, in part, be explained by the policy/service level agreement confusion within EMAS.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of police training on communicating s.136 detention decisions and reasons
Wider context from the report “4. Police training on s.136 MHA 1983 detention and mental health
I heard evidence that there is no national training for police officers on the correct wording to communicate a decision and the reasons for a s.136 detention to the detainee . Further, that there is no specific training in relation to persons who are struggling with their mental health and who may be under the influence of illicit substances. I am concerned that training in the area of mental health generally is lacking, which is impacting upon the approach of the police officers dealing with mental health related incidents.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an out-of-hours local protocol for police access to mental health advice
Wider context from the report “5. The availability of the Street Triage Team
I heard evidence that Nottinghamshire is pioneering in its provision of a Street Triage Team, a service that has been available since 2014. This team is comprised of one police officer and one community psychiatric nurse who can travel to mental health incidents to provide assessment and advice to the response officers, particularly in relation to exercising s.136 powers.
I heard that this service is available between 8am and 1am, and that the resourcing of the service (both in terms of the shift patterns and the available cars) was determined by analysis of a data set in 2017.
At the time that the incident arose with Kaine on 3 July 2022, no STT was available as it was out of hours.
I am concerned that there is a need to review the data to ensure that the demand for the service in 2025 is still reflected in the shift patterns. I am concerned, based on the evidence that I heard from EMAS in relation to an increase of ~60% in mental health related calls, that the demand for service may have changed since 2017.
I note that the Mental Health Code of Practice includes the following guidance at [16.23] in relation to triage and s.136: “When deciding that detention may be necessary, the police may also benefit from seeking advice before using section 136 powers in cases where they are unsure that the circumstances are sufficiently serious for using these powers. Local protocols should set out how this advice can be provided and who the police should contact, including outside of normal business hours”. I am concerned that I have not seen any local protocol as to who the police should contact out of hours , and I note that EMAS do have available mental health nurses between the hours of 1am and 8am. This again appears to be a local policy and communication issue.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of joined-up agency policy for s.136 detention and conveyance
Wider context from the report “2. Lack of agreed joint agency policy between EMAS and the police on s.136 MHA 1983 detentions
I issued a PFD on 17 July 2025, part way through the final inquest hearing, to raise my concern over apparent confusion with both the police and EMAS as to the applicable joint agency policy dealing with s.136 MHA 1983 detention and conveyance.
Since that PFD was issued, the evidence has developed and the position at the end of the inquest was as follows:
• The police confirmed that the document titled “Nottingham and Nottinghamshire Multi-Agency Policy & Procedure Review Group Memorandum of Understanding: Joint Agency sections 135 and 136 Mental Health Act 1983 Procedures” has been ratified within their organisation and continues to remain the relevant joint-agency policy for s.136 detention and conveyance. This policy has been implemented for the police since its inception.
• EMAS cannot confirm whether the above policy has been ratified in its current version within the organisation. They have confirmed that an employee at EMAS signed off on the 2021 version, but that this information was never disseminated within the organisation because the finalised version of the policy remained within that employee’s email inbox. The consequence appears to be that EMAS has never implemented this policy, rather they have been working to an internal policy for Mental Health Conveyance that contains different working standards.
Acknowledging that there is no confusion for the police as to the relevant policy, and that they do consider that it has been implemented, I remain concerned. My concerns can now properly be formulated as follows:
• There is no joined up thinking between agencies on the local policy for s.136 MHA 1983 detention and conveyance . For a policy to be effective, all purported parties to that policy need to know it applies to them.
• Internal disorganisation within EMAS has culminated in a situation where, even after a period of investigation between 17 July – 25 July, they are unable to tell the Court which, if any, joint agency policy applies to them. They are unable to tell the Court whether they are still part of the relevant working group. EMAS have allowed a situation to perpetuate in which they appear, on the face of the policy documents, to be party to an agreement (which includes service level agreements for conveyance) when they simply do not know if this is correct. The upshot of this is that other agencies may be placing reliance on the conveyance terms within the policy when they are dealing with s.136 detention.
My concerns are supported by the guidance available at ss. 16.30 – 16.35 of the Mental Health Code of Practice, which highlights the importance of local policy for s.136 detention. It does not appear that there is compliance with this guidance, published by the Department of Health.
The lack of joined up thinking between agencies locally gives rise to a risk of future death for persons detained under s.136 MHA 1983.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Reliance on unrealistic self-referral for people requiring mental health and substance misuse support
Wider context from the report “6. Mental Health Services – ‘the gap’
I am concerned that there is a ‘gap’ in mental health services for those people who have a dual diagnosis of a recognised mental health condition, combined with a substance misuse diagnosis. Clinically, I understand that substance misuse can provide a barrier to effective treatment of any mental health condition. However, I have heard evidence that there is no service available to patients for management, monitoring and treatment in circumstances where they are unable to abstain from substances but require care for the residual mental health condition. In circumstances where it is clinically recognised that substance misuse can exacerbate the symptoms of many mental health conditions, this gives risk to a clear risk of future death. The evidence that I have heard is that once treatment or referral options for these patients have been exhausted, they are discharged from the Local Mental Health Team with signposting to other services e.g. substance misuse services/charities or CRISIS. These services often required self-referral, which is not realistic for many people in these circumstances . Kaine fell into this gap, and I am concerned that there is a risk of future death for other patients if this gap is not filled. Again, it seems to me that this is an issue of national concern.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to align Street Triage Team capacity with current demand
Wider context from the report “5. The availability of the Street Triage Team
I heard evidence that Nottinghamshire is pioneering in its provision of a Street Triage Team, a service that has been available since 2014. This team is comprised of one police officer and one community psychiatric nurse who can travel to mental health incidents to provide assessment and advice to the response officers, particularly in relation to exercising s.136 powers.
I heard that this service is available between 8am and 1am, and that the resourcing of the service (both in terms of the shift patterns and the available cars) was determined by analysis of a data set in 2017 .
At the time that the incident arose with Kaine on 3 July 2022, no STT was available as it was out of hours.
I am concerned that there is a need to review the data to ensure that the demand for the service in 2025 is still reflected in the shift patterns . I am concerned, based on the evidence that I heard from EMAS in relation to an increase of ~60% in mental health related calls, that the demand for service may have changed since 2017 .
I note that the Mental Health Code of Practice includes the following guidance at [16.23] in relation to triage and s.136: “When deciding that detention may be necessary, the police may also benefit from seeking advice before using section 136 powers in cases where they are unsure that the circumstances are sufficiently serious for using these powers. Local protocols should set out how this advice can be provided and who the police should contact, including outside of normal business hours”. I am concerned that I have not seen any local protocol as to who the police should contact out of hours, and I note that EMAS do have available mental health nurses between the hours of 1am and 8am. This again appears to be a local policy and communication issue.
” 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 Share and discuss self-referral learning at a planned learning event to support awareness and practice change.
Verbatim wording from the response “A key area of concern was also identified in relation to people that have an identified need which can be met by another service or organisation, such as third sector or voluntary services, and the process of self-referral. Whilst services work collaboratively with people, we recognise that it is not always realistic for some people to complete the appropriate self-referral processes and time is often dedicated by staff to do this however we have updated our team’s Internal Working Instructions which outlines the expectation of staff and services to ensure that this is clear. We will also be sharing and discussing this learning within a planned learning event to further support awareness and practice change.” Source location Response from Nottinghamshire Healthcare 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 Establish a dedicated electronic-system referral pathway for dual-diagnosis support before patient discharge.
Verbatim wording from the response “The introduction of an additional three staff members and the service having its own referral pathway on the patient electronic system means that prior to any discharge, the core LMHT would be able to see the person is accessing the co-located practitioners and therefore consider any post discharge needs and liaison. As we have now established the workers within teams the staff are also embedded as part of the internal escalation meetings and processes should there be a requirement to escalate any concerns around discharge planning or unmet care needs.” Source location Response from Nottinghamshire Healthcare 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 Introduce three additional staff members to support dual-diagnosis provision within Local Mental Health Teams.
Verbatim wording from the response “The introduction of an additional three staff members and the service having its own referral pathway on the patient electronic system means that prior to any discharge, the core LMHT would be able to see the person is accessing the co-located practitioners and therefore consider any post discharge needs and liaison. As we have now established the workers within teams the staff are also embedded as part of the internal escalation meetings and processes should there be a requirement to escalate any concerns around discharge planning or unmet care needs.” Source location Response from Nottinghamshire Healthcare 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 Continue discussions with Nottinghamshire Police and EMAS to establish collaborative acute behavioural disorder training, pathways and clinical guidance.
Verbatim wording from the response “The Trust is in discussions with Nottinghamshire Police and EMAS to establish a collaborative approach to address the concerns relating to patients with a clinical presentation of ABD including training, pathways and clinical guidance. There is an agreement with EMAS to meet with the Trust to explore opportunities for collaboration. This will be continued through to completion and take into consideration any wider national guidance from any response to this Regulation 28 Report received from Secretary of State for Health and Social Care.” Source location Response from Nottinghamshire Healthcare 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 Continue strategic review and planning of dual-diagnosis access and treatment through a cross-system strategy group.
Verbatim wording from the response “Whilst the structural changes that have been made, such as resource configuration, have made a huge difference for people with dual diagnosis needs, work has also been completed to support wider mental health staff in relation to core training and awareness for people with dual diagnosis needs. We continue to review and strategically plan access and treatment for people with dual diagnosis needs and this is in the form of a strategy group and works across the system including wider system partners and organisation, so people’s needs are not just considered in isolation.” Source location Response from Nottinghamshire Healthcare 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 Embed co-located substance-misuse and peer-support workers within City Local Mental Health Teams.
Verbatim wording from the response “As part of the wider community mental health transformation programme which commenced in 2022, a key area for improvement was improving access to services for patients with a dual diagnosis. During 2022 this work was in its infancy and there was only one worker who was allocated to liaise with the four City Local Mental Health Teams (LMHTS). As the improvement work progressed, it became clear that the remote liaison was not working and, additionally, ad hoc resource was also required. Key changes have since been made which includes co-located substance misuse workers, which includes Peer Support workers who have lived experience being located into the LMHTs, working as part of the team.” Source location Response from Nottinghamshire Healthcare 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 finalise Trustwide clinical guidance for acute behavioural disorder with emergency-service pathways and wider-agency consultation.
Verbatim wording from the response “A clinical guidance document is being developed for Trustwide clinical staff and developed in conjunction with pathways established within EMAS and Nottinghamshire Police. This will be finalised by the end of September 2025. This will be supported by a revised version of the clinical algorithm within Joint Royal Colleges Ambulance Liaison Committee (JRCALC) and Royal College of Emergency Medicine. The Trust have in development a clinical decision support tool that will be available for front facing acute mental health clinicians in supporting the knowledge and actions should ABD be a suspected clinical presentation. This will be finalised following consultation with wider agencies (Nottinghamshire Police and EMAS).” Source location Response from Nottinghamshire Healthcare 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 Update internal working instructions on staff expectations for supporting people who need self-referral to other services.
Verbatim wording from the response “A key area of concern was also identified in relation to people that have an identified need which can be met by another service or organisation, such as third sector or voluntary services, and the process of self-referral. Whilst services work collaboratively with people, we recognise that it is not always realistic for some people to complete the appropriate self-referral processes and time is often dedicated by staff to do this however we have updated our team’s Internal Working Instructions which outlines the expectation of staff and services to ensure that this is clear. We will also be sharing and discussing this learning within a planned learning event to further support awareness and practice change.” Source location Response from Nottinghamshire Healthcare 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 The current Street Triage Team operating model remains appropriate because demand is highest during its existing operating hours.
Verbatim wording from the response “Since the conclusion of the inquest, the Trust has worked with Nottinghamshire Police colleagues in order to collate and analyse the data available to consider the current operational hours of the Street Triage Team. This review of the mental health incident demand experienced by Nottinghamshire police force, has actually highlighted that demand continues to be broadly at its highest during the operating hours of the Street Triage Team, meaning that the service model continues to be appropriate and offer best value and quality in its current format.” Source location Response from Nottinghamshire Healthcare NHS Foundation Trust
Open published response
7 Feb 2025 Anthony Binfield and 2 others · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 14 Inadequate basic training, supervision and mentoring of prison staff View source Inadequate prison and healthcare staffing levels View source Failure to act with candour in post-death investigations View source Use of inaccessible email channels for risk pertinent information View source Failure to identify and share risk pertinent information between prison and healthcare staff View source Insufficient safety scrutiny during prison contract transfer View source Failure to reduce isolation of foreign national prisoners View source Failure to embed learning from deaths and monitor safety culture View source Failure to provide a nurse during night state View source Unreliable and delayed access to interpretation services for foreign national prisoners View source Lack of an effective system for gathering, retaining, reviewing and disclosing investigation material View source Failure to retain sufficient experienced prison and healthcare staff View source Lack of effective NPS-specific drug policy View source Lack of a formal prison-to-prison transfer management system View source See 11 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Anthony Binfield and 2 others · 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
Anthony Binfield, David William Richards and Rolandas Karbauskas died at HMP Lowdham Grange in March 2023 after using ligatures; Anthony’s and Rolandas’s deaths were suicides, while David’s death was accidental. The report identified missed opportunities to recognise and share risk information, shortcomings in prison and healthcare staffing, training and systems, and concerns about prisoner transfers, isolation, the prison contract transfer, and learning 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate basic training, supervision and mentoring of prison staff
Wider context from the report “All of the prison staff had completed the ITC programme, and yet there was widespread evidence of failures to do the basics . Staff failed to ensure the welfare of prisoners at roll count, failed to challenge flagrant breaches of Prison rules such as passing items under cell doors, and did not know how to properly deal with obscured cell observation hatches.
This calls into question the adequacy of their basic training, and the system for supervision and mentoring during the early years of practice.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate prison and healthcare staffing levels
Wider context from the report “The inadequate prison and healthcare staffing levels led to a restricted regime and healthcare provision. The prison was unable to offer keywork to all men, and the mental health team could no longer offer a named nurse service. Both of these aspects of care are fundamental to supporting the most vulnerable prisoners.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act with candour in post-death investigations
Wider context from the report “The Healthcare Trust are subject to a statutory duty of candour. HMPPS, Serco and Sodexo failed to embrace the same ethos during these investigations.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Use of inaccessible email channels for risk pertinent information
Wider context from the report “I am also concerned by the use of email to convey risk pertinent information . In this case, prison staff communicated their concerns about Anthony’s mental health to individual nursing Sodexo email inboxes, which the nurses were not expected to regularly access . The use of email means that such concerns are not accessible to other members of staff as they would be if they were recorded in PNOMIS or Systemone.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and share risk pertinent information between prison and healthcare staff
Wider context from the report “There was a complete breakdown in the system of risk identification and information sharing . Prison and healthcare staff did not routinely consider information captured within the electronic systems , nor did they update the systems with risk pertinent information gathered during interactions with the prisoners .
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient safety scrutiny during prison contract transfer
Wider context from the report “Safety was not front and centre of the Mobilisation and Transfer project.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reduce isolation of foreign national prisoners
Wider context from the report “I heard evidence that the Big Word translation service did not work on multiple occasions across multiple sites within the prison. Staff gave evidence that even when the system did connect, they could be waiting in a queue for up to an hour to access an appropriate interpreter.
There was no plan to seek to reduce Rolandas’ obvious isolation , and seemingly no provision for expediting his induction so that he could be housed with fellow Lithuanian speakers .
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to embed learning from deaths and monitor safety culture
Wider context from the report “I heard evidence that many of the contributory factors leading to the deaths of Anthony, David and Rolandas, had been raised as issues in the investigations following previous deaths in custody at HMP Lowdham Grange.
While Serco no longer manage HMP Lowdham Grange, they continue to manage prisons, and there is a risk of future deaths if the organisation is unable to create a robust culture of seeking to identify issues early, adopt learning, and continually monitor culture to ensure any action taken is embedded to reduce the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a nurse during night state
Wider context from the report “For months prior to the deaths, the Trust failed to fulfil its commissioned obligations to provide a nurse during night state . Prison staff have only basic first aid training and lacked the expertise of a medical professional when attempting to provide CPR to Anthony.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unreliable and delayed access to interpretation services for foreign national prisoners
Wider context from the report “I heard evidence that the Big Word translation service did not work on multiple occasions across multiple sites within the prison . Staff gave evidence that even when the system did connect, they could be waiting in a queue for up to an hour to access an appropriate interpreter .
There was no plan to seek to reduce Rolandas’ obvious isolation, and seemingly no provision for expediting his induction so that he could be housed with fellow Lithuanian speakers.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective system for gathering, retaining, reviewing and disclosing investigation material
Wider context from the report “HMPPS have no effective system for gathering, retaining, reviewing and disclosing potentially relevant material so that the issues relevant to death can be identified and learning put in place.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to retain sufficient experienced prison and healthcare staff
Wider context from the report “I am concerned by the failure to retain experienced prison officers and healthcare staff . The private prison operator and the Authority were focused on the number of staff, rather than the skill sets or experience of the staffing body as a whole .
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of effective NPS-specific drug policy
Wider context from the report “There is no requirement for prisons to have an NPS specific drug policy and I am concerned that generic drug reduction strategies are ineffective against this particular threat .
NPS is highly dangerous and carries a risk of death. I am concerned that more young men will die in custody as a result of NPS use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal prison-to-prison transfer management system
Wider context from the report “I heard evidence that there is no formal policy framework or system for managing the progress of prison-to-prison transfers , including a lack of expected response times or formal escalation plan if a prison fails to provide any response.
” 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 Amend the reception supervision proforma to record clinical staff access to digital Person Escort Records.
Verbatim wording from the response “Part of the reception screening is the ability to access a digital Person Escort Record (PER). This is a prison document which follows the prisoner journey through their custodial sentence and contains risk pertinent information. There is no ability to audit this access however, the supervision proforma for the clinical staff in reception will be amended to ensure it forms part of the supervision record.” Source location Response from Nottingham 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 Audit and quality-review documentation of risk information in wing observation books.
Verbatim wording from the response “Discussions have taken place with the Head of Residential Services to discuss how appropriate risk pertinent information can be shared on the wings as part of effective information sharing with prison colleagues. Systems such as identifying clinical risk by adding a coloured dot to their name on the wing prisoner list are being scoped. Healthcare staff have been informed that they must document in the wing observation book any relevant risk pertinent information to alert staff to any potential issues. Again, this will be audited and reviewed for quality by the Head of Healthcare and Safer Custody Officer.” Source location Response from Nottingham 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 Review ACCT attendance and contributions through the safer-custody process to assure quality.
Verbatim wording from the response “ACCT: Assessment, Care in Custody and Teamwork processes are being managed through a booking process with advance notification. All first ACCT reviews are attended by a registered nurse in line with the ACCT process. Subsequent follow up reviews are attended where possible or prioritised based on clinical risk and need. Phone and email contributions are also supported if required. The process of our ACCT attendance and contribution will be reviewed as part of the safer custody process to ensure the quality is as desired and required. As part of the ACCT process” Source location Response from Nottingham 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 Maintain generic healthcare email inboxes with daily administrative monitoring for non-urgent prison queries.
Verbatim wording from the response “Email: Healthcare has generic email inboxes which are monitored daily by administrative staff which have been provided to the wings as a first point of contact for non-urgent issues. This includes a mailbox for each clinical pathway. A reminder has also been sent to Prison staff via the Governors secretary, to the wings, of the mailbox addresses and call signs on the radio for contacting healthcare. No personal emails should be used for patient related queries.” Source location Response from Nottingham 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 Complete nationally delivered training for staff using the new prison reception-screening template.
Verbatim wording from the response “Reception screening: A new national template for prison reception screening for the male prison estate was launched on the 1 April 2025. Staff are in the process of receiving the Nationally delivered” Source location Response from Nottingham 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 Deliver healthcare training to prison officers through the prison staff induction programme, expanding from emergency response to mental-health awareness.
Verbatim wording from the response “Training - Healthcare staff have arranged to attend the Prison staff induction programme so that they can deliver health training to the Prison Officers. Initially this will be focused on emergency response but will later include Mental Health awareness training. This was agreed at the Local Delivery Board and the first session was provided on 23 January 2025. Feedback from staff was very positive. Healthcare staff will continue to receive clinical risk, self-harm and suicide training, which is an inhouse training programme. Compliance will be achieved by July 2025.” Source location Response from Nottingham 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 Attend weekly Safety Interventions Meetings through Mental Health Team representation and quality-check attendance and information sharing.
Verbatim wording from the response “Safety Interventions Meeting (SIM): We have worked with Prison colleagues to ensure that SIMs are attended on a weekly basis by a member of the Mental Health Team. This meeting is to discuss any patients of concern and highlight any specific issues relating to that individual. A Prison safeguarding referral form (Annex Q) is now in use and concerns can also be raised online via the DPS system. A random spot check of attendance and the quality of information shared will be randomly reviewed by the Head of Healthcare at HMP Lowdham Grange.” Source location Response from Nottingham NHS
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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 Scope systems for sharing risk information with prison colleagues on residential wings.
Verbatim wording from the response “Discussions have taken place with the Head of Residential Services to discuss how appropriate risk pertinent information can be shared on the wings as part of effective information sharing with prison colleagues. Systems such as identifying clinical risk by adding a coloured dot to their name on the wing prisoner list are being scoped. Healthcare staff have been informed that they must document in the wing observation book any relevant risk pertinent information to alert staff to any potential issues. Again, this will be audited and reviewed for quality by the Head of Healthcare and Safer Custody Officer.” Source location Response from Nottingham 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 Disseminate healthcare mailbox addresses and radio call signs to prison wings and staff.
Verbatim wording from the response “Email: Healthcare has generic email inboxes which are monitored daily by administrative staff which have been provided to the wings as a first point of contact for non-urgent issues. This includes a mailbox for each clinical pathway. A reminder has also been sent to Prison staff via the Governors secretary, to the wings, of the mailbox addresses and call signs on the radio for contacting healthcare. No personal emails should be used for patient related queries.” Source location Response from Nottingham 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 ACCT safety plans with patients and prison colleagues, with identified escalation routes, and audit this practice.
Verbatim wording from the response “safety plans should be shared with the Patient and with prison colleagues with escalation routes identified. This will be reviewed and audited by the Head of Healthcare as part of local quality assurance processes.” Source location Response from Nottingham 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 Establish enhanced Executive-led oversight and assurance reviews for Offender Health and HMP Lowdham Grange.
Verbatim wording from the response “Improvement oversight for Offender Health and HMP Lowdham Grange - The Trust has established enhanced Executive led oversight and assurance reviews for Offender Health. This comprises a weekly meeting where progress against the Transformation Plan is reviewed with individuals held to account.” Source location Response from Nottingham 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 Complete CSIP training for healthcare staff to support risk-information sharing.
Verbatim wording from the response “CSIP: Patients can also be referred to CSIP (Challenge, Support and Intervention Plan). This is a prison risk management system and process that will enable information sharing on risk in the prison estate and also support the development of cross professional relationships. Healthcare staff are currently accessing the training for this, and full compliance is aimed to have been achieved by June 2025.” Source location Response from Nottingham 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 Continue providing healthcare staff training on clinical risk, self-harm and suicide.
Verbatim wording from the response “Training - Healthcare staff have arranged to attend the Prison staff induction programme so that they can deliver health training to the Prison Officers. Initially this will be focused on emergency response but will later include Mental Health awareness training. This was agreed at the Local Delivery Board and the first session was provided on 23 January 2025. Feedback from staff was very positive. Healthcare staff will continue to receive clinical risk, self-harm and suicide training, which is an inhouse training programme. Compliance will be achieved by July 2025.” Source location Response from Nottingham NHS
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 Access to the digital Person Escort Record cannot be audited, preventing direct monitoring of whether staff access risk information.
Verbatim wording from the response “Part of the reception screening is the ability to access a digital Person Escort Record (PER). This is a prison document which follows the prisoner journey through their custodial sentence and contains risk pertinent information. There is no ability to audit this access however, the supervision proforma for the clinical staff in reception will be amended to ensure it forms part of the supervision record.” Source location Response from Nottingham NHS
Open published response
4 Oct 2024 James Southern · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Inadequate communication with patients View source Poor record keeping View source Inadequate communication between professionals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
James Southern · 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 Southern, known as Jimmy, died on 31 May 2023 after being found unresponsive at his home in Nottinghamshire. He had suffered pain and anxiety since a 2002 motorbike accident and died from polydrug toxicity. The report identified errors and delays in care records, including records amended after death, and that he was left without care for months after his care coordinator was absent; concerns also included poor record keeping and communication.
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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication with patients
Wider context from the report “• That there remain potential issues of poor record keeping.
• There are concerns over the level of communication between professionals within the Trust and communication with patients .
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor record keeping
Wider context from the report “• That there remain potential issues of poor record keeping .
• There are concerns over the level of communication between professionals within the Trust and communication with patients.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication between professionals
Wider context from the report “• That there remain potential issues of poor record keeping.
• There are concerns over the level of communication between professionals within the Trust and communication with patients.
” 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 Develop and disseminate additional clinical record-keeping standards to Trust staff and Care Units.
Verbatim wording from the response “We also appreciate that the systems in place need to protect patients from individual errors or omissions and therefore we have also looked at this in the wider context of services and developed some additional clinical quality standards for all staff in relation to record keeping (Appendix A). This information forms part of the current policy in relation to records management and will support staff awareness and personal responsibility. This document along with other similar documents for differing grades and professional backgrounds have been shared with all Care Units within the Trust.” Source location Response from Nottinghamshire 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 Develop place-based interface meetings to oversee internal care transfers and strengthen communication between teams.
Verbatim wording from the response “This standard has been added to the Crisis Team Internal Working Instructions (IWI) and will be further discussed within their local QOG meetings from a wider learning perspective to support learning. Further work relating to place-based interface meetings between teams is currently in progress which will oversee the current process of internal transfers of care, ensure compliance and support wider team communications and closer working relationships to ensure patients receive the standard of care expected. In terms of caseload oversight and allocation there is now an improved process which is incorporated within the LMHT Internal Working Instructions that has been shared and discussed with all teams with further oversight of assurance from weekly oversight meetings, supervision and audits to inform any further potential developments required.” Source location Response from Nottinghamshire 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 Add a clinical conversation and agreed care-plan communication standard to Crisis Team discharge instructions.
Verbatim wording from the response “It was deeply concerning to hear the experience of Mr Southern and how the pathway for Mr Southern following his contact with the Crisis Team into the Local Mental Health Team (LMHT) was not properly agreed or communicated between teams, this then led to an avoidable delay which is not acceptable. We have reviewed the pathway between Crisis and LMHT services to ensure that clinical safety standards are in place. There are expected standards that Crisis teams have a clinical conversation with respective LMHT services before discharging a patient from the service. This will ensure that both teams are in agreement to the plan of care required and that this is further communicated to the patient.” Source location Response from Nottinghamshire 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 Develop bespoke record-keeping training for registered and unregistered professionals with the Royal College of Nursing.
Verbatim wording from the response “In reference to this incident and other incidents, individual accountability is a current focus of development and in collaboration with the Royal College of Nursing the trust is developing bespoke” Source location Response from Nottinghamshire 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 Introduce specific record-keeping training for all staff into the existing training programme and oversee compliance.
Verbatim wording from the response “training, for registered and unregistered professionals. Further work that has been completed in relation to ensuring quality and accurate record keeping is the development of specific training for all staff which join the current training programme and compliance overseen for assurance.” Source location Response from Nottinghamshire 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 Revise mandatory clinical supervision processes and documentation to review the quality of care evidenced in patient records.
Verbatim wording from the response “To provide a continual flow of assurance we have also changed the process and documentation used within mandatory supervision sessions with all clinical staff to include a specific review of the quality of care being evidenced within the patient records. Further work is in progress to change the current content of the quarterly patient records audit to be more specific to patients being cared for in the community alongside increasing the frequency of the audit to monthly. The outcome of the audits will then be reviewed and overseen within the Care Unit’s Quality Oversight Group (QOG) and Care Group QOG to ensure senior clinical oversight and assurance.” Source location Response from Nottinghamshire 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 Revise quarterly patient-record audits for community patients and increase their frequency to monthly, with quality-group oversight.
Verbatim wording from the response “To provide a continual flow of assurance we have also changed the process and documentation used within mandatory supervision sessions with all clinical staff to include a specific review of the quality of care being evidenced within the patient records. Further work is in progress to change the current content of the quarterly patient records audit to be more specific to patients being cared for in the community alongside increasing the frequency of the audit to monthly. The outcome of the audits will then be reviewed and overseen within the Care Unit’s Quality Oversight Group (QOG) and Care Group QOG to ensure senior clinical oversight and assurance.” Source location Response from Nottinghamshire NHS
Open published response
25 Mar 2024 Alexander Vitali Lyalyushko · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Failure to identify un-actioned service-involvement requests in post-death incident reviews View source Insufficient learning and corrective action following deaths View source Inaccurate identification of required improvements as good practice in post-death incident reviews View source Failure to consult families about concerns that could direct post-death incident reviews 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
Alexander Vitali Lyalyushko · 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 Vitali Lyalyushko took his own life by hanging at his home on 2 January 2023, where he lived alone. A request from his GP for mental health service involvement in November 2022 was not actioned, and he was not receiving mental health services at the time of his death. The report also identified deficiencies in the initial review and incident investigation following his death, including failure to identify the unactioned request and failure to consult his family.
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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify un-actioned service-involvement requests in post-death incident reviews
Wider context from the report “1. Inadequate review and incident investigation following a death
Following Mr Lyalyushko’s death, Nottinghamshire Healthcare NHS Foundation Trust completed an SI Review by way of case note review. Following evidence which considered the content of that review, the Trust stated that the review was ‘insufficient in its current form and the scope should be broadened to include the concerns raised (during the inquest hearing).’ The Trust said its Patient Safety Investigation Lead would undertake a new SI Review by 26 April 2024 (6 weeks).
I identified a number of deficiencies with the initial SI Review which had been undertaken in respect of Mr Lyalyushko: it did not identify that a request from Mr Lyalyushko’s GP in November 2022 for involvement of its service with Mr Lyalyushko had not been actioned ; it incorrectly identified areas where improvements were required as areas of good practice; and it did not involve any level of consultation with Mr Lyalyushko’s family to consider whether there were any areas of concern they had which might direct elements of the review.
If there is insufficient review and learning from a death that, in my judgment, adds to the likelihood of future deaths occurring in similar circumstances.
I am not reassured that necessary actions to address the serious issue identified i.e. inadequate initial review and incident investigation following a death, are yet in place.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient learning and corrective action following deaths
Wider context from the report “1. Inadequate review and incident investigation following a death
Following Mr Lyalyushko’s death, Nottinghamshire Healthcare NHS Foundation Trust completed an SI Review by way of case note review. Following evidence which considered the content of that review, the Trust stated that the review was ‘insufficient in its current form and the scope should be broadened to include the concerns raised (during the inquest hearing).’ The Trust said its Patient Safety Investigation Lead would undertake a new SI Review by 26 April 2024 (6 weeks).
I identified a number of deficiencies with the initial SI Review which had been undertaken in respect of Mr Lyalyushko: it did not identify that a request from Mr Lyalyushko’s GP in November 2022 for involvement of its service with Mr Lyalyushko had not been actioned; it incorrectly identified areas where improvements were required as areas of good practice; and it did not involve any level of consultation with Mr Lyalyushko’s family to consider whether there were any areas of concern they had which might direct elements of the review.
If there is insufficient review and learning from a death that, in my judgment, adds to the likelihood of future deaths occurring in similar circumstances.
I am not reassured that necessary actions to address the serious issue identified i.e. inadequate initial review and incident investigation following a death, are yet in place .
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate identification of required improvements as good practice in post-death incident reviews
Wider context from the report “1. Inadequate review and incident investigation following a death
Following Mr Lyalyushko’s death, Nottinghamshire Healthcare NHS Foundation Trust completed an SI Review by way of case note review. Following evidence which considered the content of that review, the Trust stated that the review was ‘insufficient in its current form and the scope should be broadened to include the concerns raised (during the inquest hearing).’ The Trust said its Patient Safety Investigation Lead would undertake a new SI Review by 26 April 2024 (6 weeks).
I identified a number of deficiencies with the initial SI Review which had been undertaken in respect of Mr Lyalyushko: it did not identify that a request from Mr Lyalyushko’s GP in November 2022 for involvement of its service with Mr Lyalyushko had not been actioned; it incorrectly identified areas where improvements were required as areas of good practice ; and it did not involve any level of consultation with Mr Lyalyushko’s family to consider whether there were any areas of concern they had which might direct elements of the review.
If there is insufficient review and learning from a death that, in my judgment, adds to the likelihood of future deaths occurring in similar circumstances.
I am not reassured that necessary actions to address the serious issue identified i.e. inadequate initial review and incident investigation following a death, are yet in place.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consult families about concerns that could direct post-death incident reviews
Wider context from the report “1. Inadequate review and incident investigation following a death
Following Mr Lyalyushko’s death, Nottinghamshire Healthcare NHS Foundation Trust completed an SI Review by way of case note review. Following evidence which considered the content of that review, the Trust stated that the review was ‘insufficient in its current form and the scope should be broadened to include the concerns raised (during the inquest hearing).’ The Trust said its Patient Safety Investigation Lead would undertake a new SI Review by 26 April 2024 (6 weeks).
I identified a number of deficiencies with the initial SI Review which had been undertaken in respect of Mr Lyalyushko: it did not identify that a request from Mr Lyalyushko’s GP in November 2022 for involvement of its service with Mr Lyalyushko had not been actioned; it incorrectly identified areas where improvements were required as areas of good practice; and it did not involve any level of consultation with Mr Lyalyushko’s family to consider whether there were any areas of concern they had which might direct elements of the review .
If there is insufficient review and learning from a death that, in my judgment, adds to the likelihood of future deaths occurring in similar circumstances.
I am not reassured that necessary actions to address the serious issue identified i.e. inadequate initial review and incident investigation following a death, are yet in place.
” 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 Share the completed review addendum with the coroner and the deceased’s family.
Verbatim wording from the response “It was subsequently agreed at the inquest that a further review would be undertaken and addendum to the report added to take into account this information that was not known at the time of the original CNR, as well as the additional points raised within the findings and conclusion document provided to the Trust. This is being undertaken and nearing completion. We will share this once completed with you and the family of Alexander, who have been involved in the onward investigation process. Once completed we will be better sighted to understand the wider lessons learnt and actions required to mitigate future occurrence and ensure the correct oversight is deployed.” Source location Response from Nottinghamshire Healthcare NHS FT
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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 the further review and addendum to incorporate newly identified information and issues from the inquest findings.
Verbatim wording from the response “record and therefore unavailable to the author of the CNR. This information became known about in January 2024 and agreed that this would be dealt with via a statement from the relevant team leader. This statement was to confirm that this referral was not available or known to the author of the CNR, confirm what had occurred, confirm what should have happened according to procedure, and what had since been put in place to reduce risk of recurrence.” Source location Response from Nottinghamshire Healthcare NHS FT
Open published response
29 Feb 2024 Daniel Mark Edward TUCKER · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 7 Inadequate allocation of named nurses to patients View source Continuing accessibility of an online suicide forum to vulnerable people in the UK View source Failure of 999 call grading to trigger a category 1 ambulance response for confirmed ingestion of a potent poison View source Failure to record the named nurse appointed to each patient View source Failure of clinical and nursing staff to complete and utilise ward-specific risk assessments and care plans View source Inadequate delivery of regular and effective named nurse 1:1 sessions View source Insufficient staff skills and knowledge for encouraging engagement with patients View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Daniel Mark Edward TUCKER · 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
Daniel Mark Edward Tucker was detained under the Mental Health Act and admitted to hospital following self-harm and suicidal thoughts, but was discharged on 22 April 2022 despite ongoing concerns about his mental state and risk. He ingested a lethal quantity of a substance later that evening and died. The report identifies concerns about risk assessment and care planning, named-nurse allocation, staff skills in engaging patients, emergency response to confirmed ingestion, and the accessibility of online suicide forums.
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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate allocation of named nurses to patients
Wider context from the report “2. Inadequate system of allocating a named nurse to patients and recording the same
I am concerned that, notwithstanding the existence of a clear, appropriate policy requiring the same, the current system of allocating a named nurse and ensuring patients receive regular and effective 1:1 sessions with them are inadequate. I am also concerned that no record is kept of the named nurse appointed to each patient, thus (as in this case) hindering any investigation where issue around the role and actions of that person arises.
The General Manager of Adult Mental Health at the Trust helpfully and frankly acknowledged that the evidence heard at inquest raised questions about the adequacy of the existing system, of which he was not previously aware of. It remains unclear whether Daniel was appointed a Named Nurse who failed to perform that role effectively, or whether there was a failure to appoint such a nurse at all. The General Manager’s view was that under the existing system, it is possible that a named nurse was appointed without their knowledge. While the Ward Manager gave evidence that she would have no confidence Daniel would have known who his named nurse was, even if one was appointed. The inquest heard evidence that named nurse sessions with Daniel during previous admissions had been important opportunities for engagement with staff and had elicited a substantial amount of information pertinent to his risk and treatment. The General Manager assured me that he has already requested an urgent review of the system, but he was unable to provide any further information upon conclusion of the inquest as to what further action, if any, is proposed.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Continuing accessibility of an online suicide forum to vulnerable people in the UK
Wider context from the report “1. Continuing accessibility of █████████████████████████████████████████████████████████
Dan was using an online suicide forum, █████████████████████████ Through that forum he was able to engage in discussions with other █████████████████████████ members and obtain information █████████████████████████████████████████████████████████
Notwithstanding the provisions of the Online Safety Act 2023, and apparent attempts to block access to the website, I heard evidence that it remains easily accessible to vulnerable people in the UK . I am concerned that further deaths will occur while this remains the case .
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of 999 call grading to trigger a category 1 ambulance response for confirmed ingestion of a potent poison
Wider context from the report “1. I am concerned that confirmed ingestion of ████████ during a 999 call does not trigger a category 1 response from the Ambulance Service
Dan ingested ████████ at around 20:30 on 22 April 2022. His friend informed the 999 call handler that he had done so during a first 999 call at 20:39. That call was correctly graded as requiring a category 2 response, as Dan was both conscious and awake. 14 minutes later, at 20:53, Dan collapsed. His friend’s second 999 call was correctly graded as requiring a category 1 response, as Dan had become unconscious, his breathing agon al. The first ambulance crew arrived at 21:04. Dan went into cardiac arrest at approximately 21:24. Consideration was given by the ambulance crew to ‘scoop and run’ to arrange a rendezvous to administer the necessary “drugs to counter ████████”, but this was no considered longer feasible once Dan had gone into cardiac arrest.
The inquest heard evidence from a consultant toxicologist that even in very small quantities ████████ (or ████████) is lethal; it is a potent poison. I understand it is also, tragically, an increasingly common means of suicide. Mental health professionals who gave evidence expressed deep concern at its easy availability and growing popularity for vulnerable people seeking to end their own lives. The expert toxicological evidence indicated that its acute toxic effects can be rapid (as short as 20 minutes after ingestion, depending on dose) and can quickly become irreversible.
This suggests that almost any case involving the ingestion of ████████ or ████████ is likely to be a time critical life-threatening event . Yet it is does not currently fall within that category for the purposes of grading 999 calls, unless the patient is unconscious or not breathing. While there was no evidence that a category 1 response would have prevented Dan’s death, I believe there is a risk that other deaths will occur if ingestion of ████████ continues to require a category 2 response.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record the named nurse appointed to each patient
Wider context from the report “2. Inadequate system of allocating a named nurse to patients and recording the same
I am concerned that, notwithstanding the existence of a clear, appropriate policy requiring the same, the current system of allocating a named nurse and ensuring patients receive regular and effective 1:1 sessions with them are inadequate. I am also concerned that no record is kept of the named nurse appointed to each patient , thus (as in this case) hindering any investigation where issue around the role and actions of that person arises.
The General Manager of Adult Mental Health at the Trust helpfully and frankly acknowledged that the evidence heard at inquest raised questions about the adequacy of the existing system, of which he was not previously aware of. It remains unclear whether Daniel was appointed a Named Nurse who failed to perform that role effectively, or whether there was a failure to appoint such a nurse at all. The General Manager’s view was that under the existing system, it is possible that a named nurse was appointed without their knowledge. While the Ward Manager gave evidence that she would have no confidence Daniel would have known who his named nurse was, even if one was appointed. The inquest heard evidence that named nurse sessions with Daniel during previous admissions had been important opportunities for engagement with staff and had elicited a substantial amount of information pertinent to his risk and treatment. The General Manager assured me that he has already requested an urgent review of the system, but he was unable to provide any further information upon conclusion of the inquest as to what further action, if any, is proposed.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of clinical and nursing staff to complete and utilise ward-specific risk assessments and care plans
Wider context from the report “1. A continuing practice/culture of minimising the importance of a ward specific risk assessment and care plan
I am concerned that, notwithstanding the existence of a clear, appropriate policy and significant commendable actions by the Trust since Daniel’s death to address this issue, there remain clinical and nursing staff who do not fully recognise or accept the importance of completing and utilising the required risk assessment and care plan . This suggests there may be a persisting training or cultural issue.
The inquest heard evidence that there was (and remains) a clear and robust policy in place which most staff were aware of. This requires a care plan and risk assessment be initiated upon a patient’s admission, completed within 72 hours of admission and updated as necessary during admission. Further, since Dan’s death, the Trust has gone to considerable and commendable lengths to ensure that care plans and risk assessments are in place in every case and to reinforce the requirements of this guidance within the Nursing team; that team hold primary (but not sole) responsibility for creating and updating the risk assessment and care plan document. I also heard that a recent audit found that all current patients had an appropriate care plan in place. The Ward Manager agreed this is “a basic and fundamental part” of any patient’s care. In spite of all of this, an experienced ward nurse and two psychiatrists (a consultant and a registrar) involved in Dan’s care seemed to minimise the practical importance of the required process and documentation , the latter both suggesting they would not routinely consult it.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate delivery of regular and effective named nurse 1:1 sessions
Wider context from the report “2. Inadequate system of allocating a named nurse to patients and recording the same
I am concerned that, notwithstanding the existence of a clear, appropriate policy requiring the same, the current system of allocating a named nurse and ensuring patients receive regular and effective 1:1 sessions with them are inadequate . I am also concerned that no record is kept of the named nurse appointed to each patient, thus (as in this case) hindering any investigation where issue around the role and actions of that person arises.
The General Manager of Adult Mental Health at the Trust helpfully and frankly acknowledged that the evidence heard at inquest raised questions about the adequacy of the existing system, of which he was not previously aware of. It remains unclear whether Daniel was appointed a Named Nurse who failed to perform that role effectively, or whether there was a failure to appoint such a nurse at all. The General Manager’s view was that under the existing system, it is possible that a named nurse was appointed without their knowledge. While the Ward Manager gave evidence that she would have no confidence Daniel would have known who his named nurse was, even if one was appointed. The inquest heard evidence that named nurse sessions with Daniel during previous admissions had been important opportunities for engagement with staff and had elicited a substantial amount of information pertinent to his risk and treatment. The General Manager assured me that he has already requested an urgent review of the system, but he was unable to provide any further information upon conclusion of the inquest as to what further action, if any, is proposed.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff skills and knowledge for encouraging engagement with patients
Wider context from the report “3. Inadequate skills/knowledge/training on how to encourage patients to engage
I am concerned that clinical, nursing and/or support staff may not currently have sufficient skills or knowledge in dealing with patients who appear unable or unwilling to engage with staff and/or treatment .
A psychiatrist not involved in Dan’s care gave evidence about the advice he would have given to colleagues on how to seek to assist a patient who, like Dan, was unwilling or unable to engage with staff: first, identify the likely reasons for the patient’s lack of engagement; second, having regard to those reasons, develop plans and strategies to address the specific barriers identified.
I heard little evidence that either of these steps was followed by any of the staff involved in Dan’s care. One barrier was identified (his previous negative experiences on the ward and wish to be transferred to another ward or hospital) but seemingly forgotten after an initial transfer request to the Bed Management team, which was not then followed up. Even with the benefit of hindsight, the doctors, nurses and healthcare assistants involved in Dan’s care seemed unable to offer any insight into the reasons for his difficulties engaging beyond his diagnosis of EUPD or articulate any strategies or techniques that might have helped him overcome them .
” 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 Review and revise named-nurse allocation in adult mental health acute wards, including allocation on admission where possible.
Verbatim wording from the response “It was recognised within the inquest that an urgent review was needed for the system of named nursing within AMH inpatient acute wards. This work is being led by the Head of Nursing at Highbury Hospital. The expectation would be for named nurses to be allocated on admission and wherever possible this should be the admitting nurse due to continuity of care. Where this is not possible for example where a staff member will be taking some annual leave, an alternative nurse anticipated to be working within the 72 hours will be allocated. This is current work in progress and in the engagement phase with the ward teams.” Source location Response from Nottinghamshire Healthcare
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 pilot ward safety huddles before rolling them out across adult mental health wards.
Verbatim wording from the response “Regarding risk assessments this is also a feature of the rapid improvement work with clear emphasis in the understanding of risk within the clinical areas. A key element of this is the introduction of safety huddles which is within the pilot stage within AMH before roll out to all wards. These safety huddles support the team to reflect on the dynamic risks within the ward ensuring risk is well understood and shared amongst the team to ensure effective robust plans are in place.” Source location Response from Nottinghamshire Healthcare
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 Ratify the updated Clinical Risk and Safety Policy incorporating current risk-assessment and safety-planning guidance.
Verbatim wording from the response “Trust guidance relating to risk assessment, formulation and safety planning has been reviewed in line with NICE guidelines and the latest updates from NHSE and suicide prevention evidence and literature. Nottinghamshire Healthcare’s Trust Lead for Self-harm and Suicide Prevention is leading this work and has met with NHSE and other leaders in suicide prevention to scope good practice and share learning. Updated guidance is reflected in the Trust’s new Clinical Risk and Safety Policy (due to be ratified early May 2024) and guidance documents relating to psychosocial assessment, formulation, and safety planning in relation to suicidality, including self-harm have been developed.” Source location Response from Nottinghamshire Healthcare
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 Launch and evaluate an improved multidisciplinary-team record template for risk-assessment and care-planning discussions.
Verbatim wording from the response “The need for clear risk assessment and care planning lead to the review of MDT records and an improved template to capture discussions and plans in a more meaningful manner has been completed by AMH Clinical Directors. This has been launched and is due for full evaluation in July 2024.” Source location Response from Nottinghamshire Healthcare
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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 Conduct and share monthly care-planning audits to identify and correct discrepancies.
Verbatim wording from the response “The Trust expectation remains that care plans and risk assessments are individualised and fully updated following the 72-hour assessment period. Throughout a person’s admission care plans and risk assessments are expected to be kept contemporaneous and accessible to all staff to support a patients care. At the inquest evidence was provided about how an improvement in care planning had been demonstrated and the oversight of this is a continual process to ensure this is maintained. A monthly audit is completed which is shared within” Source location Response from Nottinghamshire Healthcare
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 Record each patient’s named nurse in the care plan and audit compliance.
Verbatim wording from the response “To ensure that all patients know of their named nurses and that there is a clear record of this an interim measure has been agreed for the named nurse to be cleared detailed within the care plan. For the patients experience this will mean that upon receipt of their care plan they will have this detail to hand and will be confident of who their named nurse is. This will also provide a record should the identification of the named nurse be required for” Source location Response from Nottinghamshire Healthcare
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 Move adult mental health inpatient care planning to the Dialog+ tool.
Verbatim wording from the response “The oversight of care planning is a feature of the Trust rapid improvement programme. This is a Trust board supported priority focus to improve the quality within adult mental health (AMH) service inpatients wards. With regards care planning the emphasis of this work has been the engagement of our patients regarding their experience of care planning. Secondly the Trust is looking to move to an alternative care planning tool through the Dialog+ model. This is an evidence-based tool which has received positive feedback in their evaluations. AMH’s Head of Nursing colleagues are heavily involved in supporting the implementation plans. Additionally, an allocated worker model is in the implementation phased at Highbury Hospital.” Source location Response from Nottinghamshire Healthcare
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update risk and safety forms and audits to reflect current guidance.
Verbatim wording from the response “Trust guidance relating to risk assessment, formulation and safety planning has been reviewed in line with NICE guidelines and the latest updates from NHSE and suicide prevention evidence and literature. Nottinghamshire Healthcare’s Trust Lead for Self-harm and Suicide Prevention is leading this work and has met with NHSE and other leaders in suicide prevention to scope good practice and share learning. Updated guidance is reflected in the Trust’s new Clinical Risk and Safety Policy (due to be ratified early May 2024) and guidance documents relating to psychosocial assessment, formulation, and safety planning in relation to suicidality, including self-harm have been developed.” Source location Response from Nottinghamshire Healthcare
Open published response
29 Feb 2024 Kenneth Stanley Baylis · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 6 Inadequate suicide mitigation View source Inadequate review following a serious suicide attempt or death View source Lack of compliance with the Planned Leave policy View source Inadequate incident investigation following a serious suicide attempt or death View source Failure to routinely involve family in patients' risk assessment, care planning and safety planning View source Inadequate suicidal risk assessment View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 19
Action
Reinforce planned-leave policy compliance through staff review and acknowledgement, a leave record, and auditing of completed records.
Stated completedThe respondent said that this action was complete when they made their response on 6 March 2024. View source
Action
Provide each patient with a named nurse who agrees at least weekly family or carer contact and audits involvement in care planning and risk assessment.
Stated completedThe respondent said that this action was complete when they made their response on 6 March 2024. View source
Action
Update clinical risk guidance, safety-planning documentation, audits and healthcare-record forms in line with current evidence and guidelines.
Stated in progressThe respondent said that this action was in progress when they made their response on 6 March 2024. View source
Action
Roll out the SAFETool across all MHSOP wards with staff training on its use.
Stated completedThe respondent said that this action was complete when they made their response on 6 March 2024. View source
Action
Share approved investigation reports with relevant teams and witnesses and support incident-specific learning reflections.
Stated completedThe respondent said that this action was complete when they made their response on 6 March 2024. View source
Action
Invite families and carers to ward multidisciplinary meetings using a standard template and audit invitations and involvement.
Stated completedThe respondent said that this action was complete when they made their response on 6 March 2024. View source
Action
Conduct serious-incident discussions and thematic reviews through MHSOP safety, risk, quality-assurance and improvement forums.
Stated completedThe respondent said that this action was complete when they made their response on 6 March 2024. View source
Action
Embed SAFETool paperwork in the RIO electronic patient record and require staff to complete forms there.
Stated completedThe respondent said that this action was complete when they made their response on 6 March 2024. View source
Action
Incorporate SAFETool learning and reflection into staff supervision and monitor training and supervision compliance.
Stated in progressThe respondent said that this action was in progress when they made their response on 6 March 2024. View source
Action
Disseminate learning from serious incidents through the MHSOP Learning the Lessons bulletin and service and team meetings.
Stated completedThe respondent said that this action was complete when they made their response on 6 March 2024. View source
Action
Require investigators to address staff interviews through standard allocation emails and clinical-governance oversight.
Stated completedThe respondent said that this action was complete when they made their response on 6 March 2024. View source
Action
Introduce collaborative care-planning conversations with every newly admitted patient and their relative or carer.
Status unclearThe respondent did not make the status of this action clear when they made their response on 6 March 2024. View source
Action
Ratify the updated Clinical Risk and Safety Policy.
Stated plannedThe respondent said that this action was planned when they made their response on 6 March 2024. View source
Action
Review IR1 incidents through assigned IR2 managers, monthly completion reports, and supervision-based learning.
Stated completedThe respondent said that this action was complete when they made their response on 6 March 2024. View source
Action
Enhance and evaluate suicide-prevention and self-harm training with updated awareness and response content and consistent delivery.
Stated completedThe respondent said that this action was complete when they made their response on 6 March 2024. View source
Action
Complete the PSIRF policy and local patient-safety incident response plan following stakeholder consultation.
Stated completedThe respondent said that this action was complete when they made their response on 6 March 2024. View source
Action
Strengthen SAFETool training with family and carer involvement content and reflective case studies.
Stated completedThe respondent said that this action was complete when they made their response on 6 March 2024. View source
Action
Implement PSIRF across the Trust by August 2024.
Stated plannedThe respondent said that this action was planned when they made their response on 6 March 2024. View source
Action
Implement a standardised ward and community meeting governance template incorporating incident data and learning discussions across MHSOP wards.
Stated in progressThe respondent said that this action was in progress when they made their response on 6 March 2024. View source See 16 more actions
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AI-generated summary
Kenneth Stanley Baylis · 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
Kenneth Stanley Baylis took his own life on 23 January 2023 while on unescorted leave as an informal inpatient on Kingsley Ward. The report identified concerns including inadequate suicide risk assessment and mitigation, insufficient family involvement, failure to follow planned-leave procedures, and inadequate review and investigation after serious suicide attempts or a death.
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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate suicide mitigation
Wider context from the report “2. Inadequate suicidal risk assessment and suicide mitigation
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate review following a serious suicide attempt or death
Wider context from the report “4. Inadequate review and incident investigation following a serious suicide attempt or a death
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of compliance with the Planned Leave policy
Wider context from the report “3. Lack of compliance with the Trusts Planned Leave policy.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate incident investigation following a serious suicide attempt or death
Wider context from the report “4. Inadequate review and incident investigation following a serious suicide attempt or a death
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely involve family in patients' risk assessment, care planning and safety planning
Wider context from the report “1. Family are not routinely or regularly involved in a patients risk assessment,
care plan and safety planning.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate suicidal risk assessment
Wider context from the report “2. Inadequate suicidal risk assessment and suicide mitigation
” 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 Reinforce planned-leave policy compliance through staff review and acknowledgement, a leave record, and auditing of completed records.
Verbatim wording from the response “All wards have been supported to further review the Trust planned leave policy within team meetings and individual supervision. In addition, all staff were asked to read the policy again and sign to say that this has been read and understood. To ensure this is being routinely followed a door board/Leave record has been put in place which has detail of each planned leave. Every time a patient leaves the ward on planned leave the following is entered: date and time of planned leave, actual time left/returned to the ward, member of staff facilitating leave, what the patient was wearing, presentation of patient prior and post leave and destination of leave. This door board/leave record is audited to ensure it is being completed fully.” Source location Response from Nottinghamshire Healthcare 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 Provide each patient with a named nurse who agrees at least weekly family or carer contact and audits involvement in care planning and risk assessment.
Verbatim wording from the response “The wards within MHSOP have reviewed their processes for involving family members in care and treatment and the following is now routinely in place on all wards:” Source location Response from Nottinghamshire Healthcare 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 Update clinical risk guidance, safety-planning documentation, audits and healthcare-record forms in line with current evidence and guidelines.
Verbatim wording from the response “Trust guidance relating to risk assessment, formulation and safety planning has been reviewed in line with NICE guidelines and the latest updates from NHSE and suicide prevention evidence and literature. The Trust Lead for Self-harm and Suicide Prevention is leading this work and has met with NHSE and other leaders in suicide prevention to scope how other Trust’s have implemented this to inform Nottinghamshire Healthcare’s continued work. Updated guidance is reflected in the Trust’s new Clinical Risk and Safety Policy (due to be ratified in May 2024) and guidance documents relating to psychosocial assessment, formulation, and safety planning in relation to suicidality, including self-harm have been developed. Audits, and risk and safety forms within healthcare records are being reviewed and updated to ensure that these support improvement.” Source location Response from Nottinghamshire Healthcare 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 Roll out the SAFETool across all MHSOP wards with staff training on its use.
Verbatim wording from the response “One of the risk assessment frameworks utilised across the MHSOP care unit, and currently being introduced to the wider Mental Health Care Group, is the Suicide Assessment Framework E-Tool (SAFETool) – this is a suite of peer reviewed clinical tools to improve quality, consistency and documentation of assessment and response to suicidal patients.” Source location Response from Nottinghamshire Healthcare 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 Share approved investigation reports with relevant teams and witnesses and support incident-specific learning reflections.
Verbatim wording from the response “To ensure that Serious Incident Investigators understand the requirement for staff interviews as part of the investigation each investigator is emailed when the investigation is allocated to ensure they are informed of this requirement, this is included in a standard email template to ensure consistent communication. The MHSOP Clinical Governance team maintain contact and act as a point of reference for the investigation panel and will oversee this as a consistent practice. Upon completion and approval of the Serious Incident investigation the final report is shared with the relevant service and team/ward manager so that they can discuss in detail with their team. The support in sharing lessons learnt is tailored dependent on the incident and could include reflective discussions to team time out sessions to ensure the correct level of learning is undertaken. The MHSOP Clinical” Source location Response from Nottinghamshire Healthcare 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 Invite families and carers to ward multidisciplinary meetings using a standard template and audit invitations and involvement.
Verbatim wording from the response “• In addition to this, weekly/fortnightly multi-disciplinary meetings (MDT) take place on each ward and families and carers are routinely invited which is audited on a weekly basis. There is a universal MDT template (Appendix 3) which is used for documenting the meetings and it specifically asks if family members were invited and details their involvement in care and treatment.” Source location Response from Nottinghamshire Healthcare 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 Conduct serious-incident discussions and thematic reviews through MHSOP safety, risk, quality-assurance and improvement forums.
Verbatim wording from the response “Detailed discussion of serious incidents within the care unit is held in the MHSOP Health, Safety and Risk meeting and thematic review of serious incidents is completed via the MHSOP Quality Assurance and Improvement forum. These forums facilitate discussion and review across services and are Chaired by the Care Unit senior management team. The MHSOP care unit has a Learning the lessons bulletin which is shared across all services and teams to disseminate learning from serious incidents – this bulletin is featured on the agenda for the MHSOP Quality Operational Group and is disseminated across all service and team meetings to encourage active reporting and learning from incidents.” Source location Response from Nottinghamshire Healthcare 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 Embed SAFETool paperwork in the RIO electronic patient record and require staff to complete forms there.
Verbatim wording from the response “The use of the tool within MHSOP wards and learning from this has been identified and as a result the following changes are taking place:” Source location Response from Nottinghamshire Healthcare 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 Incorporate SAFETool learning and reflection into staff supervision and monitor training and supervision compliance.
Verbatim wording from the response “• Use of the SAFETool is not indicated for all patients admitted to the ward and where it is utilised the learning and reflection on the use of the tool will be incorporated into supervision for the member of staff to ensure the training is embedding into practice. Clinical and managerial supervision takes place monthly for staff members and provides support to staff from a named senior/experienced clinician to promote reflection, learning and development within clinical practice. Kingsley Ward supervision compliance is consistently within Trust targets and all staff have yearly mandated training from the Trust in clinical supervision to ensure this is being carried out effectively. Staff on Kingsley Ward are all currently up to date on their mandated clinical supervision training.” Source location Response from Nottinghamshire Healthcare 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 Disseminate learning from serious incidents through the MHSOP Learning the Lessons bulletin and service and team meetings.
Verbatim wording from the response “Detailed discussion of serious incidents within the care unit is held in the MHSOP Health, Safety and Risk meeting and thematic review of serious incidents is completed via the MHSOP Quality Assurance and Improvement forum. These forums facilitate discussion and review across services and are Chaired by the Care Unit senior management team. The MHSOP care unit has a Learning the lessons bulletin which is shared across all services and teams to disseminate learning from serious incidents – this bulletin is featured on the agenda for the MHSOP Quality Operational Group and is disseminated across all service and team meetings to encourage active reporting and learning from incidents.” Source location Response from Nottinghamshire Healthcare 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 Require investigators to address staff interviews through standard allocation emails and clinical-governance oversight.
Verbatim wording from the response “To ensure that Serious Incident Investigators understand the requirement for staff interviews as part of the investigation each investigator is emailed when the investigation is allocated to ensure they are informed of this requirement, this is included in a standard email template to ensure consistent communication. The MHSOP Clinical Governance team maintain contact and act as a point of reference for the investigation panel and will oversee this as a consistent practice. Upon completion and approval of the Serious Incident investigation the final report is shared with the relevant service and team/ward manager so that they can discuss in detail with their team. The support in sharing lessons learnt is tailored dependent on the incident and could include reflective discussions to team time out sessions to ensure the correct level of learning is undertaken. The MHSOP Clinical” Source location Response from Nottinghamshire Healthcare 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 Introduce collaborative care-planning conversations with every newly admitted patient and their relative or carer.
Verbatim wording from the response “• Kingsley Ward during March 2024 ran a patient and carer survey to ask about involvement in care planning and risk assessment and which they plan to continue to monitor effectiveness of changes made and identify further improvements required. This initial survey has informed the introduction of a collaborative care planning conversation with every newly admitted patient and their relative/carer to all MHSOP ward. This includes a structured conversation to co-produce the care plans for each patient as they are admitted to the in-patient ward.” Source location Response from Nottinghamshire Healthcare 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 Ratify the updated Clinical Risk and Safety Policy.
Verbatim wording from the response “Trust guidance relating to risk assessment, formulation and safety planning has been reviewed in line with NICE guidelines and the latest updates from NHSE and suicide prevention evidence and literature. The Trust Lead for Self-harm and Suicide Prevention is leading this work and has met with NHSE and other leaders in suicide prevention to scope how other Trust’s have implemented this to inform Nottinghamshire Healthcare’s continued work. Updated guidance is reflected in the Trust’s new Clinical Risk and Safety Policy (due to be ratified in May 2024) and guidance documents relating to psychosocial assessment, formulation, and safety planning in relation to suicidality, including self-harm have been developed. Audits, and risk and safety forms within healthcare records are being reviewed and updated to ensure that these support improvement.” Source location Response from Nottinghamshire Healthcare 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 Review IR1 incidents through assigned IR2 managers, monthly completion reports, and supervision-based learning.
Verbatim wording from the response “MHSOP have regular Time Out sessions with teams and in the session on the 22nd of March 2024 had a dedicated agenda item which covered learning and reflections from this quality improvement plan which included the learning about IR1s. Senior managers do regularly receive IR1s from all teams within MHSOP including ward and community teams. Following completion of an IR1 a manager is identified to complete an IR2 which reviews the incident and any learning that is identified from it. Senior managers receive monthly reports which indicate if the IR2s have been completed and ensure none have been missed and addition learning from incidents is included within management and clinical supervision which occurs monthly for each member of staff.” Source location Response from Nottinghamshire Healthcare 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 Enhance and evaluate suicide-prevention and self-harm training with updated awareness and response content and consistent delivery.
Verbatim wording from the response “• Suicide prevention and self-harm training is provided, overseen and evaluated by the Trust Lead for Self-harm and Suicide Prevention and the suicide prevention training team to ensure quality and consistency of training. The Suicide Prevention team also work with clinical teams to support implementation. This was reviewed and enhanced in early 2024, to provide assurance re quality and oversight, and include updated self-harm awareness and response training in addition to suicide prevention awareness and response training for consistent language, content and approach.” Source location Response from Nottinghamshire Healthcare 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 Complete the PSIRF policy and local patient-safety incident response plan following stakeholder consultation.
Verbatim wording from the response “To date the trust has completed the PSIRF policy and PSIRP (patient safety incident response plan), which sets out the local priorities for the next year. As part of the development of the PSIRP the trust met and consulted with a number of stakeholders; commissioners, service users, clinical staff and services and continue to do so.” Source location Response from Nottinghamshire Healthcare 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 Strengthen SAFETool training with family and carer involvement content and reflective case studies.
Verbatim wording from the response “• The training will be facilitated by one of the Trusts Clinical Educators for Suicide Prevention who also has an extensive clinical background within MHSOP. The training already incorporates family/carer involvement within risk assessment and care planning, but this has been further strengthened and includes case studies to enable staff to undertake reflection and learning during the training session.” Source location Response from Nottinghamshire Healthcare 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 Implement PSIRF across the Trust by August 2024.
Verbatim wording from the response “The Trust is in the process of moving towards the Patient Safety Incident Response Framework. (PSIRF) It represents a significant shift in the way the NHS responds to patient safety incidents and is a major step towards establishing a safety management system across the NHS and is also a key part of the NHS patient safety strategy. This new framework replaces the SI Framework and makes no distinction between ‘patient safety incidents’ and ‘Serious Incidents’ and so it removes the SI classification and the threshold for it.” Source location Response from Nottinghamshire Healthcare 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 Implement a standardised ward and community meeting governance template incorporating incident data and learning discussions across MHSOP wards.
Verbatim wording from the response “The Mental Health Care Group, of which MHSOP is part of, is introducing a new governance structure which includes a standardised template for ward and community meetings and within this data on incidents will be included and discussions take place within the team to reflect on the incidents to ascertain whether there is any learning and improvement required. This is currently being piloted within the Care Group and is due to go live across all MHSOP wards during June 2024.” Source location Response from Nottinghamshire Healthcare 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 SAFETool use is not clinically indicated for every patient admitted to the ward.
Verbatim wording from the response “• Use of the SAFETool is not indicated for all patients admitted to the ward and where it is utilised the learning and reflection on the use of the tool will be incorporated into supervision for the member of staff to ensure the training is embedding into practice. Clinical and managerial supervision takes place monthly for staff members and provides support to staff from a named senior/experienced clinician to promote reflection, learning and development within clinical practice. Kingsley Ward supervision compliance is consistently within Trust targets and all staff have yearly mandated training from the Trust in clinical supervision to ensure this is being carried out effectively. Staff on Kingsley Ward are all currently up to date on their mandated clinical supervision training.” Source location Response from Nottinghamshire Healthcare NHS Foundation Trust
Open published response
5 Jan 2024 Tammy Mary Louise WATKINS · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 12 Failure to recognise deteriorating patients View source Lack of policy specifying where foreign-body ingestion risk assessments are stored View source Lack of policy for managing suspected foreign-body ingestion medically View source Unclear requirements for action according to the early warning score View source Unclear responsibility for calling a medical emergency View source Lack of policy for assessing ingestion risk when access to risk items is permitted View source Unclear procedure for relaying emergency information to the ambulance service View source Lack of policy specifying responsibility for reviewing foreign-body ingestion risk assessment content View source Unclear requirements for the frequency of vital-sign observations View source Delays in escalating deteriorating patients for acute secondary care intervention View source Lack of policy for security measures to locate ingested foreign bodies View source Unclear requirements for recording vital-sign values 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
Tammy Mary Louise WATKINS · 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
Tammy Mary Louise Watkins died on 6 June 2021 after swallowing a plastic twistable crayon that perforated her bowel while she was detained at Rampton Hospital. The principal concerns were failures to risk-assess and manage foreign-body ingestion, recognise and escalate her deteriorating condition, follow NEWS2 requirements, and coordinate an emergency transfer to hospital. The report also identifies poor-quality acute physical healthcare and confusion about emergency medical calls.
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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise deteriorating patients
Wider context from the report “1. Poor Quality Acute Physical Healthcare in the mental health setting
Tammy’s death demonstrates a further example of a failure by medical staff to recognise a deteriorating patient and a subsequent delay in escalating for acute secondary care intervention.
Her death comes after repeated concerns have been raised about the quality of the Trust’s physical healthcare service in secure settings since 2018 (when Angus Bowie died from sepsis due to a perforation), in 2019 (when Christopher Howard Smith died from a pulmonary embolus), in 2020 (when Alexander Braund died from a chest infection) and in 2021 (when Michelle Louise Whitehead died from Hyponatraemic Encephalopathy).
At each of those inquests, the Trust committed to improving the quality of physical healthcare across all secure settings and yet the same poor quality has prevailed in Tammy’s care.
These are examples of preventable deaths and the similarity in themes across them is exceptionally worrying.
Action needs to be taken at the most senior level to effect meaningful change to the quality of physical healthcare across all secure settings at which the Trust provides services, recognising this class of patients as exceptionally vulnerable to deterioration as they are unable, either through mental health challenges and/or incarceration, to access healthcare services of their own volition.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of policy specifying where foreign-body ingestion risk assessments are stored
Wider context from the report “3. A lack of robust policy relating to Ingestion of Foreign Bodies
I heard evidence that the Trust is in the process of drafting a policy, but it became clear during evidence that the policy is not yet sufficiently robust.
The policy needs to cover the assessment of risk when access is permitted to risk items, where such a risk assessment is stored and who is responsible for its review of content, what to do when ingestion is suspected including how this should be managed medically and what security measures need to be taken to locate the item.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of policy for managing suspected foreign-body ingestion medically
Wider context from the report “3. A lack of robust policy relating to Ingestion of Foreign Bodies
I heard evidence that the Trust is in the process of drafting a policy, but it became clear during evidence that the policy is not yet sufficiently robust.
The policy needs to cover the assessment of risk when access is permitted to risk items, where such a risk assessment is stored and who is responsible for its review of content, what to do when ingestion is suspected including how this should be managed medically and what security measures need to be taken to locate the item.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear requirements for action according to the early warning score
Wider context from the report “2. Failure to Adhere to the National and Local National Early Warning Score (version 2) Policy
This is a repeated theme identified at inquest and in previous Prevention of Future Death reports. Staff remain unclear at the inquest about how frequently vital signs ought to be taken, where and how to record the values, and what action should be taken depending on the score .
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibility for calling a medical emergency
Wider context from the report “4. Emergency Medical Calls
There was significant confusion in this case as to who should call a medical emergency and how information should be relayed to the ambulance service. It had been recognised early in the day by the Security Team that Tammy may require an out of grounds medical transfer, but it was not until much later in the afternoon, when Tammy was in cardiac arrest, that an ambulance was called. The Security Team expected the physical healthcare team to place the call, the physical healthcare team expected the ward to place the call due to proximity to the patient .
Evidence called at the inquest established continued confusion amongst staff as to how an emergency should be managed.
This appears to be a training issue.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of policy for assessing ingestion risk when access to risk items is permitted
Wider context from the report “3. A lack of robust policy relating to Ingestion of Foreign Bodies
I heard evidence that the Trust is in the process of drafting a policy, but it became clear during evidence that the policy is not yet sufficiently robust.
The policy needs to cover the assessment of risk when access is permitted to risk items , where such a risk assessment is stored and who is responsible for its review of content, what to do when ingestion is suspected including how this should be managed medically and what security measures need to be taken to locate the item.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear procedure for relaying emergency information to the ambulance service
Wider context from the report “4. Emergency Medical Calls
There was significant confusion in this case as to who should call a medical emergency and how information should be relayed to the ambulance service . It had been recognised early in the day by the Security Team that Tammy may require an out of grounds medical transfer, but it was not until much later in the afternoon, when Tammy was in cardiac arrest, that an ambulance was called. The Security Team expected the physical healthcare team to place the call, the physical healthcare team expected the ward to place the call due to proximity to the patient.
Evidence called at the inquest established continued confusion amongst staff as to how an emergency should be managed.
This appears to be a training issue.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of policy specifying responsibility for reviewing foreign-body ingestion risk assessment content
Wider context from the report “3. A lack of robust policy relating to Ingestion of Foreign Bodies
I heard evidence that the Trust is in the process of drafting a policy, but it became clear during evidence that the policy is not yet sufficiently robust.
The policy needs to cover the assessment of risk when access is permitted to risk items, where such a risk assessment is stored and who is responsible for its review of content , what to do when ingestion is suspected including how this should be managed medically and what security measures need to be taken to locate the item.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear requirements for the frequency of vital-sign observations
Wider context from the report “2. Failure to Adhere to the National and Local National Early Warning Score (version 2) Policy
This is a repeated theme identified at inquest and in previous Prevention of Future Death reports. Staff remain unclear at the inquest about how frequently vital signs ought to be taken , where and how to record the values, and what action should be taken depending on the score.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in escalating deteriorating patients for acute secondary care intervention
Wider context from the report “1. Poor Quality Acute Physical Healthcare in the mental health setting
Tammy’s death demonstrates a further example of a failure by medical staff to recognise a deteriorating patient and a subsequent delay in escalating for acute secondary care intervention .
Her death comes after repeated concerns have been raised about the quality of the Trust’s physical healthcare service in secure settings since 2018 (when Angus Bowie died from sepsis due to a perforation), in 2019 (when Christopher Howard Smith died from a pulmonary embolus), in 2020 (when Alexander Braund died from a chest infection) and in 2021 (when Michelle Louise Whitehead died from Hyponatraemic Encephalopathy).
At each of those inquests, the Trust committed to improving the quality of physical healthcare across all secure settings and yet the same poor quality has prevailed in Tammy’s care.
These are examples of preventable deaths and the similarity in themes across them is exceptionally worrying.
Action needs to be taken at the most senior level to effect meaningful change to the quality of physical healthcare across all secure settings at which the Trust provides services, recognising this class of patients as exceptionally vulnerable to deterioration as they are unable, either through mental health challenges and/or incarceration, to access healthcare services of their own volition.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of policy for security measures to locate ingested foreign bodies
Wider context from the report “3. A lack of robust policy relating to Ingestion of Foreign Bodies
I heard evidence that the Trust is in the process of drafting a policy, but it became clear during evidence that the policy is not yet sufficiently robust.
The policy needs to cover the assessment of risk when access is permitted to risk items, where such a risk assessment is stored and who is responsible for its review of content, what to do when ingestion is suspected including how this should be managed medically and what security measures need to be taken to locate the item .
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear requirements for recording vital-sign values
Wider context from the report “2. Failure to Adhere to the National and Local National Early Warning Score (version 2) Policy
This is a repeated theme identified at inquest and in previous Prevention of Future Death reports. Staff remain unclear at the inquest about how frequently vital signs ought to be taken, where and how to record the values , and what action should be taken depending on the score.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update the foreign-body ingestion management procedure, including a bespoke care-plan framework for patients at clinical risk.
Verbatim wording from the response “3. A lack of robust policy relating to Ingestion of Foreign Bodies
The procedure for the management of patients who have ingested foreign bodies has been reviewed and updated following the death of Tammy. There is a focus to implement a bespoke care plan for patients who present a clinical risk of ingestion with a clear framework of how to act should this clinical incident occur. The revised policy with these additions are for ratification at the Trust Clinical Policies approval group 6 March 2024. This will then be widely disseminated to all areas whereby the risk of ingestion of foreign bodies is present.” Source location Response from Nottinghamshire Healthcare 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 Obtain ratification of the revised foreign-body ingestion policy and additions through the Trust Clinical Policies approval group.
Verbatim wording from the response “3. A lack of robust policy relating to Ingestion of Foreign Bodies
The procedure for the management of patients who have ingested foreign bodies has been reviewed and updated following the death of Tammy. There is a focus to implement a bespoke care plan for patients who present a clinical risk of ingestion with a clear framework of how to act should this clinical incident occur. The revised policy with these additions are for ratification at the Trust Clinical Policies approval group 6 March 2024. This will then be widely disseminated to all areas whereby the risk of ingestion of foreign bodies is present.” Source location Response from Nottinghamshire Healthcare 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 Undertake case reviews of subsequent similar presentations to assess whether learning from the death is embedded and sustained.
Verbatim wording from the response “To review current practice and to continue to address areas of concern, Rampton Hospital are undertaking case reviews of subsequent similar presentations to identify if the learning from Tammy’s death has been embedded and sustained. We will ensure that any learning or areas for continued training are identified within these case reviews are responded to and included within Hospital Life Support training/ any future enhanced training that is provided.” Source location Response from Nottinghamshire Healthcare 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 Introduce scenario-based NEWS2 examples during clinical supervision to assess staff competency around escalation.
Verbatim wording from the response “Having senior Quality Matrons deliver and provide clinical supervision further strengthens this approach and encourages a culture of continuous learning and improvement. Quality Matrons will use clinical supervision to introduce scenario-based examples of patients who require escalation to assess staff members competency around NEWS2.” Source location Response from Nottinghamshire Healthcare 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 Review and reinforce the emergency medical-call process, requiring staff to call an ambulance when immediate physical-health concerns arise.
Verbatim wording from the response “4. Emergency Medical Calls
The process for emergency medical calls within Rampton Hospital has been reviewed and the process has been reinforced back to all staff that where immediate concerns are present regarding the physical health of a patient, it is expected that they will call for an ambulance. This is reviewed in line with the increased senior leadership and local learning.” Source location Response from Nottinghamshire Healthcare 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 Provide clinical supervision through senior Quality Matrons to support NEWS2 practice and continuous learning.
Verbatim wording from the response “In addition to this, at a glance posters are within each of the inpatient wards alongside lanyard attachments to support easy to access guidance when undertaking a NEWS2 assessment. A full audit process around NEWS2 is now in place and is monitored and responded to within normal governance frameworks with current compliance at 98%. Rampton hospital have ensured that senior nursing staff have increased visibility and presence in patient facing areas, to provide’ in action’ learning, role modelling and opportunity to provide direct feedback to colleagues. Clinical supervision is also recognised as a key aid to supporting and developing practice by sharing feedback and providing one to one clinical input to improve practice and aid a culture of learning.” Source location Response from Nottinghamshire Healthcare 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 Provide NEWS2 at-a-glance ward posters and lanyard guidance attachments.
Verbatim wording from the response “In addition to this, at a glance posters are within each of the inpatient wards alongside lanyard attachments to support easy to access guidance when undertaking a NEWS2 assessment. A full audit process around NEWS2 is now in place and is monitored and responded to within normal governance frameworks with current compliance at 98%. Rampton hospital have ensured that senior nursing staff have increased visibility and presence in patient facing areas, to provide’ in action’ learning, role modelling and opportunity to provide direct feedback to colleagues. Clinical supervision is also recognised as a key aid to supporting and developing practice by sharing feedback and providing one to one clinical input to improve practice and aid a culture of learning.” Source location Response from Nottinghamshire Healthcare 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 Disseminate the ratified foreign-body ingestion policy to all areas where that risk is present.
Verbatim wording from the response “3. A lack of robust policy relating to Ingestion of Foreign Bodies
The procedure for the management of patients who have ingested foreign bodies has been reviewed and updated following the death of Tammy. There is a focus to implement a bespoke care plan for patients who present a clinical risk of ingestion with a clear framework of how to act should this clinical incident occur. The revised policy with these additions are for ratification at the Trust Clinical Policies approval group 6 March 2024. This will then be widely disseminated to all areas whereby the risk of ingestion of foreign bodies is present.” Source location Response from Nottinghamshire Healthcare 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 Scope physical healthcare models across inpatient services and roll the work out across all services.
Verbatim wording from the response “1. Poor Quality Acute Physical Healthcare in the Mental Health Setting
The Trust recognises that Physical Healthcare is a key quality priority to improve the care to patients and reduce the risk of harm. The Trust have recognised the need to fully review how and what physical healthcare is offered across all inpatient services and successfully recruited an Associated Director of Physical Healthcare last year. This is a strategic post and covers all three care groups. Their initial priority has been to scope all physical health models of care across inpatient services with the aim of understanding the unique needs of patients across our services. The next phase will look to address the associated training needs and structure of who provides what care across the inpatient services to mitigate future harm associated with the deteriorating patient.” Source location Response from Nottinghamshire Healthcare 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 Deliver NEWS2 training to all frontline clinical staff required to undertake the assessment.
Verbatim wording from the response “NEWS 2 training has been delivered to all frontline clinical staff who would be required to undertake this assessment and supports the policy requirements.” Source location Response from Nottinghamshire Healthcare 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 Undertake a further training needs analysis to identify enhancements to frontline knowledge and clinical skills.
Verbatim wording from the response “A further training needs analysis is currently being undertaken to understand if this can be enhanced to support and improve front line knowledge and clinical skills. HM Coroner will be updated as this moves forward.” Source location Response from Nottinghamshire Healthcare NHS Foundation Trust
Open published response
4 Oct 2023 Michelle Louise WHITEHEAD · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Lack of guidance on detection and management of psychogenic polydipsia View source Failure of Rapid Tranquilisation policy to specify vital-sign observations and recording for sleeping patients View source Failure to embed Rapid Tranquilisation monitoring requirements through staff learning and development View source Failure of Rapid Tranquilisation policy to specify action for suspected unconsciousness View source Rapid Tranquilisation policy departing from national guidance without supported clinical rationale View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 13
Action
Communicate revised Rapid Tranquilisation policy requirements Trustwide and cascade them through leadership, team meetings and supervision.
Stated plannedThe respondent said that this action was planned when they made their response on 18 October 2023. View source
Action
Support wards and services to embed Rapid Tranquilisation standards through case reviews and staff case-based learning.
Stated in progressThe respondent said that this action was in progress when they made their response on 18 October 2023. View source
Action
Amend the Rapid Tranquilisation policy to require NEWS2 monitoring, consciousness assessment, escalation and enhanced observation for sleeping or higher-risk patients.
Stated completedThe respondent said that this action was complete when they made their response on 18 October 2023. View source
Action
Undertake a full Rapid Tranquilisation training review informed by inquest learning, including competency assessment for healthcare support workers.
Stated plannedThe respondent said that this action was planned when they made their response on 18 October 2023. View source
Action
Use the junior doctor learning space to share Rapid Tranquilisation policy learning and changes.
Stated plannedThe respondent said that this action was planned when they made their response on 18 October 2023. View source
Action
Include psychogenic polydipsia and overhydration symptoms, risks and escalation in Trustwide physical healthcare training.
Stated completedThe respondent said that this action was complete when they made their response on 18 October 2023. View source
Action
Revise the Trustwide Nutrition and Hydration Policy to cover psychogenic polydipsia risks, signs, symptoms and escalation.
Stated in progressThe respondent said that this action was in progress when they made their response on 18 October 2023. View source
Action
Share psychogenic polydipsia learning with relevant staff groups through professional development, journal clubs, meetings and the Learning the Lessons bulletin.
Stated in progressThe respondent said that this action was in progress when they made their response on 18 October 2023. View source
Action
Review identified secure-setting polydipsia cases to assess management and inform learning and guideline development.
Stated plannedThe respondent said that this action was planned when they made their response on 18 October 2023. View source
Action
Strengthen Hospital Life Support training to distinguish sleep from reduced consciousness using the ACVPU scale.
Stated completedThe respondent said that this action was complete when they made their response on 18 October 2023. View source
Action
Amend Rapid Tranquilisation training to reflect revised monitoring requirements.
Stated plannedThe respondent said that this action was planned when they made their response on 18 October 2023. View source
Action
Use amended RiO NEWS2 and non-contact observation templates to alert staff to Rapid Tranquilisation observation-frequency requirements.
Stated completedThe respondent said that this action was complete when they made their response on 18 October 2023. View source
Action
Deliver bite-sized inpatient teaching on post-Rapid Tranquilisation observations, NEWS2 and escalation.
Stated in progressThe respondent said that this action was in progress when they made their response on 18 October 2023. View source See 10 more actions
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AI-generated summary
Michelle Louise WHITEHEAD · 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
Michelle Louise Whitehead died on 7 May 2021 while an inpatient, after acute hyponatraemia caused by psychogenic polydipsia. The report identified failures to follow the Rapid Tranquilisation policy, including inadequate monitoring of consciousness and delays in responding to her deterioration, and raised concerns about staff training, policy clarity, monitoring guidance, and the detection and management of psychogenic polydipsia.
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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on detection and management of psychogenic polydipsia
Wider context from the report “4. Psychogenic Polydipsia – there appears to be no guidance, either locally or nationally, on the management of this condition , despite the research literature demonstrating that 50% of reported cases of over-hydration appear to be linked to psychosis. The Mental Health Commission for Scotland issued a report on the final day of Michelle’s inquest, related to the death of another mental health patient, Mr D, making recommendations for all NHS bodies to ensure staff have information to detect and manage acute psychical health scenarios including polydipsia and water intoxication.
The Trust should take urgent action to ensure their staff are able to detect and manage this rare but potentially fatal condition.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Rapid Tranquilisation policy to specify vital-sign observations and recording for sleeping patients
Wider context from the report “2. The Trust’s Rapid Tranquilisation policy is not sufficiently clear on what action should be taken if a patient is considered to be unconscious during the period of monitoring, or is felt to be asleep.
The current iteration of the policy (revised after Michelle’s death) does not make it clear that any suspected unconsciousness should result in the immediate summoning of a doctor and alerting the ambulance service via 999.
Further, the revised policy does not make it clear which vital sign observations should be undertaken and recorded if a patient is thought to be asleep in the period post rapidly tranquilisation and until the patient is ambulatory . This is despite the policy listing reduced consciousness and respiratory depression as known risks of sedative use, which can lead to death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to embed Rapid Tranquilisation monitoring requirements through staff learning and development
Wider context from the report “1. The Trust’s Rapid Tranquilisation policy has not been sufficiently embedded through learning and development to ensure that all staff have a good working knowledge of the requirements for safely monitoring patients following the use of sedative medications
I heard evidence that ward staff had all received training on the policy as part of their initial induction, but all staff in this case had conscientiously failed to follow the policy , including senior ward leaders and medical staff, who informed the court that they were simply not aware of the necessary safeguards to monitor a patient’s consciousness level after administering tranquilisation medications, or how to do so when the patient was thought to be sleeping .
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Rapid Tranquilisation policy to specify action for suspected unconsciousness
Wider context from the report “2. The Trust’s Rapid Tranquilisation policy is not sufficiently clear on what action should be taken if a patient is considered to be unconscious during the period of monitoring , or is felt to be asleep.
The current iteration of the policy (revised after Michelle’s death) does not make it clear that any suspected unconsciousness should result in the immediate summoning of a doctor and alerting the ambulance service via 999 .
Further, the revised policy does not make it clear which vital sign observations should be undertaken and recorded if a patient is thought to be asleep in the period post rapidly tranquilisation and until the patient is ambulatory. This is despite the policy listing reduced consciousness and respiratory depression as known risks of sedative use, which can lead to death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Rapid Tranquilisation policy departing from national guidance without supported clinical rationale
Wider context from the report “3. The Trust’s current policy appears to depart from National guidance – NICE issued Rapid Tranquillisation Guidance in Notice NG10 in May 2015
The Trust advised me in the course of the inquest that their policy was in line with other local mental health Trusts. However, a review of NICE guidance and other Mental Health Trust policies, available via a brief internet search, demonstrates differences in the advised monitoring protocols . I have shared with the Trust both the NICE guideline and a copy of the publicly available policy issued by a London Trust in February 2022 for comparison.
” 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 Communicate revised Rapid Tranquilisation policy requirements Trustwide and cascade them through leadership, team meetings and supervision.
Verbatim wording from the response “Amendments to the policy as outlined further in this letter will be communicated Trust Wide in our Chief Executive briefing. Leaders will be tasked with cascading through team meetings, through supervision and overseeing the changes in practice. Associated monitoring tools are also in the process of being updated to understand compliance in practice.” Source location Response from Nottinghamshire Healthcare 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 Support wards and services to embed Rapid Tranquilisation standards through case reviews and staff case-based learning.
Verbatim wording from the response “To ensure training is embedded into practice, as an immediate action we have shared resource across our Forensics and Adult Mental Health care groups of the expertise of a Quality Improvement lead role who will be supporting the Trust is working with wards and services to embed the standards within the policy and ensuring that staff are familiar with this policy and expectations. This will include review of individual cases of RT post observation and staff case-based discussion learning. This is now in place and will remain under review with the learning and improvements monitored through Quality Oversight group.” Source location Response from Nottinghamshire Healthcare 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 Amend the Rapid Tranquilisation policy to require NEWS2 monitoring, consciousness assessment, escalation and enhanced observation for sleeping or higher-risk patients.
Verbatim wording from the response “Immediate actions
The Trust have responded to the concerns raised regarding the clarity within the Rapid Tranquilisation policy about the escalation requirements relating to known risks associated with the use of medication with Rapid Tranquilisation. The relevant section within the policy concerning escalation of a deteriorating patient has been amended to specifically respond to the risks of reduced consciousness, monitoring when a patient is asleep post rapid tranquilisation and the use of NEWS2 escalation.” Source location Response from Nottinghamshire Healthcare 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 Undertake a full Rapid Tranquilisation training review informed by inquest learning, including competency assessment for healthcare support workers.
Verbatim wording from the response “The policy changes that have since been made will be reflected within the training offer to ensure all staff are aware of the additional monitoring requirements. We recognise that staff did not understand the policy standards as necessary and whilst training will be amended to reflect the subsequent changes relating to monitoring, a full training review in line with the learning from the inquest will be undertaken in relation to Rapid Tranquilisation to ensure we have the correct approaches in place post induction. For example, a review of the e-learning package to Health Care Support workers to ensure competency assessment features as part of this process.” Source location Response from Nottinghamshire Healthcare 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 Use the junior doctor learning space to share Rapid Tranquilisation policy learning and changes.
Verbatim wording from the response “There is a learning space for Junior Doctors within the Organisation which will be utilised to share the learning related to the use of Rapid Tranquilisation, ensuring those are sighted on the policy and the related changes.” Source location Response from Nottinghamshire Healthcare 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 Include psychogenic polydipsia and overhydration symptoms, risks and escalation in Trustwide physical healthcare training.
Verbatim wording from the response “Immediate actions
The Trust have included a teaching session within the ‘Trustwide 2-day Physical healthcare Training’ for mental health staff on the symptoms, risk, and necessary escalation of overhydration including Psychogenic Polydipsia as a core training section.
The sharing of the learning from Michelle’s inquest has and will continue to be shared to raise awareness in relation to Psychogenic polydipsia within staff groups. This includes within the Trustwide Dietitians Professional Advisory Group, physical healthcare staff and medical teams though continued professional development sessions, journal clubs, and Trustwide Physical Healthcare meetings as well as inclusion within the Trustwide Learning the Lessons Safety Bulletin circulated to all staff.” Source location Response from Nottinghamshire Healthcare 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 Revise the Trustwide Nutrition and Hydration Policy to cover psychogenic polydipsia risks, signs, symptoms and escalation.
Verbatim wording from the response “Short term actions
The Trustwide Nutrition and Hydration Policy is currently under review – psychogenic polydipsia will be specifically referenced within the overhydration section, including risks, signs and symptoms and escalation – this review has commenced and planned to be finalised by the end of February 2024.” Source location Response from Nottinghamshire Healthcare 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 Share psychogenic polydipsia learning with relevant staff groups through professional development, journal clubs, meetings and the Learning the Lessons bulletin.
Verbatim wording from the response “Immediate actions
The Trust have included a teaching session within the ‘Trustwide 2-day Physical healthcare Training’ for mental health staff on the symptoms, risk, and necessary escalation of overhydration including Psychogenic Polydipsia as a core training section.
The sharing of the learning from Michelle’s inquest has and will continue to be shared to raise awareness in relation to Psychogenic polydipsia within staff groups. This includes within the Trustwide Dietitians Professional Advisory Group, physical healthcare staff and medical teams though continued professional development sessions, journal clubs, and Trustwide Physical Healthcare meetings as well as inclusion within the Trustwide Learning the Lessons Safety Bulletin circulated to all staff.” Source location Response from Nottinghamshire Healthcare 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 Review identified secure-setting polydipsia cases to assess management and inform learning and guideline development.
Verbatim wording from the response “Following the learning from the inquest, the Trust have identified a number of cases of polydipsia within our secure settings. A clinical case review of these patients will be undertaken to ensure the management of these patients is appropriate and support any learning and guideline development. The case reviews will be undertaken in December 2023, the learning from which will inform further actions necessary.” Source location Response from Nottinghamshire Healthcare 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 Strengthen Hospital Life Support training to distinguish sleep from reduced consciousness using the ACVPU scale.
Verbatim wording from the response “The above changes are to be reflected, with immediate effect, within the training offer provided for Rapid Tranquilisation as outlined in above section. In addition, Within the Trust Hospital Life Support training, the use of ACVPU scale for assessment of reduced consciousness is included, this has been strengthened to include the considerations and ability to differentiate a patient that is asleep versus a patient with reduced consciousness.” Source location Response from Nottinghamshire Healthcare 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 Amend Rapid Tranquilisation training to reflect revised monitoring requirements.
Verbatim wording from the response “The policy changes that have since been made will be reflected within the training offer to ensure all staff are aware of the additional monitoring requirements. We recognise that staff did not understand the policy standards as necessary and whilst training will be amended to reflect the subsequent changes relating to monitoring, a full training review in line with the learning from the inquest will be undertaken in relation to Rapid Tranquilisation to ensure we have the correct approaches in place post induction. For example, a review of the e-learning package to Health Care Support workers to ensure competency assessment features as part of this process.” Source location Response from Nottinghamshire Healthcare 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 Use amended RiO NEWS2 and non-contact observation templates to alert staff to Rapid Tranquilisation observation-frequency requirements.
Verbatim wording from the response “The NEWS2 and Non-Contact Observations templates on RiO have been amended to create an alert for ward staff when these observations are carried out due to Rapid Tranquilisation there is a mandatory requirement to change the frequency of observations as per the policy. This change will support the changes in practice and act as a reminder to clinicians as to the monitoring requirements.” Source location Response from Nottinghamshire Healthcare 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 Deliver bite-sized inpatient teaching on post-Rapid Tranquilisation observations, NEWS2 and escalation.
Verbatim wording from the response “The above resource will additionally be delivering bite-size teaching across the In-Patient units with a focus on post Rapid Tranquilisation Observations including NEWS2 and escalation.” Source location Response from Nottinghamshire Healthcare NHS Foundation Trust
Open published response
4 Aug 2023 Gerard Murray · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Extremely limited family and carer involvement in care planning and ward rounds View source Limited staff awareness of the ligature risk reduction pathway View source Inadequate door board system for monitoring patient returns after unescorted leave View source Limited risk assessment and risk management planning View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 15
Action
Procure Storm Skills Training for inpatient services and prepare for its planned rollout.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023. View source
Action
Procure and pilot an electronic leave-alarm system, then consider wider rollout based on pilot feedback.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023. View source
Action
Assign ward staff to verify leave parameters, record departures and expected returns, and manage associated safety and property checks.
Stated completedThe respondent said that this action was complete when they made their response on 30 October 2023. View source
Action
Review service-wide risk assessment and care planning processes for therapeutic leave, including the boundaries between ground and community leave.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023. View source
Action
Deliver updated suicide awareness and response training incorporating NICE guidance and embed the SAFE Tool in clinical systems for documentation and audit.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023. View source
Action
Require multidisciplinary teams to decide ward leave during weekly ward rounds or daily board reviews and document the associated risk assessment and clinical rationale.
Stated completedThe respondent said that this action was complete when they made their response on 30 October 2023. View source
Action
Deliver bespoke family-intervention training to the Beech Ward multidisciplinary team.
Stated plannedThe respondent said that this action was planned when they made their response on 30 October 2023. View source
Action
Conduct daily senior-nurse spot checks of door board compliance, staff understanding, and escalation of late returns.
Stated completedThe respondent said that this action was complete when they made their response on 30 October 2023. View source
Action
Strengthen adherence to the door board process across Beech Ward and the wider site.
Stated completedThe respondent said that this action was complete when they made their response on 30 October 2023. View source
Action
Introduce admission-based Carer Contact Plans recording patients’ preferences for family and carer involvement and information sharing.
Stated plannedThe respondent said that this action was planned when they made their response on 30 October 2023. View source
Action
Add leave-related risk assessment and clinical rationale requirements to the Adult Mental Health Operational Policy.
Stated plannedThe respondent said that this action was planned when they made their response on 30 October 2023. View source
Action
Develop and consult on a Trust-wide collaborative risk assessment and care planning policy with implementation and compliance-monitoring requirements.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023. View source
Action
Complete Triangle of Care self-assessments across Adult Mental Health inpatient areas and review findings to agree improvement actions.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023. View source
Action
Recruit and deploy a Carer Peer Support Worker for acute wards to strengthen liaison with patients, families, carers, and multidisciplinary teams.
Stated completedThe respondent said that this action was complete when they made their response on 30 October 2023. View source
Action
Complete suicide awareness and response training for qualified nurses and multidisciplinary team members at Sherwood Oaks.
Stated completedThe respondent said that this action was complete when they made their response on 30 October 2023. View source See 12 more actions
×
AI-generated summary
Gerard Murray · 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
Gerard Murray died on 16 July 2022 after leaving the mental health ward at Bassetlaw Hospital on unescorted leave and being found deceased later that day. The report identifies concerns about limited risk assessment and management, inadequate monitoring of patients returning from leave, limited family and carer involvement, and staff awareness of the ligature risk reduction pathway.
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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Extremely limited family and carer involvement in care planning and ward rounds
Wider context from the report “3. There was extremely limited family and carer involvement in Gerard’s care ,
with no involvement in the care plan, nor involvement in ward rounds on
ward B2 now Beech 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited staff awareness of the ligature risk reduction pathway
Wider context from the report “4. There was limited awareness of the ligature risk reduction pathway by staff
on B2 now Beech 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate door board system for monitoring patient returns after unescorted leave
Wider context from the report “2. There was an inadequate door board system for monitoring the return of
patients after unescorted leave on ward B2. The same arrangements
remain currently, despite the ward move to Beech ward on new premises
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited risk assessment and risk management planning
Wider context from the report “1. There was a limited risk assessment and risk management plan
documented for Gerard on ward B2 now Beech ward
” 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 Procure Storm Skills Training for inpatient services and prepare for its planned rollout.
Verbatim wording from the response “The Trust has also identified Storm Skills Training as being applicable for our inpatient services, and we are in the process of procuring this training package, with an anticipated roll out through Quarter 4 of 2023/24. The Storm Skills Training is an evidenced skills-based training programme with a focus on suicide prevention and self-harm reduction. These training courses complement each other to support staff to make informed decisions regarding an individual risk of suicide or self-harm including, but not exclusively regarding the risk of ligatures. This will then inform the overall risk formulation and allow our clinicians to make individualised decisions regarding access to items that could be used to ligate.” Source location Response from Nottingham Heathcare
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 Procure and pilot an electronic leave-alarm system, then consider wider rollout based on pilot feedback.
Verbatim wording from the response “The staff member maintains a running log of when patients leave the ward, and are due back, their clothing, and a brief description to aid searching if a patient chooses not to return. Given the frequent use of leave from patients across the site, the Care Group has sought ways to enhance this monitoring. As such, an electronic device is being procured which will allow multiple alarms to be set for each person’s leave, ensuring an audible alarm will sound when a patient is due back on the ward. This will be trialled and rolled out based on the feedback of this pilot. We will share with you the output of this in due course.” Source location Response from Nottingham Heathcare
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 Assign ward staff to verify leave parameters, record departures and expected returns, and manage associated safety and property checks.
Verbatim wording from the response “Each ward has a dedicated member of staff responsible for assessing individual mental state, checking leave parameters, and reiterating these to the patient prior to leave, confirming legality and permission issues with the nurse in charge, and managing those possessions a patient may take on or return with from leave, IE Cigarette Lighters and items bought at the local shops etc.” Source location Response from Nottingham Heathcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review service-wide risk assessment and care planning processes for therapeutic leave, including the boundaries between ground and community leave.
Verbatim wording from the response “In addition to the changes made at Sherwood Oaks, there is currently a service wide review of the risk assessment and care planning processes linked to agreeing therapeutic leave, which will include the definitions of where leave in the grounds and leave in the community begin. This is being progressed via the AMH inpatient Rapid Improvement Group which is chaired by the Executive Director of Nursing and AHPs.” Source location Response from Nottingham Heathcare
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 updated suicide awareness and response training incorporating NICE guidance and embed the SAFE Tool in clinical systems for documentation and audit.
Verbatim wording from the response “As an organisation we have been delivering updated suicide awareness and suicide response training using content developed by 4 Mental Health, since Dec 2022. This training includes updated NICE guidelines in relation to assessment, risk mitigation and safety planning for suicidality and provides a Suicide Assessment Framework E-Tool (SAFE Tool) which has been embedded in RIO and SystmOne for documentation and audit.” Source location Response from Nottingham Heathcare
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 Require multidisciplinary teams to decide ward leave during weekly ward rounds or daily board reviews and document the associated risk assessment and clinical rationale.
Verbatim wording from the response “This has been discussed with the Multi-Disciplinary Team (MDT) across the unit and agreed that all leave from the ward areas, will only to be decided upon during weekly ward rounds, or the daily board review where the full MDT is present. To support this the ward round template has been updated to include the documentation of risk assessment analysis and clinical rationale linked to leave decisions. This will be monitored through the oversight quality checks completed by the Practice Development Leads and locally by the Ward Manager. It will also be added to the Adult Mental Health Operational Policy.” Source location Response from Nottingham Heathcare
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 bespoke family-intervention training to the Beech Ward multidisciplinary team.
Verbatim wording from the response “Finally, the family intervention team have devised a bespoke one-day training package which all of the Beech ward team including the MDT are booked on to attend. A copy of the training program is included below, and is scheduled to start in January 2023, with roll out through to June 2024.” Source location Response from Nottingham Heathcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct daily senior-nurse spot checks of door board compliance, staff understanding, and escalation of late returns.
Verbatim wording from the response “To ensure there is consistent compliance with the door board system, a checking process has been incorporated in the Senior Nurse’s daily observation spot checks. This includes a band 6 nurse or above observing staff completing their observations rounds, and quality checking their understanding and performance within the role. The spot checks also test individual understanding of the door board process, their knowledge of who is on and off the ward, and discussions to ensure they understand clearly how to escalate concerns if a patient hasn’t returned.” Source location Response from Nottingham Heathcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen adherence to the door board process across Beech Ward and the wider site.
Verbatim wording from the response “Historically the system of monitoring who leaves and returns to the wards, (locally known as the Door Board) was poorly adhered to in some areas. Significant work has been completed with the team on Beech (and across the site) to strengthen their adherence to the process which has seen a significant improvement in practice.” Source location Response from Nottingham Heathcare
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 Introduce admission-based Carer Contact Plans recording patients’ preferences for family and carer involvement and information sharing.
Verbatim wording from the response “To enhance the work of the Carer Peer Support Worker, it is planned that all patients will on admission complete a carer contact plan. This will include who the patient would like to be involved in their care and care discussions, and what level of information should be shared. The Carer Contact Plan is in the final stage of agreement and should be used through the in-patient wards by the end of December 2023. The use of the Carer Contact Plan will be reviewed in Quarter 4 of 2023/34.” Source location Response from Nottingham Heathcare
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 Add leave-related risk assessment and clinical rationale requirements to the Adult Mental Health Operational Policy.
Verbatim wording from the response “This has been discussed with the Multi-Disciplinary Team (MDT) across the unit and agreed that all leave from the ward areas, will only to be decided upon during weekly ward rounds, or the daily board review where the full MDT is present. To support this the ward round template has been updated to include the documentation of risk assessment analysis and clinical rationale linked to leave decisions. This will be monitored through the oversight quality checks completed by the Practice Development Leads and locally by the Ward Manager. It will also be added to the Adult Mental Health Operational Policy.” Source location Response from Nottingham Heathcare
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 consult on a Trust-wide collaborative risk assessment and care planning policy with implementation and compliance-monitoring requirements.
Verbatim wording from the response “At a Trust level, we recognise that having one Policy that identifies the principles of risk assessments and collaborative and coproduced care planning for children, young people and adults is beneficial, and how it reduces confusion for the clinical teams. As a result, a Policy has been drafted and outlines the expectations for the clinical teams, while allowing flexibility to ensure that the correct risk assessment tools are used for each service. The Policy will also outline how the appropriate Risk Assessment tools are agreed, how the implementation will be managed and how the Trust will monitor the compliance with the Policy.” Source location Response from Nottingham Heathcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete Triangle of Care self-assessments across Adult Mental Health inpatient areas and review findings to agree improvement actions.
Verbatim wording from the response “The involvement of patient’s family, friends and carers is vital when planning and delivering the patients care and treatment. We recognise that at times, we have got this wrong. To understand how to improve in this area, all Adult Mental Health inpatient areas have completed the Triangle of Care Self-Assessment.” Source location Response from Nottingham Heathcare
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 Recruit and deploy a Carer Peer Support Worker for acute wards to strengthen liaison with patients, families, carers, and multidisciplinary teams.
Verbatim wording from the response “To aid and support this partnership, all-acute wards have recruited a Carer Peer Support worker whose working week is dedicated to liaising with patients and their families/carers and ensuring the link with MDT members, and clinical discussions is strong. This person will also support the patients and their family/carers in Ward round discussions and ensure that follow up actions are completed and communicated effectively.” Source location Response from Nottingham Heathcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete suicide awareness and response training for qualified nurses and multidisciplinary team members at Sherwood Oaks.
Verbatim wording from the response “To ensure a consistent risk assessment skill level across the workforce, all the qualified nurses and MDT members at Sherwood Oaks have attended suicide awareness and response training, which includes a focus on risks associated with patient accessing leave. This is discussed further in section 4.” Source location Response from Nottingham Heathcare
Open published response
20 Jul 2023 Andrew Vizard · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Delays in ward doctor attendance for patients with concerns for their breathing View source Delays in calling an ambulance for patients with concerns for their breathing View source Emergency response systems failing to ensure an immediate and effective response to concerns about patient breathing View source Inadequate staff training for immediate and effective emergency response to concerns about patient breathing View source Delays in obtaining and utilising physical monitoring equipment for patients with concerns for their breathing View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Andrew Vizard · 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
Andrew Vizard, aged 58, died from a pulmonary embolism on 14 July 2022 after suffering cardiac arrests while detained in hospital under section 2 of the Mental Health Act 1983. The report identified delays in obtaining monitoring equipment, a ward doctor attending, and calling an ambulance when concerns arose about his breathing. It also raised concern that existing staff training and emergency-response systems may not ensure an immediate and effective response in similar life-threatening 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in ward doctor attendance for patients with concerns for their breathing
Wider context from the report “Despite there being concerns for an unresponsive patient’s breathing, it took:
a) At least 6 minutes to obtain and utilise physical monitoring equipment.
b) Nearly ten minutes for a ward doctor to attend the patient.
c) Over 10 minutes for an ambulance to be called.
Existing staff training and systems of emergency response do not appear to ensure an immediate and effective response in circumstances where there are concerns for a patient’s breathing.
Although the delays did not cause or contribute to death in this case, I am concerned that if there are similar delays in similar life-threatening situations in future, deaths will occur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in calling an ambulance for patients with concerns for their breathing
Wider context from the report “Despite there being concerns for an unresponsive patient’s breathing, it took:
a) At least 6 minutes to obtain and utilise physical monitoring equipment.
b) Nearly ten minutes for a ward doctor to attend the patient.
c) Over 10 minutes for an ambulance to be called.
Existing staff training and systems of emergency response do not appear to ensure an immediate and effective response in circumstances where there are concerns for a patient’s breathing.
Although the delays did not cause or contribute to death in this case, I am concerned that if there are similar delays in similar life-threatening situations in future, deaths will occur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Emergency response systems failing to ensure an immediate and effective response to concerns about patient breathing
Wider context from the report “Despite there being concerns for an unresponsive patient’s breathing, it took:
a) At least 6 minutes to obtain and utilise physical monitoring equipment.
b) Nearly ten minutes for a ward doctor to attend the patient.
c) Over 10 minutes for an ambulance to be called.
Existing staff training and systems of emergency response do not appear to ensure an immediate and effective response in circumstances where there are concerns for a patient’s breathing.
Although the delays did not cause or contribute to death in this case, I am concerned that if there are similar delays in similar life-threatening situations in future, deaths will occur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate staff training for immediate and effective emergency response to concerns about patient breathing
Wider context from the report “Despite there being concerns for an unresponsive patient’s breathing, it took:
a) At least 6 minutes to obtain and utilise physical monitoring equipment.
b) Nearly ten minutes for a ward doctor to attend the patient.
c) Over 10 minutes for an ambulance to be called.
Existing staff training and systems of emergency response do not appear to ensure an immediate and effective response in circumstances where there are concerns for a patient’s breathing.
Although the delays did not cause or contribute to death in this case, I am concerned that if there are similar delays in similar life-threatening situations in future, deaths will occur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining and utilising physical monitoring equipment for patients with concerns for their breathing
Wider context from the report “Despite there being concerns for an unresponsive patient’s breathing, it took:
a) At least 6 minutes to obtain and utilise physical monitoring equipment.
b) Nearly ten minutes for a ward doctor to attend the patient.
c) Over 10 minutes for an ambulance to be called.
Existing staff training and systems of emergency response do not appear to ensure an immediate and effective response in circumstances where there are concerns for a patient’s breathing.
Although the delays did not cause or contribute to death in this case, I am concerned that if there are similar delays in similar life-threatening situations in future, deaths will occur.
” Open source report
7 Jul 2023 Christopher Howard SMITH · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 8 Unsafe clinical observations through cell door hatches View source Failure to record and retain material relevant to inquests View source Failure to use NEWS2 monitoring for acutely unwell prisoners View source Failure of senior healthcare leadership oversight of care planning and deterioration View source Lack of robust GP clinical assessments for prisoners View source Delays in identifying and supplying material relevant to inquests View source Lack of candour and openness in post-death investigations View source Failure to analyse evidence and learn from deaths View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 13
Action
Introduce two independent investigators to support Offender Health and lead new serious-incident investigations.
Stated in progressThe respondent said that this action was in progress when they made their response on 6 November 2023. View source
Action
Make NEWS2 training available online and incorporate the NEWS2, sepsis and SBAR package into monthly induction for new starters.
Stated completedThe respondent said that this action was complete when they made their response on 6 November 2023. View source
Action
Amend the Sysmone Unit to make recording NEWS2 observations easier for staff.
Stated completedThe respondent said that this action was complete when they made their response on 6 November 2023. View source
Action
Provide dedicated Resus Lead support, onsite training, scenario coaching, code-call shadowing and feedback for deteriorating-patient care.
Stated in progressThe respondent said that this action was in progress when they made their response on 6 November 2023. View source
Action
Develop and operate a NEWS2 audit programme, compile recommendations and feed findings into governance and dissemination.
Stated plannedThe respondent said that this action was planned when they made their response on 6 November 2023. View source
Action
Hold weekly Inquest Oversight Meetings to identify required documents and staff earlier and escalate non-engagement.
Stated completedThe respondent said that this action was complete when they made their response on 6 November 2023. View source
Action
Improve the witness-statement template with guidance on training, policies, reflection and professional candour.
Stated completedThe respondent said that this action was complete when they made their response on 6 November 2023. View source
Action
Implement a core-information checklist and weekly senior oversight of post-incident information collation and storage.
Stated completedThe respondent said that this action was complete when they made their response on 6 November 2023. View source
Action
Deliver inquest training days and bespoke group training on coronial requirements, openness, reflection and staff obligations.
Stated completedThe respondent said that this action was complete when they made their response on 6 November 2023. View source
Action
Complete a formal review of Offender Health cases requiring coronial processes and undertake further review where identified.
Stated completedThe respondent said that this action was complete when they made their response on 6 November 2023. View source
Action
Review and strengthen the Offender Health candour process through Family Liaison Team support and training.
Stated completedThe respondent said that this action was complete when they made their response on 6 November 2023. View source
Action
Provide pre-inquest opportunities for staff to raise candour concerns and support addendum statements when later reflections arise.
Status unclearThe respondent did not make the status of this action clear when they made their response on 6 November 2023. View source
Action
Ratify and disseminate an escalation flow chart covering access problems and emergency response.
Stated completedThe respondent said that this action was complete when they made their response on 6 November 2023. View source See 10 more actions
×
AI-generated summary
Christopher Howard SMITH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher Howard Smith was a serving prisoner at HMP Lowdham Grange who died at Queen’s Medical Centre on 19 May 2019 from cardiac arrest due to a massive pulmonary embolism, predisposed by deep vein thrombosis. The report describes progressive deterioration, inadequate monitoring and clinical assessment, delayed escalation and ambulance transfer, and failures in communication and care. It also identifies concerns about unsafe clinical-care practices, inadequate record keeping and disclosure, and a lack of candour in post-death investigations.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unsafe clinical observations through cell door hatches
Wider context from the report “1. An inability to provide prisoners at HMP Lowdham Grange with safe clinical care
I heard evidence, and the jury reached findings, that there was an unsafe practice of staff conducting important healthcare and wellbeing observations via the cell door observation hatch . Observing an unwell prisoner through a hatch slightly larger than a letterbox undermines the safety of the clinical assessment .
Healthcare staff did not utilise the NEWS2 system of monitoring the condition of an acutely unwell prisoner, despite the Trust having adopted this recognised healthcare tool many years prior. The Forensic Directorate has continued to lag behind other areas of the Trust where NEWS2 is fully embedded and this has previously been identified as an issue linked to other deaths.
There was a lack of robust GP visits, despite such being mandated by the Prison Rules. When visits did take place, they were often via the cell door observation hatch and conducted as “fleeting glances” rather than robust clinical assessments. Again, this is unsafe.
There was a lack of effective leadership of the healthcare department to ensure that staff had created a safe plan of care for Christopher. Senior personnel were not aware of Christopher’s week-long deterioration in the segregation unit until very late in the chronology of events, nor were they aware of a dispute between the mental health and physical health teams as to the differential diagnoses that might be causing his concerning symptoms and deterioration. Despite daily lunch time meetings, there was a stark lack of professional curiosity from senior staff as to the plan of care for Christopher and what safety netting, if any, was in place.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record and retain material relevant to inquests
Wider context from the report “2. An inability to record, retain and supply HM Coroner with material relevant to the inquest
The progress of this inquest, taking places years after Christopher’s death, was halted many times due to the late disclosure of material relevant to the inquest. Policies and procedures said to exist at the time were produced mid-hearing.
Despite the Trust having conducted their own review of the case, being provided with ample notice of the inquest hearing, and having attended multiple pre-inquest review hearings, there was an inability to identify key material and to supply that to the court in good time.
The ability to reflect on the care provided in advance of a prisoner’s death is dependant on the Trust’s ability to isolate the relevant evidence, and to analyse it. Without the appropriate professional curiosity to understand exactly what happened, the Trust will repeatedly miss opportunities to learn from deaths and to take action to seek to prevent future deaths.
An example of this, is the issue of a lack of safe system for NEWS2 monitoring of acutely unwell patients. This issue has repeatedly been raised at inquests involving the Trust’s forensic division.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use NEWS2 monitoring for acutely unwell prisoners
Wider context from the report “1. An inability to provide prisoners at HMP Lowdham Grange with safe clinical care
I heard evidence, and the jury reached findings, that there was an unsafe practice of staff conducting important healthcare and wellbeing observations via the cell door observation hatch. Observing an unwell prisoner through a hatch slightly larger than a letterbox undermines the safety of the clinical assessment.
Healthcare staff did not utilise the NEWS2 system of monitoring the condition of an acutely unwell prisoner , despite the Trust having adopted this recognised healthcare tool many years prior. The Forensic Directorate has continued to lag behind other areas of the Trust where NEWS2 is fully embedded and this has previously been identified as an issue linked to other deaths.
There was a lack of robust GP visits, despite such being mandated by the Prison Rules. When visits did take place, they were often via the cell door observation hatch and conducted as “fleeting glances” rather than robust clinical assessments. Again, this is unsafe.
There was a lack of effective leadership of the healthcare department to ensure that staff had created a safe plan of care for Christopher. Senior personnel were not aware of Christopher’s week-long deterioration in the segregation unit until very late in the chronology of events, nor were they aware of a dispute between the mental health and physical health teams as to the differential diagnoses that might be causing his concerning symptoms and deterioration. Despite daily lunch time meetings, there was a stark lack of professional curiosity from senior staff as to the plan of care for Christopher and what safety netting, if any, was in place.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of senior healthcare leadership oversight of care planning and deterioration
Wider context from the report “1. An inability to provide prisoners at HMP Lowdham Grange with safe clinical care
I heard evidence, and the jury reached findings, that there was an unsafe practice of staff conducting important healthcare and wellbeing observations via the cell door observation hatch. Observing an unwell prisoner through a hatch slightly larger than a letterbox undermines the safety of the clinical assessment.
Healthcare staff did not utilise the NEWS2 system of monitoring the condition of an acutely unwell prisoner, despite the Trust having adopted this recognised healthcare tool many years prior. The Forensic Directorate has continued to lag behind other areas of the Trust where NEWS2 is fully embedded and this has previously been identified as an issue linked to other deaths.
There was a lack of robust GP visits, despite such being mandated by the Prison Rules. When visits did take place, they were often via the cell door observation hatch and conducted as “fleeting glances” rather than robust clinical assessments. Again, this is unsafe.
There was a lack of effective leadership of the healthcare department to ensure that staff had created a safe plan of care for Christopher. Senior personnel were not aware of Christopher’s week-long deterioration in the segregation unit until very late in the chronology of events, nor were they aware of a dispute between the mental health and physical health teams as to the differential diagnoses that might be causing his concerning symptoms and deterioration. Despite daily lunch time meetings, there was a stark lack of professional curiosity from senior staff as to the plan of care for Christopher and what safety netting, if any, was in place .
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of robust GP clinical assessments for prisoners
Wider context from the report “1. An inability to provide prisoners at HMP Lowdham Grange with safe clinical care
I heard evidence, and the jury reached findings, that there was an unsafe practice of staff conducting important healthcare and wellbeing observations via the cell door observation hatch. Observing an unwell prisoner through a hatch slightly larger than a letterbox undermines the safety of the clinical assessment.
Healthcare staff did not utilise the NEWS2 system of monitoring the condition of an acutely unwell prisoner, despite the Trust having adopted this recognised healthcare tool many years prior. The Forensic Directorate has continued to lag behind other areas of the Trust where NEWS2 is fully embedded and this has previously been identified as an issue linked to other deaths.
There was a lack of robust GP visits , despite such being mandated by the Prison Rules. When visits did take place, they were often via the cell door observation hatch and conducted as “fleeting glances” rather than robust clinical assessments . Again, this is unsafe.
There was a lack of effective leadership of the healthcare department to ensure that staff had created a safe plan of care for Christopher. Senior personnel were not aware of Christopher’s week-long deterioration in the segregation unit until very late in the chronology of events, nor were they aware of a dispute between the mental health and physical health teams as to the differential diagnoses that might be causing his concerning symptoms and deterioration. Despite daily lunch time meetings, there was a stark lack of professional curiosity from senior staff as to the plan of care for Christopher and what safety netting, if any, was in place.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in identifying and supplying material relevant to inquests
Wider context from the report “2. An inability to record, retain and supply HM Coroner with material relevant to the inquest
The progress of this inquest, taking places years after Christopher’s death, was halted many times due to the late disclosure of material relevant to the inquest . Policies and procedures said to exist at the time were produced mid-hearing.
Despite the Trust having conducted their own review of the case, being provided with ample notice of the inquest hearing, and having attended multiple pre-inquest review hearings, there was an inability to identify key material and to supply that to the court in good time .
The ability to reflect on the care provided in advance of a prisoner’s death is dependant on the Trust’s ability to isolate the relevant evidence, and to analyse it. Without the appropriate professional curiosity to understand exactly what happened, the Trust will repeatedly miss opportunities to learn from deaths and to take action to seek to prevent future deaths.
An example of this, is the issue of a lack of safe system for NEWS2 monitoring of acutely unwell patients. This issue has repeatedly been raised at inquests involving the Trust’s forensic division.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of candour and openness in post-death investigations
Wider context from the report “3. A complete lack of candour, openness and honesty when engaging in post death investigations.
Without exception, each witness from the healthcare trust accepted some level of failing in the care they provided to Christopher. Yet none of the witness statements submitted in advance of the inquest contained any such reflection of what went wrong or what should have happened . Despite a Direction from the court that the Head of Healthcare was to submit a statement “nailing colours to the mast” as to what the genuine issues of care were i.e. what policies were in place at the material time and whether care had departed from those policies, a candid statement satisfying this Direction was not forthcoming . This left the Coroner and the other Interested Persons, especially Christopher’s family, at a distinct disadvantage in identifying the actual issues, because of an overwhelming unwillingness to act in an open and honest manner , contrary to the expectations of a state agency when engaging in an inquest.
If staff are either unwilling, or are not given the opportunity, to reflect on what went wrong in an open and honest manner, then the Trust cannot seek to learn from events at the earliest opportunity, and these issues of concern will persist, leading to further 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to analyse evidence and learn from deaths
Wider context from the report “2. An inability to record, retain and supply HM Coroner with material relevant to the inquest
The progress of this inquest, taking places years after Christopher’s death, was halted many times due to the late disclosure of material relevant to the inquest. Policies and procedures said to exist at the time were produced mid-hearing.
Despite the Trust having conducted their own review of the case, being provided with ample notice of the inquest hearing, and having attended multiple pre-inquest review hearings, there was an inability to identify key material and to supply that to the court in good time.
The ability to reflect on the care provided in advance of a prisoner’s death is dependant on the Trust’s ability to isolate the relevant evidence, and to analyse it. Without the appropriate professional curiosity to understand exactly what happened, the Trust will repeatedly miss opportunities to learn from deaths and to take action to seek to prevent future deaths.
An example of this, is the issue of a lack of safe system for NEWS2 monitoring of acutely unwell patients. This issue has repeatedly been raised at inquests involving the Trust’s forensic division.
” 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 Introduce two independent investigators to support Offender Health and lead new serious-incident investigations.
Verbatim wording from the response “I can confirm that moving forward, I have bought in two independent investigators to support and work alongside Offender Health and they will also be allocated new Serious Incident Investigations with the aim of improving, supporting and providing leadership in this area of practice.” Source location Response from Nottinghamshire Healthcare 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 Make NEWS2 training available online and incorporate the NEWS2, sepsis and SBAR package into monthly induction for new starters.
Verbatim wording from the response “• Additionally, training has been made available online to provide ease of access for staff members.” Source location Response from Nottinghamshire Healthcare 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 Amend the Sysmone Unit to make recording NEWS2 observations easier for staff.
Verbatim wording from the response “• Amendments have been made to the Sysmone Unit to ensure it is easier for staff to capture and record observations relating to NEWS2.” Source location Response from Nottinghamshire Healthcare 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 Provide dedicated Resus Lead support, onsite training, scenario coaching, code-call shadowing and feedback for deteriorating-patient care.
Verbatim wording from the response “As a result of identifying a need to develop a training programme and approach that would ensure our staff have a greater understanding of NEWS 2 and the application of NEWS2 in a patient setting, a number of actions have been undertaken in order to address this:” Source location Response from Nottinghamshire Healthcare 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 Develop and operate a NEWS2 audit programme, compile recommendations and feed findings into governance and dissemination.
Verbatim wording from the response “• Development of an audit programme relating to NEWS2, latest audit undertaken in August 2023, report and recommendations being compiled which will feed into internal governance infrastructures and be disseminated.” Source location Response from Nottinghamshire Healthcare 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 Hold weekly Inquest Oversight Meetings to identify required documents and staff earlier and escalate non-engagement.
Verbatim wording from the response “The Medico Legal Team and senior managers now hold a weekly Inquest Oversight Meeting whereby the specific requirements of each case are reviewed and updated to ensure documents and staff members required are identified and located at an earlier stage of the process. Discussions are held in terms of any witness conflict concerns, noting the important learning that came from Mr Smith’s inquest in this regard. In addition, any staff members not engaging with the process are identified and this is escalated appropriately, with clear guidance that the Trust cannot represent staff members who do not engage with the Trust support in terms of statement provision and preparation for the inquest itself.” Source location Response from Nottinghamshire Healthcare 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 Improve the witness-statement template with guidance on training, policies, reflection and professional candour.
Verbatim wording from the response “The Trust’s Medico Legal Team have worked hard to review their processes in terms of preparing staff members for inquests, particularly those carried out in line with Article 2. As part of this review, the Trust witness statement template has been improved upon, with clear and specific guidance included in a number of areas, including relevant training and policies, reflections and duty of professional candour.” Source location Response from Nottinghamshire Healthcare 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 a core-information checklist and weekly senior oversight of post-incident information collation and storage.
Verbatim wording from the response “It is with deep regret that we were not able to supply you with the relevant materials to support the Coronial process. We recognise the impact this had on your investigation but also the distress to the family, which is not acceptable. We are committed to improving this process across the Trust to ensure you and your team are provided with all relevant information to support your enquiries, and that there is support for Clinical Teams post serious incident, including where a death has occurred.” Source location Response from Nottinghamshire Healthcare 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 Deliver inquest training days and bespoke group training on coronial requirements, openness, reflection and staff obligations.
Verbatim wording from the response “There have been four Inquest Training Days within the last 18 months, with another two planned, which have equipped attendees with the information required to fully understand and engage with the coronial process. In addition, the Medico Legal Team have been providing bespoke training” Source location Response from Nottinghamshire Healthcare 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 Complete a formal review of Offender Health cases requiring coronial processes and undertake further review where identified.
Verbatim wording from the response “You will be aware that we have undertaken a formal review of all Offender Health cases which are due to be heard as a Coronial process and this has identified a number of cases where further review is required. This review recognised that not all investigations unfortunately met the Trust’s high standards of quality, candour and reflection. The further information provided as part of these reviews aims to strengthen our evidence and understand more about the required learning.” Source location Response from Nottinghamshire Healthcare 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 Review and strengthen the Offender Health candour process through Family Liaison Team support and training.
Verbatim wording from the response “We recognise and regret that we did not undertake our duty of Candour with Mr Smith’s family on this occasion. We have reviewed the process of how we embed a meaningful culture of candour in the Offender Health Care Group. This includes access to support and training from the Family Liaison Team specifically in relation to Duty of Candour.” Source location Response from Nottinghamshire Healthcare 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 Provide pre-inquest opportunities for staff to raise candour concerns and support addendum statements when later reflections arise.
Verbatim wording from the response “During the pre-inquest preparation meetings with the Medico Legal Team, and where relevant any legal representative, provide a further opportunity for staff members to raise concerns as a group or individually in terms of their professional duty of candour, and addendum statements will be supported in any case whereby staff raise their concerns or reflections at a later date than their initial statements were made.” Source location Response from Nottinghamshire Healthcare 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 Ratify and disseminate an escalation flow chart covering access problems and emergency response.
Verbatim wording from the response “• Escalation flow chart has been developed to assist staff and provide scenarios / context of when this might apply and what to do if unable to access an unwell patient. This has been ratified and disseminated to staff.” Source location Response from Nottinghamshire Healthcare NHS Foundation Trust
Open published response
6 Jul 2023 Gordon Harry Renfrew · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Failure to maintain effective communication and working relationships between stroke and neurosurgical teams View source Lack of clear Stroke team understanding of NICE guidance on decompression craniectomy View source Limited opportunities for joint case discussion and learning between Stroke and Neurosurgical teams View source Failure to finalise the Standard Operating Procedure for decompression craniectomy monitoring and referral criteria 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
Gordon Harry Renfrew · 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 Harry Renfrew died at Queens Medical Centre on 14 June 2022 after a severe and extensive stroke caused by a large cerebral infarction. The report identified concerns about limited communication and working relationships between the stroke and neurosurgical teams, limited understanding of NICE guidance on decompression craniectomy, and insufficient opportunities for joint case discussion and learning. It stated that the NICE guidance was not followed and that discussions with the family about the timing of decompression craniectomy should have occurred earlier.
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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain effective communication and working relationships between stroke and neurosurgical teams
Wider context from the report “• There is limited evidence to date of improved communication, and a stronger working relationship, between the stroke team and the neurosurgical team at the Trust
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear Stroke team understanding of NICE guidance on decompression craniectomy
Wider context from the report “• There is limited evidence to date of the Stroke team having a clear understanding of the NICE guidance regarding Decompression Craniectomy, specifically the importance of detailed careful monitoring post stroke, with clarity about referral criteria to Neurosurgery . The planned Standard Operating Procedure, which may set out this clarity is not yet finalised.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited opportunities for joint case discussion and learning between Stroke and Neurosurgical teams
Wider context from the report “• There are currently limited opportunities for joint case discussion and learning between the Stroke and Neurosurgical teams . The Interventional Neuroradiologists could of course also usefully participate in such Educational opportunities - I note it was ████████, (Consultant in Interventional Neuroradiology) rather than the Stroke team, who asked that Gordon was reviewed by the Neurosurgical team on the early evening of the 7th June 2022
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to finalise the Standard Operating Procedure for decompression craniectomy monitoring and referral criteria
Wider context from the report “• There is limited evidence to date of the Stroke team having a clear understanding of the NICE guidance regarding Decompression Craniectomy, specifically the importance of detailed careful monitoring post stroke, with clarity about referral criteria to Neurosurgery. The planned Standard Operating Procedure, which may set out this clarity is not yet finalised .
” Open source report
5 Jun 2023 Jonathan “Jonny” Philip Cole [JC] · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 11 Lack of understanding of services available for Veterans View source Insufficiently robust Trust investigation and review process View source Failure to ensure soldiers receive appropriate mental health treatment and diagnosis View source Insufficient training and experience of Veterans UK Medical Advisors View source Insufficient DCMH clinician influence in vulnerability risk management for suicidal soldiers View source Failure to identify and address suicide risk for Veterans View source Lack of understanding by Trust mental health practitioners of appropriate referral services for Veterans View source Lack of understanding or effort in obtaining military DCMH medical records View source Failure to assist Veterans in accessing appropriate services View source Insufficient availability of psychiatrists and psychologists accessible to serving personnel View source Rejection of PTSD claims despite evidence from other medical professionals without consultant diagnosis View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 24
Action
Share learning from the preventing-future-deaths report through ongoing serious-incident investigation training.
Stated plannedThe respondent said that this action was planned when they made their response on 12 June 2023. View source
Action
Continue providing two-day systems-based serious-incident investigation training for investigators.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023. View source
Action
Disseminate the military-records procedure through Trust briefings, bulletins, Connect and care-group governance forums.
Stated plannedThe respondent said that this action was planned when they made their response on 12 June 2023. View source
Action
Support veterans who need self-referral by completing referrals collaboratively with them or on their behalf.
Stated completedThe respondent said that this action was complete when they made their response on 12 June 2023. View source
Action
Implement and publish a procedure for requesting and obtaining military DCMH medical records.
Stated completedThe respondent said that this action was complete when they made their response on 12 June 2023. View source
Action
Present veteran-service information to the Adult Mental Health Quality and Risk Group.
Stated plannedThe respondent said that this action was planned when they made their response on 12 June 2023. View source
Action
Use a panel sign-off process to review Mental Health Care Group serious-incident investigations.
Stated completedThe respondent said that this action was complete when they made their response on 12 June 2023. View source
Action
Disseminate the Veterans and Suicide Prevention Champions Network presentation Trustwide through communications and the intranet.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023. View source
Action
Disseminate veteran-service learning through Trust bulletins, governance communications and team meetings.
Stated completedThe respondent said that this action was complete when they made their response on 12 June 2023. View source
Action
Deliver six serious-incident quality-assurance training events for investigation report reviewers and approvers during 2023–2024.
Stated plannedThe respondent said that this action was planned when they made their response on 12 June 2023. View source
Action
Audit practice for supporting self-referral and making veteran referrals on patients’ behalf over three months.
Stated plannedThe respondent said that this action was planned when they made their response on 12 June 2023. View source
Action
Distribute veteran-service posters to all community team bases and conduct follow-up checks.
Stated plannedThe respondent said that this action was planned when they made their response on 12 June 2023. View source
Action
Conduct a proactive, objective review of active Trust inquests to identify lessons and improvement themes.
Stated plannedThe respondent said that this action was planned when they made their response on 12 June 2023. View source
Action
Reflect veteran suicide-prevention learning at the annual Trust suicide-prevention conference, with veteran-service information available.
Stated plannedThe respondent said that this action was planned when they made their response on 12 June 2023. View source
Action
Complete the three-year Suicide Strategy review with specific consideration of veteran suicide risk and implications for clinical practice.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023. View source
Action
Scope mandatory veteran-status recording, service hyperlinks and referral-support prompts in RiO.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023. View source
Action
Share the Veteran folder across Mental Health Services after suitability review.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023. View source
Action
Distribute veteran-service leaflets, posters and QR-linked intranet information to mental-health practitioners and Trust services.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023. View source
Action
Review and plan wider dissemination of veteran information, with emphasis on area-specific training.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023. View source
Action
Use developed neurodiversity guidance to support investigators in considering individual needs and reasonable adjustments.
Stated completedThe respondent said that this action was complete when they made their response on 12 June 2023. View source
Action
Include self-referral support and veteran referral requirements in the updated LMHT Standard Operating Procedure and distribute it to staff.
Stated plannedThe respondent said that this action was planned when they made their response on 12 June 2023. View source
Action
Maintain a Trustwide Lead for Suicide Prevention responsible for strategy, training, clinical practice and learning.
Stated completedThe respondent said that this action was complete when they made their response on 12 June 2023. View source
Action
Update essential suicide awareness and response training to reflect enhanced risk among veterans.
Stated plannedThe respondent said that this action was planned when they made their response on 12 June 2023. View source
Action
Display veteran-service posters at all inpatient sites.
Stated completedThe respondent said that this action was complete when they made their response on 12 June 2023. View source See 21 more actions
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AI-generated summary
Jonathan “Jonny” Philip Cole [JC] · 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
Jonny Cole was found hanging at Old Stone Bridge, Butterley Park, on 9 August 2018, after having acted with the intention to end his life. He had PTSD, anxiety and suicidal ideation and was under the care of his local mental health trust. The report raised concerns about inadequate identification and management of his suicide risk, gaps in trauma treatment and veteran services, shortcomings in Ministry of Defence mental-health provision and compensation processes, and the robustness of the Trust’s investigation.
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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of services available for Veterans
Wider context from the report “5. I have a concern that there is:
a) a lack of understanding as to the appropriate services to make referrals to for Veterans by Trust mental health practitioners;
b) a lack of understanding as to services available for Veterans ;
c) too much emphasis on Veterans being solely responsible for self-referral, with no assistance to assist in accessing appropriate services;
d) A lack of understanding (or effort) as to how to request and obtain military DCMH medical records.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust Trust investigation and review process
Wider context from the report “6. I have a concern as to the quality of the Trust’s Investigation Report and that the process of review is not sufficiently robust
I acknowledge that the Trust recognises that the investigation reports provided in respect of Jonny Cole’s death were unsatisfactory and also and that the review of Rapid Response Liaison Psychiatry involvement in 2022, “was a missed opportunity to retrospectively review the investigation in its entirety”. However, it is of concern that the 2022 review was also insufficient and inadequate .
The concerning information relating to the attempt Jonny made to ligate in a tree was not analysed. ████████ told me that an attempt on life by suicide increases the risk 100-fold that you would die by suicide in the next 12 months and is the most significant risk factor in Jonny’s history that massively elevated the risk until that period of time has lapsed which requires clinical risk assessment.
The Investigation report and the updated report following review failed to identify themes of concern ², and did not reassure me that the Trust had taken an appropriate response to investigate the concerning facts of this case and to ensure lessons were learned and not repeated for other patients and appropriate audit undertaken .
I am told that the Trust is, “committed to continuing our improvement journey in this area”, however, I remain concerned that the Trust’s investigation was insufficient, lacked robustness and did not fully engage with the duty of candour .
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure soldiers receive appropriate mental health treatment and diagnosis
Wider context from the report “1. I have a concern as to the number and availability of psychiatrists and psychologists within the Ministry of Defence and accessible to serving personnel. This concern extends to ensuring a soldier receives access to appropriate treatment including diagnosis .
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient training and experience of Veterans UK Medical Advisors
Wider context from the report “3. I have a concern about:
a. the training and experience of the Medical Advisors at Veterans UK providing advice under the Armed Forces Compensation Scheme .
b. rejection of claims for PTSD under the Armed Forces Compensation Scheme if there is not a formal diagnosis by a consultant psychiatrist or psychologist but evidence of PTSD within medical records from other medical professionals.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient DCMH clinician influence in vulnerability risk management for suicidal soldiers
Wider context from the report “2. I have a concern that the Vulnerability Risk Management Process [Suicide Vulnerability Risk Management as was] is Unit led and that DCMH clinicians do not have a greater role in influencing the Army’s vulnerability risk management (VRM) process for suicidal soldiers .
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and address suicide risk for Veterans
Wider context from the report “4. I have a concern that the Trust is doing too little to identify and address the risk of suicide for Veterans .
A 2021 Nottinghamshire Suicide Prevention Action Plan to which the Trust was a partner identified for Veterans the need to, “undertake evidence review on the needs of veterans in relation to mental health and suicide, to inform future developments. Promote and raise awareness of the Op Courage MH Pathway and Armed Forces Health eLearning (commissioned by NHSE/Improvement Armed Forces Health). Ensure an ongoing dialogue with NHSE/Improvement around provision of mental health, suicide prevention and postvention. bereavement support to veterans and engage in any NHSE Midlands masterclass with Integrated Care Boards (ICBs) - date to be agreed. Identify veterans within the local Suicide Cluster Response Plan Guidance in the first annual refresh Review learning from the NHSE/Improvement review/investigation of Serious Incidents.”
Despite this, the Trust’s Suicide Prevention Strategy and Suicide Prevention Annual Plan 2020-2023 provided to me and due to be reviewed this year does not specifically touch upon Veterans. I am told that there is a commitment to ensure this is a key feature of the review already commencing within the organisation.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding by Trust mental health practitioners of appropriate referral services for Veterans
Wider context from the report “5. I have a concern that there is:
a) a lack of understanding as to the appropriate services to make referrals to for Veterans by Trust mental health practitioners ;
b) a lack of understanding as to services available for Veterans;
c) too much emphasis on Veterans being solely responsible for self-referral, with no assistance to assist in accessing appropriate services;
d) A lack of understanding (or effort) as to how to request and obtain military DCMH medical records.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding or effort in obtaining military DCMH medical records
Wider context from the report “5. I have a concern that there is:
a) a lack of understanding as to the appropriate services to make referrals to for Veterans by Trust mental health practitioners;
b) a lack of understanding as to services available for Veterans;
c) too much emphasis on Veterans being solely responsible for self-referral, with no assistance to assist in accessing appropriate services;
d) A lack of understanding (or effort) as to how to request and obtain military DCMH medical records .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assist Veterans in accessing appropriate services
Wider context from the report “5. I have a concern that there is:
a) a lack of understanding as to the appropriate services to make referrals to for Veterans by Trust mental health practitioners;
b) a lack of understanding as to services available for Veterans;
c) too much emphasis on Veterans being solely responsible for self-referral, with no assistance to assist in accessing appropriate services ;
d) A lack of understanding (or effort) as to how to request and obtain military DCMH medical records.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of psychiatrists and psychologists accessible to serving personnel
Wider context from the report “1. I have a concern as to the number and availability of psychiatrists and psychologists within the Ministry of Defence and accessible to serving personnel . This concern extends to ensuring a soldier receives access to appropriate treatment including diagnosis.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Rejection of PTSD claims despite evidence from other medical professionals without consultant diagnosis
Wider context from the report “3. I have a concern about:
a. the training and experience of the Medical Advisors at Veterans UK providing advice under the Armed Forces Compensation Scheme.
b. rejection of claims for PTSD under the Armed Forces Compensation Scheme if there is not a formal diagnosis by a consultant psychiatrist or psychologist but evidence of PTSD within medical records from other medical professionals .
” 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 Share learning from the preventing-future-deaths report through ongoing serious-incident investigation training.
Verbatim wording from the response “The learning from the outcome of this preventing future deaths report will be shared as part of on-going training provided to staff undertaking serious incident investigations and those involved within the approval process of investigations.” Source location Response from Nottinghamshire Healthcare
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 Continue providing two-day systems-based serious-incident investigation training for investigators.
Verbatim wording from the response “We continue to work with external partners to ensure that staff undertaking serious incident investigations are trained and knowledgeable in investigation techniques. We will continue in our commitment to providing a two-day training event for investigators based on a “Systems Based Approach” (SBA). This approach is advocated by the Patient Safety Incident Response Framework (PSIRF) which will be implemented within NHS Organisations during the Autumn of 2023. The role of SBA is to identify the systems-based problems when an incident occurs, rather than focusing on the individuals involved. Our aim is to provide five two-day Serious Incident Investigation training sessions each year, which enables the opportunity for 125 attendees across those sessions.” Source location Response from Nottinghamshire Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the military-records procedure through Trust briefings, bulletins, Connect and care-group governance forums.
Verbatim wording from the response “As a result of the development of this, it will be circulated via the Executive Weekly Briefing, the Line Managers’ Bulletin and a link will be added to the Veteran information page on Connect, as well as being included in the next Trustwide Lessons Learned Bulletin. Each Care Group and Care Unit within the Trust has developed their own sharing mechanisms which include discussion in the Care Unit Quality Oversight Group/Quality and Risk Meetings, Service Business Meetings and Team/Ward Meetings with Governance leads ensuring this is included in the relevant agendas.” Source location Response from Nottinghamshire Healthcare
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 Support veterans who need self-referral by completing referrals collaboratively with them or on their behalf.
Verbatim wording from the response “The Trust has reflected upon the self-referral pathway for Veteran related services that require a self-referral and recognise that this can present with difficulties in accessing further appropriate services. For example, the impact having to tell a personal and sensitive story repeatedly can be distressing and result in a barrier to such services being accessed.” Source location Response from Nottinghamshire Healthcare
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 and publish a procedure for requesting and obtaining military DCMH medical records.
Verbatim wording from the response “Support has been sought from the Head of Information Governance (IG) to identify the process in which to have any military records released. The Trust was informed by the MoD that the records needed to be formally requested and written consent sought from the individual prior to the application being made.
IG colleagues then worked to produce a procedure that would clarify this process for staff with the appropriate contact numbers included for each armed forces and the necessary consent forms enclosed as an appendix.” Source location Response from Nottinghamshire Healthcare
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 Present veteran-service information to the Adult Mental Health Quality and Risk Group.
Verbatim wording from the response “Op Courage and Army and You. The Nottinghamshire Healthcare culture and staff engagement facilitators are presenting to the members of the Adult Mental Health Quality and Risk Group, which is attended by senior operational managers, service managers team leaders and trainers on 07 September 2023.” Source location Response from Nottinghamshire Healthcare
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 a panel sign-off process to review Mental Health Care Group serious-incident investigations.
Verbatim wording from the response “The Mental Health Care Group introduced a panel sign off process which collectively reviews the investigation to provide a higher level of quality assurance and triangulation of information. We envisage our reviewed and strengthened governance will mitigate this risk moving forward.” Source location Response from Nottinghamshire Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the Veterans and Suicide Prevention Champions Network presentation Trustwide through communications and the intranet.
Verbatim wording from the response “3. The topic for July’s Trustwide Suicide Prevention Champions Network meeting was Veterans and Suicide Prevention with the Operation Lead for OpCourage Midlands attending as the guest speaker to present and share information about the Armed Forces Covenant and OpCourage with colleagues. This meeting was recorded and is being shared Trustwide through various Communications, including being made available on the Trust’s intranet.” Source location Response from Nottinghamshire Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate veteran-service learning through Trust bulletins, governance communications and team meetings.
Verbatim wording from the response “Concern that there is a lack of understanding as to the services available for Veterans.” Source location Response from Nottinghamshire Healthcare
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 six serious-incident quality-assurance training events for investigation report reviewers and approvers during 2023–2024.
Verbatim wording from the response “We also recognised that we needed to strengthen our overall review of our investigation reports and ensure those individuals who are reviewing/approving/authorising the final report have the skills to critically appraise the report and ensure it is fit for purpose.” Source location Response from Nottinghamshire Healthcare
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 practice for supporting self-referral and making veteran referrals on patients’ behalf over three months.
Verbatim wording from the response “The Trust will need to have assurance that this practice is embedded, therefore an audit will take place over a period of three-month period to identify that staff are exploring if a service user requires support to access self-referral services and for the specific needs of Veterans these referrals are being made on their behalf.” Source location Response from Nottinghamshire Healthcare
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 Distribute veteran-service posters to all community team bases and conduct follow-up checks.
Verbatim wording from the response “Concern that there is a lack of understanding as to the services available for Veterans.” Source location Response from Nottinghamshire Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a proactive, objective review of active Trust inquests to identify lessons and improvement themes.
Verbatim wording from the response “Review of active Investigations & Inquests:” Source location Response from Nottinghamshire Healthcare
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 Reflect veteran suicide-prevention learning at the annual Trust suicide-prevention conference, with veteran-service information available.
Verbatim wording from the response “2. The Trust holds an annual Suicide Prevention conference where this learning will be reflected. Our colleagues in OpCourage and Trust Armed Forces Community Network will also be in attendance and hosting an information stall.” Source location Response from Nottinghamshire Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the three-year Suicide Strategy review with specific consideration of veteran suicide risk and implications for clinical practice.
Verbatim wording from the response “receive support. Subsequently, they can present with an increased risk of harm. We are committed as an organisation to supporting this patient group and plan to do the following –” Source location Response from Nottinghamshire Healthcare
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 Scope mandatory veteran-status recording, service hyperlinks and referral-support prompts in RiO.
Verbatim wording from the response “The Patient Medical records (RiO) now request that a section to be completed which seeks to ask if they are a veteran. We are in the process of scoping if this can be a mandated question and to also add a hyperlink which will guide the practitioner to the services available. We also plan to add a prompt about ensuring that the patient is supported with the referral if required. This functionality will be audited in 6 months’ time to review accessibility and whether this can be used more widely.” Source location Response from Nottinghamshire Healthcare
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 Veteran folder across Mental Health Services after suitability review.
Verbatim wording from the response “A Veteran folder (Appendix 4) has been developed to help and support referrals for Veterans, this has been shared throughout the Adult Mental Health services And is currently being reviewed by our Mental Health Services for Older Peoples leads and Specialist Services leads to check suitability for patient group and will be shared across Mental Health Services by 18 August 2023.” Source location Response from Nottinghamshire Healthcare
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 Distribute veteran-service leaflets, posters and QR-linked intranet information to mental-health practitioners and Trust services.
Verbatim wording from the response “The Trust has taken action to gain knowledge of appropriate Veteran services which are available, and we are able to make referrals to. As a result of this, we have looked to update our mental health practitioners with regards to this information. All this information has been collated from Nottinghamshire Healthcare culture and staff engagement facilitators, who are part of the Veterans’ Network. Leaflets and posters have been provided and are being distributed throughout the Mental Health Care Group and shared with the wider Trust for review and distribution. As part of the information provided is a card that has a QR code on it, practitioners can scan this code and it takes them to the Veteran information pages on the Nottinghamshire Healthcare Trust intranet site ‘Connect.’” Source location Response from Nottinghamshire Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and plan wider dissemination of veteran information, with emphasis on area-specific training.
Verbatim wording from the response “This information has been shared with the Trust for wider learning and Care Group relevant business managers and governance leads are review plans to disseminate this information with the emphasis being focused for the specific areas to include training.” Source location Response from Nottinghamshire Healthcare
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 developed neurodiversity guidance to support investigators in considering individual needs and reasonable adjustments.
Verbatim wording from the response “The course will provide the attendees with skills to critically assess the investigation report and ensure it concentrates on Systems Based outcomes and SMART actions. Our aim is that within the six sessions we can train approximately 150 individuals. The purpose of this training is to provide senior leaders who have responsibility for approving reports with the skills to analyse the report, ensure fairness, that systems-based learning has been applied and that the report and findings reflect the agreed terms of reference and any questions raised by the patient or family. The Trust recognises the need to consider neurodiversity when undertaking investigations. Guidance has now been developed to support investigators to consider individual need, reasonable adjustments, access to learning development and consultation forums.” Source location Response from Nottinghamshire Healthcare
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 Include self-referral support and veteran referral requirements in the updated LMHT Standard Operating Procedure and distribute it to staff.
Verbatim wording from the response “In addition, guidance has been written for staff to demonstrate professional curiosity in relation to a service users’ motivation or ability to complete self-referrals. This identifies those who need support to self-refer and clinicians will complete this with the individual or for them if appropriate. This guidance will be included in the updated version of the Local Mental Health Team (LMHT) Standard Operating Procedure (SOP), which will be provided for reference once completed by the end of August 2023. This SOP will incorporate the need to refer Veterans to OpCourage rather than rely on self-referral due to the known difficulty our Veterans have in seeking support. All LMHT staff will be provided with a copy via email and this section will be highlighted in the business meetings.” Source location Response from Nottinghamshire Healthcare
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 Maintain a Trustwide Lead for Suicide Prevention responsible for strategy, training, clinical practice and learning.
Verbatim wording from the response “Nottinghamshire Healthcare Trust is committed to working collaboratively with patients and staff to prevent suicide and reduce harm. This includes how we work with patients to meet their needs and also equip our workforce to have the right knowledge and skill to respond effectively to suicidality and promote safety. As such, we have a Trustwide Lead for Suicide Prevention, Rachel Lees. This role is a Trustwide role which is responsible for developing and implementing Nottinghamshire Healthcare’s suicide prevention strategy, and working with other partners across the wider system. This role works strategically and clinically to reduce harm and promote safety in relation to suicidality, particularly focusing on training delivery, clinical practice and sharing of learning and key messages.” Source location Response from Nottinghamshire Healthcare
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 Update essential suicide awareness and response training to reflect enhanced risk among veterans.
Verbatim wording from the response “1. The three yearly review of the Suicide Strategy is underway and will include a focus on staff awareness of factors which may be affecting different sub-groups of patients and clinical considerations and implications for practice. Specifically, this will reflect the enhanced risk for the veteran patient group from what we have learnt in the Trust and nationally. Our Trust essential training for Suicide Awareness and response will also reflect this.” Source location Response from Nottinghamshire Healthcare
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 Display veteran-service posters at all inpatient sites.
Verbatim wording from the response “Concern that there is a lack of understanding as to the services available for Veterans.” Source location Response from Nottinghamshire Healthcare
Open published response
4 Apr 2023 Thomas Jayamaha · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Failure to have necessary actions in place to address issues identified through the Serious Incident Investigation process View source Delayed progress of the Autism Strategy work View source Insufficient progress with complex case management View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Thomas Jayamaha · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Thomas Jayamaha died by suicide after taking Pentobarbital ordered from a website abroad. He had Autism Spectrum Disorder, longstanding mental health difficulties, suicidal ideation and previous self-harm or suicide attempts, alongside other reported vulnerabilities. The principal concerns were delayed progress on the Trust’s Autism Strategy, insufficient progress with complex case management, and the Serious Incident Investigation process.
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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to have necessary actions in place to address issues identified through the Serious Incident Investigation process
Wider context from the report “3. The Serious Incident Investigation process
I am not reassured that necessary actions to address these serious issues identified are in place .
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delayed progress of the Autism Strategy work
Wider context from the report “1. Delayed progress of the Autism Strategy work across the Trust. I ask that the Nottingham and Nottinghamshire Integrated Care Board provide a joint response with the Trust to address this concern, as I accept progress with the Autism work will depend upon resources and the agreed Com-missioning of specific services
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient progress with complex case management
Wider context from the report “2. Insufficient progress with Complex case management
” 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 Develop and implement quality improvement plans based on discussion of investigation recommendations.
Verbatim wording from the response “Recommendations are also discussed and based on this, quality improvement plans are developed and implemented.” Source location Response from Nottinghamshire Healthcare 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 Establish weekday multidisciplinary daily triage meetings across Adult Mental Health and Local Mental Health Teams for complex referral decisions.
Verbatim wording from the response “To safeguard against this in the future a clinician-led triage assessment is being rolled out in a staged manner across the teams (as part of our Transformation Programme). In addition, a Monday – Friday, Daily Triage Meeting attended by leads from multiple teams within the Directorate, is also being introduced across all Adult Mental Health (AMH), Local Mental Health Teams (LMHTs).” Source location Response from Nottinghamshire Healthcare 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 Produce an autism strategy action plan covering identification, reasonable adjustments, peer support, care planning and workforce measures.
Verbatim wording from the response “The Trust and the ICB have worked in partnership to produce an action plan (Appendix 1) outlining the implementation of key components of the autism strategy and implementation plan including flagging and identification, reasonable adjustments, peer support, care planning and workforce. The” Source location Response from Nottinghamshire Healthcare 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 Commission and deliver Serious Incident Quality Assurance training to strengthen critical appraisal of investigation reports and SMART, systems-based actions.
Verbatim wording from the response “Quality Assurance of Investigation Reports:
We also recognised that we needed to strengthen our overall review of our investigation reports and ensure those individuals who are approving/authorising the final report have the skills to critically appraise the report and ensure it is fit for purpose.” Source location Response from Nottinghamshire Healthcare NHS Foundation Trust
Open published response
20 Dec 2022 Alexander Michael BRAUND · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 6 Failure to consistently apply NEWS2 assessment and monitoring, supported by adequate training and guidance View source Failure of NEWS2 compliance auditing to reliably monitor adherence View source Absence of an agreed joint care plan for acutely unwell prisoners remaining in prison View source Unclear cell-entry criteria for prison officers during life-threatening emergencies View source Misunderstanding among discipline staff of medical emergency code criteria View source Failure to clearly flag amendments to SystmOne medical records View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alexander Michael BRAUND · 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 Michael Braund was a 25-year-old remand prisoner at HMP Nottingham who became acutely unwell with an undetected atypical pneumonia and died on 10 March 2020 after cardiac arrest and withdrawal of life support. The principal concerns included failures in NEWS2 assessment and monitoring, the absence of a joint healthcare and prison-staff care plan, delays in entering his cell and calling a medical emergency code, and potential weaknesses in the integrity of amended electronic medical records.
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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consistently apply NEWS2 assessment and monitoring, supported by adequate training and guidance
Wider context from the report “1.(HEALTHCARE) Lack of safe system, supported by training, guidance, and compliance auditing, for the provision of physical healthcare assessment and monitoring by NEWS2 for acutely unwell patients in a secure setting.
The Jury found shortcomings in the healthcare afforded to Alex at HMP Nottingham in the form of "continuous failures to provide adequate healthcare, which probably more than minimally contributed to his death".
I heard evidence that staff were not consistently assessing acutely unwell patients using the NEWS2 system , despite the scoring system having been adopted across the NHS over the past decade and having been adopted by this Trust many years prior.
In 2017, when relaunching the NEWS system, the Royal College of Physicians noted, "Every so often, someone comes up with an idea that is so obvious, no one can understand why it wasn’t thought of before. I am proud that the RCP’s National Early Warning Score (NEWS) is one of those initiatives – not just a chart (or iPad) at the end of the bed to record the patient’s physical signs and symptoms, but the chart at the end of the bed – a single point of truth to unify recording of symptoms across the NHS, consolidate training for doctors and nurses in the recording of symptoms, and thereby improve patient safety. When the RCP launched the NEWS in 2012, we hoped to see the score adopted across the NHS. What has been more astonishing is the adoption of the score internationally, with requests to use NEWS coming from health services across the world from Europe to India and the USA, including the US Naval Air Forces!"
I heard evidence of an inconsistent application of NEWS2 by staff, an inconsistent awareness of NEWS2 across the staff body, and an absence of clear and robust training supported by guidance , ensuring staff were aware of the expectations of their employer with regards to the use of NEWS2 in monitoring acutely unwell patients.
Sadly, Alex’s is not an isolated case. I have been repeatedly assured at a senior level from Nottinghamshire Healthcare NHS Foundation Trust that they are seeking to embed NEWS2 across their Directorates, yet successive inquests have heard of patients failed by the lack of use of the system by the clinical staff responsible for their medical care. If this issue is not addressed across the Trust, with sufficient urgency, patients will continue to die in Trust settings due to a failure to recognise the deteriorating patient, and to arrange for timely healthcare intervention.
Further, I heard evidence that the newly implemented compliance audit plans for NEWS2 are not safe or robust because the audit is limited to monitoring the emergency review template on Systmone, which staff are routinely failing to utilise, instead preferring to add free text entries to the running record, which cannot be audited with ease. If the Trust is incapable of monitoring compliance with the initiative, there will be repeated missed opportunities to provide support and guidance to Directorates, wards or individual staff who are deviating from expected practice with regards to NEWS2.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of NEWS2 compliance auditing to reliably monitor adherence
Wider context from the report “1.(HEALTHCARE) Lack of safe system, supported by training, guidance, and compliance auditing, for the provision of physical healthcare assessment and monitoring by NEWS2 for acutely unwell patients in a secure setting.
The Jury found shortcomings in the healthcare afforded to Alex at HMP Nottingham in the form of "continuous failures to provide adequate healthcare, which probably more than minimally contributed to his death".
I heard evidence that staff were not consistently assessing acutely unwell patients using the NEWS2 system, despite the scoring system having been adopted across the NHS over the past decade and having been adopted by this Trust many years prior.
In 2017, when relaunching the NEWS system, the Royal College of Physicians noted, "Every so often, someone comes up with an idea that is so obvious, no one can understand why it wasn’t thought of before. I am proud that the RCP’s National Early Warning Score (NEWS) is one of those initiatives – not just a chart (or iPad) at the end of the bed to record the patient’s physical signs and symptoms, but the chart at the end of the bed – a single point of truth to unify recording of symptoms across the NHS, consolidate training for doctors and nurses in the recording of symptoms, and thereby improve patient safety. When the RCP launched the NEWS in 2012, we hoped to see the score adopted across the NHS. What has been more astonishing is the adoption of the score internationally, with requests to use NEWS coming from health services across the world from Europe to India and the USA, including the US Naval Air Forces!"
I heard evidence of an inconsistent application of NEWS2 by staff, an inconsistent awareness of NEWS2 across the staff body, and an absence of clear and robust training supported by guidance, ensuring staff were aware of the expectations of their employer with regards to the use of NEWS2 in monitoring acutely unwell patients.
Sadly, Alex’s is not an isolated case. I have been repeatedly assured at a senior level from Nottinghamshire Healthcare NHS Foundation Trust that they are seeking to embed NEWS2 across their Directorates, yet successive inquests have heard of patients failed by the lack of use of the system by the clinical staff responsible for their medical care. If this issue is not addressed across the Trust, with sufficient urgency, patients will continue to die in Trust settings due to a failure to recognise the deteriorating patient, and to arrange for timely healthcare intervention.
Further, I heard evidence that the newly implemented compliance audit plans for NEWS2 are not safe or robust because the audit is limited to monitoring the emergency review template on Systmone, which staff are routinely failing to utilise, instead preferring to add free text entries to the running record, which cannot be audited with ease . If the Trust is incapable of monitoring compliance with the initiative, there will be repeated missed opportunities to provide support and guidance to Directorates, wards or individual staff who are deviating from expected practice with regards to NEWS2.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of an agreed joint care plan for acutely unwell prisoners remaining in prison
Wider context from the report “2. (HEALTHCARE AND HMP) The absence of a safe joint system of care (between discipline and healthcare staff) for supporting and managing acutely unwell patients who remain in the prison setting, rather than being transferred to a dedicated healthcare facility.
The very nature of incarceration curtails the prisoner’s free movement and ready access to healthcare. Instead, their incarceration places them wholly reliant on the communication between discipline staff on the wing, and healthcare staff available elsewhere within the setting, to obtain timely healthcare assessment and monitoring.
I heard evidence that Alex had been told to "press his cell bell" if he "felt worse". Both Alex and his cell mate did so repeatedly between 9 and 10 March 2020, with varying degrees of success regarding healthcare attendance at his cell.
Despite discipline and healthcare staff knowing that Alex was suffering with an acute illness, and in the knowledge that there was no plan for him to be transferred to a hospital, there was an absence of agreed joint plan between health and discipline staff as to how often Alex would be seen by each profession, what constitutes a deterioration for him, and what to do in the event of such a deterioration , to seek to detect and manage his risk of physical healthcare deterioration.
In contrast, in circumstances whereby a prisoner is thought to be at risk of self-harm or suicide, there is an agreed joint care planning system (ACCT Version 6) which sets out the clear expectations placed on each profession to seek to keep the prisoner safe (enshrined in Prison Service Instruction). There is no such equivalent system in operation nationally with regards to the risk of physical healthcare deterioration, but that does not absolve each service from ensuring acutely unwell patients are kept safe by way of robust joint local care planning.
If acutely unwell patients continue to be managed in the prison setting without an agreed joint plan of care between health and discipline staff , deaths will continue to occur in these 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear cell-entry criteria for prison officers during life-threatening emergencies
Wider context from the report “3. (HM PRISON SERVICE) There continues to be a misunderstanding across discipline staff as to what constitutes a CODE BLUE/CODE RED situation, and in what circumstances a cell can be entered by a prison officer for the purpose of preserving life , despite this having been enshrined in Prison Service Instruction for many years.
I heard evidence from the PCO that he erroneously believed it was necessary for 3 discipline staff to be present before a cell door could be opened during night state even in circumstances where Alex was collapsed and unresponsive on the floor.
This is not the first-time issues of this nature have been identified at HMP Nottingham. Indeed, successive Prison and Probation Ombudsman reports have recommended that the Governor take action to address these issues since the cluster of deaths in 2017/2018, and while the prison has been subject to Urgent Notification procedures.
I heard evidence from a medical expert that post-cardiac arrest, every minute which elapses without appropriate CPR and defibrillator use reduces the patient’s chances of survival. Timely life support is critical, and staff must be clear on when to call a medical emergency code, and when to enter the cell, subject to their dynamic risk assessment.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Misunderstanding among discipline staff of medical emergency code criteria
Wider context from the report “3. (HM PRISON SERVICE) There continues to be a misunderstanding across discipline staff as to what constitutes a CODE BLUE/CODE RED situation , and in what circumstances a cell can be entered by a prison officer for the purpose of preserving life, despite this having been enshrined in Prison Service Instruction for many years.
I heard evidence from the PCO that he erroneously believed it was necessary for 3 discipline staff to be present before a cell door could be opened during night state even in circumstances where Alex was collapsed and unresponsive on the floor.
This is not the first-time issues of this nature have been identified at HMP Nottingham. Indeed, successive Prison and Probation Ombudsman reports have recommended that the Governor take action to address these issues since the cluster of deaths in 2017/2018, and while the prison has been subject to Urgent Notification procedures.
I heard evidence from a medical expert that post-cardiac arrest, every minute which elapses without appropriate CPR and defibrillator use reduces the patient’s chances of survival. Timely life support is critical, and staff must be clear on when to call a medical emergency code , and when to enter the cell, subject to their dynamic risk assessment.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly flag amendments to SystmOne medical records
Wider context from the report “4. (TPP-UK) Amendment of Medical Records without clear evidence of such amendment on the face of the SystmOne patient summary
The vast majority of primary care health services across the community and secure settings, such as prisons, utilise an electronic patient health record known as SystmOne.
I heard evidence that the system automatically records the date, time, and user, shown along the left-hand side of each entry in the printed patient summary, as below.
17 Apr 2019 08:11 Surgery: ████████ Health Professional Access Role)
I was assured by health staff that any retrospective entry or amendment to a previous entry in the patient record would be flagged by a new date and time stamp towards the right-hand side of the entry, as below.
24 Apr 2019 15:55 Surgery: ████████ Health Professional Access Role) Entered: 25 Apr 2019 11:55
However, in this case, I discovered from scrutinising an audit record, that an entry made in Alex’s patient record at 06.46 hours on 10 March 2020, had been amended by way of the deletion of some words, and the addition of others, at 09.30 hours on the same date, without any such time stamp being generated on the right-hand side of the entry . This made it look as if the entire text visible in the record would have been visible from around 06.46 hours that date.
The Head of Healthcare was unable to explain how the health professional who made the entry had been able to amend her previous entry, without it being obvious on the face of the record , after it became apparent Alex was critically unwell
This potentially raises serious safety issues about the integrity of the patient record, and at the very least, if the record is not as robust as first thought by its users, this ought to be made clear. I shall share this report with TPP-UK, the creators of SystmOne, to see if they can explain the safety features in place to ensure amended records are clearly marked as such , especially as in this case, the witness was not forthcoming about her amendment of Alex’s patient record. Accurate record keeping is integral to learning from incidents and seeking 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 Update and recirculate the joint urgent-assessment protocol for deteriorating patients, including emergency and code-response procedures.
Verbatim wording from the response “The joint protocol for the urgent assessment process for the deteriorating patient is to be updated and re-circulated to all prison and healthcare staff. This includes the PSO 1300 emergency response and the management of code red and code blue. Joint training is to be provided to Prison staff to ensure they are familiar with the process and are confident in its use.” Source location Response from Nottingham Healthcare 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 Assess NEWS2 competency at all sites through Clinical Lead visits and provide additional support or training where required.
Verbatim wording from the response “It is recognised that training alone is not sufficient to assess individuals’ learning and understanding of the toolkit and responses required for unwell patients. The Trust essential training will assess employees’ understanding of the News2 toolkit. In addition, Clinical Leads will be attending all sites on a rolling basis to assess competency of staff using NEWS2 and provide further support/ training where required. We are currently working with the wider Trust to look at how this can be delivered regularly to the all the teams across Offender Health.” Source location Response from Nottingham Healthcare 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 Distribute NEWS2 flashcards and paper templates across sites as emergency-response aids and working documents.
Verbatim wording from the response “To support Trust employees, a NEWS2 Flashcard and paper templates have been reviewed and distributed across all sites and will be available in all emergency response bags as an aide memoire and working documents (Appendix 2). This is to support ease of access and act as a reminder during emergency situations across the sites, communicating clear expectations and requirements for patient safety. The NEWS2 observation template is also clearly visible on the Clinical Tree and should link to the observations template within SystmOne.” Source location Response from Nottingham Healthcare 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 Monitor NEWS2 training completion through weekly communications, compliance updates and exception reporting.
Verbatim wording from the response “In the first instance employees were requested to ensure they had completed the online training by 31st December 2022. To date, as of 13th February 2023, across the Offender Health Directorate we have achieved 86% in relation to staff who have completed the training. This is for those staff currently working and not absent.” Source location Response from Nottingham Healthcare 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 a regular NEWS2 competency-assessment and support model for Offender Health teams.
Verbatim wording from the response “It is recognised that training alone is not sufficient to assess individuals’ learning and understanding of the toolkit and responses required for unwell patients. The Trust essential training will assess employees’ understanding of the News2 toolkit. In addition, Clinical Leads will be attending all sites on a rolling basis to assess competency of staff using NEWS2 and provide further support/ training where required. We are currently working with the wider Trust to look at how this can be delivered regularly to the all the teams across Offender Health.” Source location Response from Nottingham Healthcare 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 Assess staff understanding of the NEWS2 toolkit through essential training.
Verbatim wording from the response “It is recognised that training alone is not sufficient to assess individuals’ learning and understanding of the toolkit and responses required for unwell patients. The Trust essential training will assess employees’ understanding of the News2 toolkit. In addition, Clinical Leads will be attending all sites on a rolling basis to assess competency of staff using NEWS2 and provide further support/ training where required. We are currently working with the wider Trust to look at how this can be delivered regularly to the all the teams across Offender Health.” Source location Response from Nottingham Healthcare 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 Circulate the NEWS2 and sepsis training tool to sites for delivery during continuing professional development sessions.
Verbatim wording from the response “In addition, the Clinical Lead for Physical Healthcare has provided a training tool regarding NEWS2 and SEPSIS. This has been circulated to all sites for the clinical matrons to deliver this training during CPD sessions.” Source location Response from Nottingham Healthcare 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 Provide joint training for prison staff on the urgent-assessment and code-response process.
Verbatim wording from the response “The joint protocol for the urgent assessment process for the deteriorating patient is to be updated and re-circulated to all prison and healthcare staff. This includes the PSO 1300 emergency response and the management of code red and code blue. Joint training is to be provided to Prison staff to ensure they are familiar with the process and are confident in its use.” Source location Response from Nottingham Healthcare 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 Develop a rolling 12-month Offender Health training programme addressing identified critical topics.
Verbatim wording from the response “The Clinical Leads for Offender Health, alongside the Head of Nursing are currently undertaking a training gap analysis exercise with a view to identifying the critical training needs for all healthcare staff and develop a robust training programme for Offender Health on a rolling 12 monthly basis. This has been planned on Prison lockdown days and we have identified critical topics that need to be addressed including but not exhaustive, emergency response to NEWS2, Mental Capacity Record Keeping and Assessment, Care in Custody and Team work, Suicide and Self Harm training (Appendix 4).” Source location Response from Nottingham Healthcare 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 Complete a training gap analysis to identify critical training needs for Offender Health healthcare staff.
Verbatim wording from the response “The Clinical Leads for Offender Health, alongside the Head of Nursing are currently undertaking a training gap analysis exercise with a view to identifying the critical training needs for all healthcare staff and develop a robust training programme for Offender Health on a rolling 12 monthly basis. This has been planned on Prison lockdown days and we have identified critical topics that need to be addressed including but not exhaustive, emergency response to NEWS2, Mental Capacity Record Keeping and Assessment, Care in Custody and Team work, Suicide and Self Harm training (Appendix 4).” Source location Response from Nottingham Healthcare 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 Develop a joint training programme with HMP Nottingham prioritising learning from the Regulation 28 notice.
Verbatim wording from the response “The Head of Healthcare and the Prison Governor are working in partnership to devise a joint training programme for all staff, ensuring the learning from the Regulation 28 Notice has been prioritised.” Source location Response from Nottingham Healthcare 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 Align essential NEWS2 and physical healthcare training with practical NEWS2 requirements.
Verbatim wording from the response “Following this, the Heads of Healthcare have weekly communication to all employees to ensure they have undertaken the training, with audits in place to monitor compliance. To support this process of monitoring training, Heads of Healthcare are provided with weekly updates on their teams’ compliance and a requirement to provide an exception report to the Divisional Management Team (DMT) for non-compliance. This will alert the DMT to any hot spot areas and identify where to dedicate further support to allow training. Nottinghamshire Healthcare NHS Foundation Trust Learning and Development Department are working closely with the Offender Health DMT to ensure essential training on NEWS2, and physical healthcare meets the requirements to teach staff how to use NEWS2 in practice.” Source location Response from Nottingham Healthcare 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 Schedule live emergency-response simulations with prison colleagues across all sites over the next twelve months.
Verbatim wording from the response “Heads of Healthcare and Clinical Matrons undertake regular audits on SystmOne as part of monitoring staff compliance to the training with NEWS2. We have engaged with the Trustwide resuscitation trainers to explore using live simulations on sites to ensure that emergency responses are fully tested with our Prison colleagues. This will be scheduled throughout the next twelve months on all sites.” Source location Response from Nottingham Healthcare 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 Email Offender Health staff the report findings and NEWS2 failure information.
Verbatim wording from the response “Subsequent to receiving the Regulation 28 Report on 21st December 2022, all Trust employees of Offender Health were emailed in regard to the findings and in particular the outcome of NEWS2 failures.” Source location Response from Nottingham Healthcare NHS Foundation Trust
Open published response
14 Jun 2022 Keith Andrew NOTTLE · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Failure to ensure specialist mental health assessment of patients triaged by telephone workers View source Failure of the multi-disciplinary team to respond appropriately to repeated re-referrals View source Lack of clarity in multi-disciplinary team decision-making about discharge View source Lack of care co-ordination for patients receiving assistance from multiple agencies and persons 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
Keith Andrew NOTTLE · 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 Andrew Nottle died on 5 July 2021 after taking an overdose of two prescribed medications, which the inquest concluded was an accident. Concerns included telephone triage practices that could bypass specialist mental health assessment, the apparent lack of care coordination, and unclear decision-making around his discharge and repeated re-referrals to mental health services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure specialist mental health assessment of patients triaged by telephone workers
Wider context from the report “Evidence was heard regarding the operation of a triage for patients who may be experiencing a mental health crisis. A practice had developed of bypassing specialist mental health assessment by means of telephone workers making their own judgments about the level of risk a person presents to themselves and others, and a judgment about whether or not they require urgent mental health assessment and / or treatment, based on a very limited criteria. This had the result of only a very small proportion of potentially unwell patients being considered by a person with qualifications to assess and treat mental health. This was a culture and practice which stood in conflict with the procedure the Trust had in writing for the role of the telephone workers.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the multi-disciplinary team to respond appropriately to repeated re-referrals
Wider context from the report “Lastly, I was concerned that there was evidence of a lack of clarity of thinking within the multi-disciplinary team in relation to the decision to discharge Mr Nottle and the apparent recalcitrance of the multi-disciplinary team in relation to repeated re-referrals into the service . This may be linked with the lack of care co-ordination or may be a cultural or practice issue within the operation of the multi-disciplinary team.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in multi-disciplinary team decision-making about discharge
Wider context from the report “Lastly, I was concerned that there was evidence of a lack of clarity of thinking within the multi-disciplinary team in relation to the decision to discharge Mr Nottle and the apparent recalcitrance of the multi-disciplinary team in relation to repeated re-referrals into the service. This may be linked with the lack of care co-ordination or may be a cultural or practice issue within the operation of the multi-disciplinary team.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of care co-ordination for patients receiving assistance from multiple agencies and persons
Wider context from the report “I was also concerned regarding the apparent lack of involvement of a care co-ordinator at the Trust , given that a variety of agencies and persons were involved in seeking to assist and treat Mr Nottle.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and disseminate the Urgent Access line Standard Operating Procedure to relevant staff through email, supervision, and team meetings.
Verbatim wording from the response “The Standard Operating Procedure (SOP) (Appendix 3) for the Urgent Access line has been reviewed and shared with all relevant staff via email and also during supervision and team meetings.” Source location Response from NHS Nottinghamshire Healthcare
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 Update the Recovery Worker competency assessment to strengthen competence in call management, systems use, and risk and safety escalation.
Verbatim wording from the response “The Recovery Workers also undertake a competency assessment to ensure they have a high level of competence in managing calls, using correct systems and utilising appropriate escalation protocols in relation to risk and safety management. The competency assessment has been updated in light of this inquest. The updated competency assessment is attached (Appendix 2).” Source location Response from NHS Nottinghamshire Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review local UK Mental Health Triage Scale guidance and establish a more robust process for escalating call-transfer difficulties.
Verbatim wording from the response “We have been assured by Turning Point that in her evidence regarding transfers to CRHT the staff member was referring to June 2021 when the Urgent Access line was first set up, where there were some initial issues with the transfer of calls. The local guidance for the UK Mental Health Triage Scale has been reviewed with a more robust escalation process should there be any difficulty encountered in transfer of a call.” Source location Response from NHS Nottinghamshire Healthcare
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 Introduce a digital telephony system that records calls and enables regular audit of call activity.
Verbatim wording from the response “A new digital telephony system is being introduced into the Trust which will provide greater insight into call activity. All calls will be recorded which will enable the roll out of regular audit. It is anticipated that the telephony system will be operational by Mid-August 2022.” Source location Response from NHS Nottinghamshire Healthcare
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce monthly sampling and auditing of telephone recordings to assess SOP compliance and provide training or remedial action where needed.
Verbatim wording from the response “An audit system is being introduced whereby telephone recordings of a sample of telephone calls will be listened to monthly and utilised for audit and training purposes. This will include monitoring if the calls are being handled in accordance with the SOP and taking remedial action if needed.” Source location Response from NHS Nottinghamshire Healthcare
Open published response
19 Jan 2022 Michelle Whitehead · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 8 Failure to ensure the correct type and dose of sedation medication View source Delays in paramedics gaining access to the ward View source Delays in recognising declining patient condition View source Lack of Consultant involvement after admission View source Failure to provide timely access to the Duty Doctor for deteriorating patients View source Poor documentation of sedation medication View source Lack of medical clerking after admission View source Delays in calling paramedics for deteriorating patients View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 9
Action
Deliver comprehensive NEWS2, anaphylaxis and emergency-treatment training with scenario-based exercises for inpatient staff.
Stated in progressThe respondent said that this action was in progress when they made their response on 24 January 2022. View source
Action
Add an Emergency Services Liaison Responder to each ward shift to meet and escort emergency services, with compliance audits reported to senior management.
Stated completedThe respondent said that this action was complete when they made their response on 24 January 2022. View source
Action
Provide a Non-Medical Approved Clinician role with programmed senior medical support, supervision and education for ward care.
Stated completedThe respondent said that this action was complete when they made their response on 24 January 2022. View source
Action
Review the Hospital Life Support lesson plan to confirm adequate coverage and competency assessment for NEWS2, anaphylaxis and emergency treatment.
Stated in progressThe respondent said that this action was in progress when they made their response on 24 January 2022. View source
Action
Implement a dedicated NHS wireless network enabling junior doctors’ smartphones to use Wi-Fi calling at identified Kingsmill locations, and distribute user guidance.
Stated completedThe respondent said that this action was complete when they made their response on 24 January 2022. View source
Action
Redistribute NEWS2 quick-reference guides across inpatient sites and directorates.
Stated completedThe respondent said that this action was complete when they made their response on 24 January 2022. View source
Action
Agree priority-one ambulance responses for emergencies from Mental Health units until the hospital crash process is operational.
Stated completedThe respondent said that this action was complete when they made their response on 24 January 2022. View source
Action
Review the Rapid Tranquillisation Policy, consult an external intensivist and define assessment, learning and development requirements for patients who fall asleep afterward.
Stated in progressThe respondent said that this action was in progress when they made their response on 24 January 2022. View source
Action
Deploy handheld devices for electronic NEWS2 recording, automatic scoring and escalation alerts across Adult Mental Health inpatient areas.
Stated completedThe respondent said that this action was complete when they made their response on 24 January 2022. View source See 6 more actions
×
AI-generated summary
Michelle Whitehead · 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
Michelle Whitehead died on 7 May 2021 from a hypoxic brain injury after experiencing deterioration in her breathing and oxygen saturation while detained under Section 2 of the Mental Health Act. The report identifies concerns about unclear sedation medication and documentation, delayed recognition and treatment of her deterioration, lack of medical and consultant involvement, difficulty contacting the duty doctor, and delays in calling and admitting paramedics.
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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure the correct type and dose of sedation medication
Wider context from the report “1. Unclear dose/type of sedation medication given, possible excess dose given , poor documentation
2. Delayed recognition of Mrs Whitehead’s declining condition
3. No medical clerking from admission until her collapse
4. No Consultant involvement after admission
5. Inability to reach Duty Doctor for deteriorating patient
6. Delay in calling paramedics
7. Delay in Paramedics gaining access to the ward
Many of these issues have been the subject of scrutiny in at least two previous Inquests, that have followed deaths on inpatient wards of the Trust. I have received reassurance during these Hearings that the issues have been addressed, but this case illustrates that they clearly remain. The issues are very serious in my view.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in paramedics gaining access to the ward
Wider context from the report “1. Unclear dose/type of sedation medication given, possible excess dose given, poor documentation
2. Delayed recognition of Mrs Whitehead’s declining condition
3. No medical clerking from admission until her collapse
4. No Consultant involvement after admission
5. Inability to reach Duty Doctor for deteriorating patient
6. Delay in calling paramedics
7. Delay in Paramedics gaining access to the ward
Many of these issues have been the subject of scrutiny in at least two previous Inquests, that have followed deaths on inpatient wards of the Trust. I have received reassurance during these Hearings that the issues have been addressed, but this case illustrates that they clearly remain. The issues are very serious in my view.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in recognising declining patient condition
Wider context from the report “1. Unclear dose/type of sedation medication given, possible excess dose given, poor documentation
2. Delayed recognition of Mrs Whitehead’s declining condition
3. No medical clerking from admission until her collapse
4. No Consultant involvement after admission
5. Inability to reach Duty Doctor for deteriorating patient
6. Delay in calling paramedics
7. Delay in Paramedics gaining access to the ward
Many of these issues have been the subject of scrutiny in at least two previous Inquests, that have followed deaths on inpatient wards of the Trust. I have received reassurance during these Hearings that the issues have been addressed, but this case illustrates that they clearly remain. The issues are very serious in my view.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of Consultant involvement after admission
Wider context from the report “1. Unclear dose/type of sedation medication given, possible excess dose given, poor documentation
2. Delayed recognition of Mrs Whitehead’s declining condition
3. No medical clerking from admission until her collapse
4. No Consultant involvement after admission
5. Inability to reach Duty Doctor for deteriorating patient
6. Delay in calling paramedics
7. Delay in Paramedics gaining access to the ward
Many of these issues have been the subject of scrutiny in at least two previous Inquests, that have followed deaths on inpatient wards of the Trust. I have received reassurance during these Hearings that the issues have been addressed, but this case illustrates that they clearly remain. The issues are very serious in my view.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely access to the Duty Doctor for deteriorating patients
Wider context from the report “1. Unclear dose/type of sedation medication given, possible excess dose given, poor documentation
2. Delayed recognition of Mrs Whitehead’s declining condition
3. No medical clerking from admission until her collapse
4. No Consultant involvement after admission
5. Inability to reach Duty Doctor for deteriorating patient
6. Delay in calling paramedics
7. Delay in Paramedics gaining access to the ward
Many of these issues have been the subject of scrutiny in at least two previous Inquests, that have followed deaths on inpatient wards of the Trust. I have received reassurance during these Hearings that the issues have been addressed, but this case illustrates that they clearly remain. The issues are very serious in my view.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor documentation of sedation medication
Wider context from the report “1. Unclear dose/type of sedation medication given, possible excess dose given, poor documentation
2. Delayed recognition of Mrs Whitehead’s declining condition
3. No medical clerking from admission until her collapse
4. No Consultant involvement after admission
5. Inability to reach Duty Doctor for deteriorating patient
6. Delay in calling paramedics
7. Delay in Paramedics gaining access to the ward
Many of these issues have been the subject of scrutiny in at least two previous Inquests, that have followed deaths on inpatient wards of the Trust. I have received reassurance during these Hearings that the issues have been addressed, but this case illustrates that they clearly remain. The issues are very serious in my view.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of medical clerking after admission
Wider context from the report “1. Unclear dose/type of sedation medication given, possible excess dose given, poor documentation
2. Delayed recognition of Mrs Whitehead’s declining condition
3. No medical clerking from admission until her collapse
4. No Consultant involvement after admission
5. Inability to reach Duty Doctor for deteriorating patient
6. Delay in calling paramedics
7. Delay in Paramedics gaining access to the ward
Many of these issues have been the subject of scrutiny in at least two previous Inquests, that have followed deaths on inpatient wards of the Trust. I have received reassurance during these Hearings that the issues have been addressed, but this case illustrates that they clearly remain. The issues are very serious in my view.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in calling paramedics for deteriorating patients
Wider context from the report “1. Unclear dose/type of sedation medication given, possible excess dose given, poor documentation
2. Delayed recognition of Mrs Whitehead’s declining condition
3. No medical clerking from admission until her collapse
4. No Consultant involvement after admission
5. Inability to reach Duty Doctor for deteriorating patient
6. Delay in calling paramedics
7. Delay in Paramedics gaining access to the ward
Many of these issues have been the subject of scrutiny in at least two previous Inquests, that have followed deaths on inpatient wards of the Trust. I have received reassurance during these Hearings that the issues have been addressed, but this case illustrates that they clearly remain. The issues are very serious in my view.
” 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 comprehensive NEWS2, anaphylaxis and emergency-treatment training with scenario-based exercises for inpatient staff.
Verbatim wording from the response “Two senior staff members have been identified to work with individuals and groups from the Lucy Wade Unit to ensure they fully understand how to undertake comprehensive NEWS2 assessments. The key focus of the sessions is about confidence-building, particularly regarding decision-making at the time of an urgent clinical incident. They will additionally ensure that all staff are supported to recognise signs of an Anaphylaxis reaction and its associated emergency treatment with Adrenaline. This will include individual group training and the completion of medical emergency scenarios to test knowledge and processes in a more realistic, true-life environment. We are initially prioritising the wards in the north of the county and intend to have this area fully compliant with the training target in this area by mid-April 2022.” Source location 2022-0016-Response-from-Nottinghamshire-Healthcare_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 Add an Emergency Services Liaison Responder to each ward shift to meet and escort emergency services, with compliance audits reported to senior management.
Verbatim wording from the response “The Directorate has reviewed the formation and functioning of the Incident Response Team and now added the allocation of an Emergency Services Liaison Responder for each ward. This role is allocated to each ward by the nurse in charge as part of every handover at the start of each new shift. This individual functions within the team during normal incident scenarios, however, when a medical emergency is identified, they will immediately go to the main reception, wait for the emergency services to attend, and will escort them immediately to the casualty. This role will also be used in the event of Police or Fire Service support being required and will be allocated to a named individual each shift.” Source location 2022-0016-Response-from-Nottinghamshire-Healthcare_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 Provide a Non-Medical Approved Clinician role with programmed senior medical support, supervision and education for ward care.
Verbatim wording from the response “Lucy Wade ward is staffed by two consultants, Dr ████████, Consultant Clinical Psychologist and Dr ████████, Consultant Psychiatrist. Dr ████████ is a fully qualified approved clinician under the Mental Health Act. This is a new role, known as a Non-Medical Approved Clinician or also known as Multi Professional Approved Clinician. In order for medical aspects of inpatient care to be fully provided Dr ████████ has a programmed activity in his job plan to support them. They have a regular Tuesday meeting to discuss her patients, and he sees some of her patients directly if indicated. He provides senior medical input if needed during the rest of the week. He also supervises the clinical work and education of the junior medical staff on the ward.” Source location 2022-0016-Response-from-Nottinghamshire-Healthcare_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 Review the Hospital Life Support lesson plan to confirm adequate coverage and competency assessment for NEWS2, anaphylaxis and emergency treatment.
Verbatim wording from the response “All direct care in-patient staff in the Trust complete Hospital Life Support training every eighteen months, which includes the completion of NEWS2 assessments and associated escalations; plus, recognition of Anaphylaxis and its emergency treatment using Adrenaline. Currently Adult Mental Health services are at 84 percent compliance, which is within target for the Directorate. The lesson plan for this core training is being reviewed to confirm that sufficient time is spent on all aspects of” Source location 2022-0016-Response-from-Nottinghamshire-Healthcare_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 dedicated NHS wireless network enabling junior doctors’ smartphones to use Wi-Fi calling at identified Kingsmill locations, and distribute user guidance.
Verbatim wording from the response “The option of a “back up bleep” to be an alternative contact method if the mobile phone fails was then considered. Advice from IT was that there is a function to remove bleeping from the NHS, which was to be achieved by the end of 2021. Alternative options include various apps, but they all require a smartphone and a reliable signal or Wi-Fi calling. We have therefore reviewed all first on call rotas to establish all locations where the junior doctor may need to visit as part of their duties. For the duty doctor at Millbrook, in addition to Millbrook itself, this consists of all of Kingsmill Hospital Campus – including Kingsmill Hospital Pathology Lab, along with Alexander House, Bracken House and the road in between. ICT have now developed a solution using Wi-Fi calling via a specific NHS wireless network.” Source location 2022-0016-Response-from-Nottinghamshire-Healthcare_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 Redistribute NEWS2 quick-reference guides across inpatient sites and directorates.
Verbatim wording from the response “As a response the Directorate has re-printed new refreshed supplies of the credit card sized NEWS2 quick reference guides (Appendix 1), which identify the physical health parameters and trigger points for escalation to local medical colleagues or the emergency ambulance service. The card is to be worn on a lanyard alongside individual identification badges, acting as an immediate reminder. These have now been confirmed as having been redistributed across our inpatient sites within Adult Mental Health Services and have been shared with the other directorates to ensure consistency across sites.” Source location 2022-0016-Response-from-Nottinghamshire-Healthcare_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 Agree priority-one ambulance responses for emergencies from Mental Health units until the hospital crash process is operational.
Verbatim wording from the response “The primary message to staff, is that they must call for immediate support from the Ambulance service when they recognise that someone’s physical health is rapidly deteriorating, and a medical emergency is or is likely to occur. This has been included clearly within the notification of learning letter already referred to within this response (Appendix 3).” Source location 2022-0016-Response-from-Nottinghamshire-Healthcare_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 Review the Rapid Tranquillisation Policy, consult an external intensivist and define assessment, learning and development requirements for patients who fall asleep afterward.
Verbatim wording from the response “The Trust Resuscitation committee is convening (initially on 9 March 2022) to review the Rapid Tranquilisation Policy and will explore, review and determine what actions should be taken should a patient fall asleep post rapid tranquilisation administration. At the initial meeting it has been agreed that an external intensivist will be consulted to advise as part of this process. A clear understanding of how staff will make the assessment to determine if the patient is sleeping or if the patient is unconscious will be confirmed and any additional learning and development planned.” Source location 2022-0016-Response-from-Nottinghamshire-Healthcare_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 Deploy handheld devices for electronic NEWS2 recording, automatic scoring and escalation alerts across Adult Mental Health inpatient areas.
Verbatim wording from the response “Additionally, the Division is rolling out handheld devices that allow staff to immediately enter physical observations into the NEWS2 electronic system (and patient record). This will automatically calculate the NEWS2 scores and alert if interventions or emergency care is required. Confirmation has been received that these have been made available and are in use on all Adult Mental Health inpatient areas.” Source location 2022-0016-Response-from-Nottinghamshire-Healthcare_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 A crash bleep was discounted because the duty doctor covered multiple sites and could not provide an immediate response.
Verbatim wording from the response “The recommendation from the SI report was to have a “crash bleep”. This was considered but discounted as the duty doctor covers a number of geographical sites and cannot provide an immediate response. Therefore, the response to a medical emergency needs to remain as 999.” Source location 2022-0016-Response-from-Nottinghamshire-Healthcare_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The administered dosages were within British National Formulary guidelines and were assessed as unlikely to harm physical health.
Verbatim wording from the response “A medication error did occur during Mrs. Whitehead’s care. This involved the incorrect dose of administered Oral Diazepam being communicated to the Ward Manager and Duty Doctor. With this incorrect information they agreed to administer Rapid Tranquillisation in the form of an Intramuscular injection of Lorazepam.” Source location 2022-0016-Response-from-Nottinghamshire-Healthcare_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 Available consultant psychiatrist support was not accessed because clinicians considered it unnecessary at the time.
Verbatim wording from the response “Dr ████████ or Dr ████████ could have accessed consultant psychiatrist support at this point in time from Dr ████████. They did not do so as, at the time, they did not think this was necessary. Unfortunately, Mrs Whitehead had suffered the respiratory arrest and had been transferred before the face-to-face consultant review could take place.” Source location 2022-0016-Response-from-Nottinghamshire-Healthcare_Published
Open published response
14 Oct 2021 Paul Ashley Barton · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Failure to account for fluctuating and contradictory suicidal intentions when assessing patient risk View source Failure of investigations to challenge false assumptions View source Failure of investigation processes to identify themes of concern View source Failure of investigations to maintain accurate evidence-based findings View source Failure of crisis resolution home treatment to prioritise protection of life beyond preventing hospital admission View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 6
Action
Develop and implement the approved Trust suicide-prevention training model, including tiered training, tailored team learning, reflective practice, clinical tools and ongoing evaluation.
Stated plannedThe respondent said that this action was planned when they made their response on 18 October 2021. View source
Action
Share investigation learning with staff to reinforce the importance of factual accuracy.
Stated completedThe respondent said that this action was complete when they made their response on 18 October 2021. View source
Action
Update the CRHTT operating procedure with broader assessment, safety-planning and risk-assessment guidance, then disseminate it through email, team meetings and supervision.
Stated plannedThe respondent said that this action was planned when they made their response on 18 October 2021. View source
Action
Deliver quality-assurance training for staff approving concise and comprehensive investigation reports.
Stated completedThe respondent said that this action was complete when they made their response on 18 October 2021. View source
Action
Update the Quality Improvement Plan to capture and address identified investigation-quality themes, with a nominated lead monitoring delivery.
Stated in progressThe respondent said that this action was in progress when they made their response on 18 October 2021. View source
Action
Provide systems-based investigation training, mentoring and centralised investigative support for staff conducting serious-incident investigations.
Stated in progressThe respondent said that this action was in progress when they made their response on 18 October 2021. View source See 3 more actions
×
AI-generated summary
Paul Ashley Barton · 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
Paul Ashley Barton experienced significant distress, personality changes, dysfunctional behaviour, possible paranoid or delusional thoughts, and repeated suicidal thoughts and acts. He died by hanging on 28 November 2020. Concerns included the Crisis Resolution Home Treatment Team’s focus on avoiding inpatient admission, reliance on patients’ expressed intentions or denials despite fluctuating suicidal intentions, and shortcomings in the Trust’s investigation of his death.
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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to account for fluctuating and contradictory suicidal intentions when assessing patient risk
Wider context from the report “(2) This inquest was one of a number of inquests I have conducted where staff members from Nottinghamshire Healthcare NHS Foundation Trust have placed great reliance upon their interpretation of a patient’s intention and / or a patient’s denial of ongoing suicidal intention . This is so even where, as was the case for Mr Barton, there is a clear and established pattern of fluctuating and contradictory intentions and desires towards suicide.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of investigations to challenge false assumptions
Wider context from the report “(3) The quality of the Trust’s own investigation into the circumstances of Mr Barton’s death. It failed to identify themes of concern. It included many false and inaccurate statements, failed to challenge false assumptions made at the time and introduced new false information which was not taken from any available records. It caused distress to the family and did not reassure me that the Trust had taken an appropriate response to the concerning facts of this case.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of investigation processes to identify themes of concern
Wider context from the report “(3) The quality of the Trust’s own investigation into the circumstances of Mr Barton’s death. It failed to identify themes of concern. It included many false and inaccurate statements, failed to challenge false assumptions made at the time and introduced new false information which was not taken from any available records. It caused distress to the family and did not reassure me that the Trust had taken an appropriate response to the concerning facts of this case.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of investigations to maintain accurate evidence-based findings
Wider context from the report “(3) The quality of the Trust’s own investigation into the circumstances of Mr Barton’s death. It failed to identify themes of concern. It included many false and inaccurate statements , failed to challenge false assumptions made at the time and introduced new false information which was not taken from any available records . It caused distress to the family and did not reassure me that the Trust had taken an appropriate response to the concerning facts of this case.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of crisis resolution home treatment to prioritise protection of life beyond preventing hospital admission
Wider context from the report “(1) The approach of the Crisis Resolution Home Treatment Team of considering their role to be limited to avoiding the need for patients to receive inpatient treatment . The primary role of any medical professional ought to be the protection of life, but within the written and oral evidence from the CRHTT the focus was on prevention of hospital admission alone .
” 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 Develop and implement the approved Trust suicide-prevention training model, including tiered training, tailored team learning, reflective practice, clinical tools and ongoing evaluation.
Verbatim wording from the response “A priority of the Trust’s Towards Zero Suicide Strategy (2020–2023) was to review the Trust’s suicide prevention training offer and implement a new training model to bring this into line with the Trust’s Towards Zero Suicide approach (2020) and Health Education England’s Suicide Prevention Competencies. A paper to agree the proposed training, method of delivery and resource requirements was presented to the Trust’s Senior Leadership Team on 26 November 2021 for approval.” Source location 2021-0338-Response-from-Nottingham-Healthcare-NHS-Foundation-Trust_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 Share investigation learning with staff to reinforce the importance of factual accuracy.
Verbatim wording from the response “This has been shared with the investigator for their learning and reflection. In the short-term, this will also be raised as a more general lesson learned to remind all staff of the importance of factual accuracy.” Source location 2021-0338-Response-from-Nottingham-Healthcare-NHS-Foundation-Trust_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 Update the CRHTT operating procedure with broader assessment, safety-planning and risk-assessment guidance, then disseminate it through email, team meetings and supervision.
Verbatim wording from the response “As demonstrated, the expectations of a CRHTT assessment and plan are clear and require detailed information gathering and consideration of a wide variety of factors on which to base care planning and decision making. This should include whether a hospital admission is required but this cannot be the sole determining factor.” Source location 2021-0338-Response-from-Nottingham-Healthcare-NHS-Foundation-Trust_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver quality-assurance training for staff approving concise and comprehensive investigation reports.
Verbatim wording from the response “Quality Assurance of Investigation Reports
We also recognised that we also needed to strengthen our overall review of our investigation reports and ensure those individuals who are approving/authorising the final report have the skills to critically appraise the report and ensure it is fit for purpose.” Source location 2021-0338-Response-from-Nottingham-Healthcare-NHS-Foundation-Trust_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 Update the Quality Improvement Plan to capture and address identified investigation-quality themes, with a nominated lead monitoring delivery.
Verbatim wording from the response “We were sincerely apologetic for the distress and disruption caused because of our mistakes. The Operational Manager has reviewed this report and the relevant themes have been identified. The Quality Improvement Plan is being updated to ensure these are captured and acted upon. We will share this with you on completion.” Source location 2021-0338-Response-from-Nottingham-Healthcare-NHS-Foundation-Trust_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 Provide systems-based investigation training, mentoring and centralised investigative support for staff conducting serious-incident investigations.
Verbatim wording from the response “We have also taken the opportunity to develop a centralised Investigation Team, at present this is a small team of 2 SI Investigation Leads who will primarily be appointed the most significant and time critical cases. However, we are looking to support this centralised team with the employment of a limited number of experienced bank SI investigators, again these individuals are independent of the divisions/services and will have significant experience of being involved in investigations.” Source location 2021-0338-Response-from-Nottingham-Healthcare-NHS-Foundation-Trust_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The CRHTT’s role is broader than preventing admission; hospital admission is one consideration, not the sole determinant of care.
Verbatim wording from the response “As demonstrated, the expectations of a CRHTT assessment and plan are clear and require detailed information gathering and consideration of a wide variety of factors on which to base care planning and decision making. This should include whether a hospital admission is required but this cannot be the sole determining factor.” Source location 2021-0338-Response-from-Nottingham-Healthcare-NHS-Foundation-Trust_Published
Open published response
25 Mar 2021 Sean Daniel FEGAN · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 7 Failure to account for autistic presentation when understanding mental health needs View source Failure to establish informed agreement before withdrawing mental health services View source Failure to proactively engage with family members and receive their concerns when services withdraw View source Unavailability of services for patients with dual diagnosis and significant drugs misuse problems View source Failure to provide access to needed mental health treatment View source Failure to make secondary mental health care decisions using adequate information and assessment View source Overriding care plans without assessment by decision-makers and review of the risk assessment View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 19
Action
Provide an additional weekend prescribing clinic operated by the team’s non-medical prescriber.
Stated completedThe respondent said that this action was complete when they made their response on 30 March 2021. View source
Action
Share audit findings through the internal lessons-learned bulletin and regular Quality and Risk Meetings.
Stated plannedThe respondent said that this action was planned when they made their response on 30 March 2021. View source
Action
Pilot and plan Trust delivery of tiered mandatory learning-disability and autism training for health and social-care staff.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 March 2021. View source
Action
Operate the established collaborative dual-diagnosis clinical reference group for case discussion and pathway identification.
Stated completedThe respondent said that this action was complete when they made their response on 30 March 2021. View source
Action
Embed three substance-misuse workers within Local Mental Health Teams to support complex cases, collaboration, training and best-practice procedures.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 March 2021. View source
Action
Emphasise accurate documentation of changed care plans, discussion, rationale and risk review in staff feedback.
Stated plannedThe respondent said that this action was planned when they made their response on 30 March 2021. View source
Action
Maintain the implemented care peer-support worker post in the Mid-Notts Crisis Resolution Home Treatment team to assist family liaison.
Stated completedThe respondent said that this action was complete when they made their response on 30 March 2021. View source
Action
Incorporate learning from the autism-deaths review into training and future service developments.
Stated plannedThe respondent said that this action was planned when they made their response on 30 March 2021. View source
Action
Explore shared learning with clinicians, teams and the family from Mr Fegan’s case.
Stated plannedThe respondent said that this action was planned when they made their response on 30 March 2021. View source
Action
Expand Crisis Resolution Home Treatment staffing with additional band 6 nurses and healthcare support workers.
Stated completedThe respondent said that this action was complete when they made their response on 30 March 2021. View source
Action
Recruit a dedicated speech and language therapist to support autistic people in community crisis.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 March 2021. View source
Action
Provide additional training on autism-spectrum-disorder presentations for Crisis Resolution Home Treatment staff.
Stated plannedThe respondent said that this action was planned when they made their response on 30 March 2021. View source
Action
Add a discharge checklist checkpoint requiring staff to assess and complete family liaison obligations and more carefully communicate care plans.
Stated plannedThe respondent said that this action was planned when they made their response on 30 March 2021. View source
Action
Operate the established Neurodevelopmental Case Discussion Forum for clinicians to present complex cases and obtain advice.
Stated completedThe respondent said that this action was complete when they made their response on 30 March 2021. View source
Action
Develop an audit providing ongoing assurance about crisis-team step-down decision making.
Stated plannedThe respondent said that this action was planned when they made their response on 30 March 2021. View source
Action
Review crisis-team step-down guidance in the Standard Operating Procedure.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 March 2021. View source
Action
Operate the established Neurodevelopmental Specialist Service to provide autism diagnosis, post-diagnostic support, training, assessment advice, care planning and crisis support.
Stated completedThe respondent said that this action was complete when they made their response on 30 March 2021. View source
Action
Resume Crisis Resolution Home Treatment training on telephone-call handling, including family calls, triage and subsequent actions.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 March 2021. View source
Action
Pilot primary-care mental-health referral triage by contacting referrers and patients and providing senior multidisciplinary discussion for complex cases.
Stated plannedThe respondent said that this action was planned when they made their response on 30 March 2021. View source See 16 more actions
×
AI-generated summary
Sean Daniel FEGAN · 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
Sean Daniel Fegan, who had autism, complex mental health conditions and drug misuse, died from toxicity after taking a combination of prescribed and illicit substances on or before 26 April 2020. The report raised concerns about decisions regarding secondary mental health care, access to treatment, dual diagnosis services, liaison with family members, implementation of care plans and autism awareness.
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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to account for autistic presentation when understanding mental health needs
Wider context from the report “6. Autism awareness – I was concerned that Mr Fegan’s presentation acted as a barrier to a proper understanding of his mental health needs . In line with his autism diagnosis, he did not present in a socially typical way of expressing his feelings and emotions in a demonstrative manner, but rather ‘jumped’ to his view about what treatment he required, namely prescriptions. This was misunderstood by professionals on more than one occasion .
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish informed agreement before withdrawing mental health services
Wider context from the report “5. Implementation of care plans – a care plan was devised by the liaison nurse and psychiatrist, only to be overruled by persons who had not themselves assessed Mr Fegan, on an incorrect basis, and without a review of the risk assessment justifying that decision. Mr Fegan was called and invited to agree to the withdrawal of services. Such a practice runs the significant risk that patients who are less assertive or who have poor insight into their mental health needs will be said to have ‘agreed’ that a service is no longer 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to proactively engage with family members and receive their concerns when services withdraw
Wider context from the report “4. Liaison with family members – there was no evidence of proactive attempts to engage with family members, even when services withdrew . When a family member sought to share concerns, these were rebuffed .
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of services for patients with dual diagnosis and significant drugs misuse problems
Wider context from the report “3. Dual diagnosis – it was acknowledged that there was a ‘gap’ within the services in relation to dual diagnosis patients . There was evidence of a resistance to agreeing to provide a service to patients with significant drugs misuse problems .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide access to needed mental health treatment
Wider context from the report “2. Access to mental health treatment – Mr Fegan had complex mental health conditions and experienced very high levels of distress and anxiety as a consequence. He was declined mental health treatment on two occasions by the Trust . Mr Fegan took an overdose due to his frustration at not being able to access mental health services which he needed . Whilst this was not the cause of Mr Fegan’s death, it created a dangerous state of affairs .
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make secondary mental health care decisions using adequate information and assessment
Wider context from the report “1. Decision making surrounding the need for secondary mental health care – as set out above, a decision was taken in December 2019 that Mr Fegan did not require mental health treatment at all in the absence of adequate information or assessment and for reasons which appeared incorrect .
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Overriding care plans without assessment by decision-makers and review of the risk assessment
Wider context from the report “5. Implementation of care plans – a care plan was devised by the liaison nurse and psychiatrist, only to be overruled by persons who had not themselves assessed Mr Fegan , on an incorrect basis, and without a review of the risk assessment justifying that decision . Mr Fegan was called and invited to agree to the withdrawal of services. Such a practice runs the significant risk that patients who are less assertive or who have poor insight into their mental health needs will be said to have ‘agreed’ that a service is no longer required.
” 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 Provide an additional weekend prescribing clinic operated by the team’s non-medical prescriber.
Verbatim wording from the response “We recognise and sincerely regret that the family’s experience of contact with the crisis team led to a feeling of being rebuffed, and we have reviewed a recording of the telephone call. A sense of a time pressure is evident in the call. We note that the crisis worker did listen to the concerns raised and managed to relay that there was a plan in place for contact with Mr Fegan the following day. The CRHT Team has since been expanded to relieve some of these pressures on staff. This includes an additional 5/6 band 6 nurses and 3 health care support workers. There is also an additional prescribing clinic run at the weekend by the team’s non-medical prescriber.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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 audit findings through the internal lessons-learned bulletin and regular Quality and Risk Meetings.
Verbatim wording from the response “We are reviewing guidance to staff in the Standard Operating Procedure for the crisis teams to ensure accurate decision making when stepping down from crisis team care, and an audit will be developed to provide ongoing assurance. Findings will be shared through our internal lessons learned bulletin, and the Trust’s regular Quality & Risk Meetings.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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 Pilot and plan Trust delivery of tiered mandatory learning-disability and autism training for health and social-care staff.
Verbatim wording from the response “The ████████ mandatory training in learning disability and autism is being piloted from April 2021 for all health and social care staff. This training will be delivered in three tiers: Tier 1: autism awareness, Tier 2: for all clinicians and Tier 3, for advanced specialists. There is an ongoing national pilot on the delivery of this training. The Trust’s Learning and Development teams are involved in planning delivery of this training within the Trust in line with national recommendations. As mentioned earlier the Trust has the Neurodevelopment Steering group established with a working group in place, including AMH and NeSS, with the aim of developing and enhancing the clinical care pathways.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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 Operate the established collaborative dual-diagnosis clinical reference group for case discussion and pathway identification.
Verbatim wording from the response “The Trust’s strategy for promoting integrated care for people with comorbid mental health and substance misuse comprises of a number of components. This includes training on dual diagnosis which is enhanced by the appointment of the substance misuse staff. There is a bi-monthly collaborative clinical reference group for dual diagnosis now established, which includes a range of clinical staff from different services across Nottinghamshire, enabling case discussion and identification of pathways for mental health and substance misuse. There is also good engagement with public health in relation to the wider strategy in developing this area. The trust is currently exploring employment of peer support workers including number of posts and their deployment, supervision and training requirements, any specific roles to be undertaken by peer support workers and how to evaluate their impact.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed three substance-misuse workers within Local Mental Health Teams to support complex cases, collaboration, training and best-practice procedures.
Verbatim wording from the response “As part of the Trust’s Transformation Project and as part of a pilot there will be three substance misuse workers embedded within the LMHTs, who will facilitate closer working with CGL, and recruitment is now underway to fill these posts . The substance misuse workers will also provide training and best practice procedures to staff, whilst also assisting with the more complex presentations.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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 Emphasise accurate documentation of changed care plans, discussion, rationale and risk review in staff feedback.
Verbatim wording from the response “The Trust will always aim to work with patients to decide the most appropriate level of care. This process is a dynamic one, and we will always seek to include the patient in the decision making. The decision making to discharge from CRHT at that point was based on immediate needs and in the knowledge that Mr Fegan did have psychiatic diagnoses and he had an open referral for assessment with the LMHT and could re refer to CRHT if his situation changed. It will be emphasised to staff that if a care plan is changed, there needs to be clear, accurate documentation relating to the discussion and rationale for this change, including review of risk. This will be captured in feedback to the team, including reflections on the decision making to discharge at that point and the evidence behind it.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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 Maintain the implemented care peer-support worker post in the Mid-Notts Crisis Resolution Home Treatment team to assist family liaison.
Verbatim wording from the response “Continuity in a person’s care and liaison with family is really important to us. The Crisis Resolution Home Treatment (CRHT) Team operate to respond to, manage and contain risk, and therefore liaison with the family is very helpful and essential to support holistic assessment and treatment where they are engaged. The Trust has now implemented a care peer support worker post in the Mid-Notts CRHT team which can specifically assist with this liaison.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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 Incorporate learning from the autism-deaths review into training and future service developments.
Verbatim wording from the response “The service has also undertaken work around learning from deaths of individuals with autism, part of which is the Learning from Autism Deaths Thematic Review. The learning from this will be included in training and future service developments.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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 Explore shared learning with clinicians, teams and the family from Mr Fegan’s case.
Verbatim wording from the response “Nevertheless we acknowledge that at this point in time he had had a previous admission of some length and more information could have been obtained from his GP about his current mental health, and more consideration could have been given to the details pertaining to his previous admission into B2. The team have reflected over this, and consider that undertaking an assessment at this point would have enabled a clearer formulation to be developed with him, with a rounded consideration of the interplay between Mr Fegan’s ASD, substance misuse and any underlying mental illness, to inform a plan for him. The Clinical Director will explore opportunities for shared learning with other clinicians and teams from Mr Fegan’s story. This will also be explored in discussion with his family.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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 Expand Crisis Resolution Home Treatment staffing with additional band 6 nurses and healthcare support workers.
Verbatim wording from the response “We recognise and sincerely regret that the family’s experience of contact with the crisis team led to a feeling of being rebuffed, and we have reviewed a recording of the telephone call. A sense of a time pressure is evident in the call. We note that the crisis worker did listen to the concerns raised and managed to relay that there was a plan in place for contact with Mr Fegan the following day. The CRHT Team has since been expanded to relieve some of these pressures on staff. This includes an additional 5/6 band 6 nurses and 3 health care support workers. There is also an additional prescribing clinic run at the weekend by the team’s non-medical prescriber.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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 Recruit a dedicated speech and language therapist to support autistic people in community crisis.
Verbatim wording from the response “The Trust is also strengthening the support provided to people with autism in crisis by recruiting a speech and language therapist dedicated to work with autistic people in crisis in the community, by making use of the additional funding that will be made available from NHS England. There is an ongoing mental health division wide steering group for autism that brings together clinical and non-clinical colleagues to clarify treatment pathways for autistic people and share good practice within the mental health division.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide additional training on autism-spectrum-disorder presentations for Crisis Resolution Home Treatment staff.
Verbatim wording from the response “The Crisis team has since been enhanced and expanded to allow for the increasing number of patients on its caseload, and there will be more training available specifically relating to ASD presentations as outlined in paragraph one and six.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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 Add a discharge checklist checkpoint requiring staff to assess and complete family liaison obligations and more carefully communicate care plans.
Verbatim wording from the response “The Trust operates under the Triangle of Care. The Triangle of Care (ToC) membership scheme promotes shared working between carers, professionals and people using services. Each service within the Trust has to self-assess what this will look like. Within the CRHT, considering the terms of the ToC, the communication of the care plan will be more carefully considered. Upon discharge from the service, a checkpoint will be added to the checklist for the discharging team evaluate and discharge their obligation to liaise with the family at that point.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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 Operate the established Neurodevelopmental Case Discussion Forum for clinicians to present complex cases and obtain advice.
Verbatim wording from the response “Also established is the Neurodevelopmental Case Discussion Forum, facilitated by an experienced clinician in the NeSS service, where clinicians can bring complex cases to present and discuss, and obtain advice.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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 an audit providing ongoing assurance about crisis-team step-down decision making.
Verbatim wording from the response “We are reviewing guidance to staff in the Standard Operating Procedure for the crisis teams to ensure accurate decision making when stepping down from crisis team care, and an audit will be developed to provide ongoing assurance. Findings will be shared through our internal lessons learned bulletin, and the Trust’s regular Quality & Risk Meetings.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review crisis-team step-down guidance in the Standard Operating Procedure.
Verbatim wording from the response “We are reviewing guidance to staff in the Standard Operating Procedure for the crisis teams to ensure accurate decision making when stepping down from crisis team care, and an audit will be developed to provide ongoing assurance. Findings will be shared through our internal lessons learned bulletin, and the Trust’s regular Quality & Risk Meetings.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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 Operate the established Neurodevelopmental Specialist Service to provide autism diagnosis, post-diagnostic support, training, assessment advice, care planning and crisis support.
Verbatim wording from the response “A Neurodevelopmental Specialist Service (NeSS) is now established, from 1st April 2021, to offer diagnosis and post-diagnostic support for autistic people. NeSS will provide training and development of competence in mental health services to support assessment, care planning, advice, and crisis support for autistic people with mental health conditions in the community. Advice can be sought in relation to complex referral decision making involving individuals with autism as a diagnosis.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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 Resume Crisis Resolution Home Treatment training on telephone-call handling, including family calls, triage and subsequent actions.
Verbatim wording from the response “CRHT training on handling of telephone calls was rolled out at the start of the pandemic and is about to be resumed. This includes triage of call (including family member calls), how to handle calls, and subsequent actions.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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 Pilot primary-care mental-health referral triage by contacting referrers and patients and providing senior multidisciplinary discussion for complex cases.
Verbatim wording from the response “with the Local Mental Health Teams. This will ensure much better oversight, closer working relationships and better communication. As part of the Trust’s Transformation Project, we are now working more closely with primary care. There is a pilot scheme due to start in May 2021, involving band 6 mental health nurses, triaging referrals by contacting both the referrer and the patient. There will be access to a senior MDT panel for discussion in complex cases.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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 Discharge from crisis care was based on immediate needs, an open mental health referral, and the option to re-refer if circumstances changed.
Verbatim wording from the response “The CHRT Teams provide services for those with immediate needs and aim to prevent admissions to hospital. If there are no immediate risks, the patient can be discharged from the CRHT caseload, with the option to self-refer if risks were to increase.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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 There is no resistance or policy against treating people with co-occurring mental health and substance misuse conditions.
Verbatim wording from the response “There is no resistance to, or policy within the Trust against treating dual diagnosis patients. The Trust is commissioned to work with CGL (Change, Grow, Live), who provide this service. We regret that the family and the inquest were left with the impression that the Trust is reluctant to engage with this patient group and stress that this is not the case; people with co morbid substance misuse are supported by our services.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
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 referral decision was jointly and carefully considered using available information, although additional GP information could have improved the assessment.
Verbatim wording from the response “At the time the decision was made, it was made in joint approach with the commissioned service for drug and alcohol support, Change, Grow, Live (CGL), who were present at the time, and with the benefit of his substance misuse notes. The prescriber and the consultant were also there and considered the referral carefully. Whilst the patient own clozapine and melatonin to be considered it is felt unlikely that these particular drugs would have been prescribed given his risks, particularly given the addictive potential of clonazepam. Melatonin is not licensed for use in adults, it is a grey drug on the Area Prescribing Committee, as the evidence for benefit is too limited.” Source location 2021-0083-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust-Redacted
Open published response
28 Aug 2020 Carlington Maurice Spencer · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 18 Lack of training on confirmation bias affecting staff decision making View source Lack of clear escalation pathways for presumed Spice-related incidents View source Failure to establish the timing, quantity and potency of drug consumption View source Lack of instructions on duration of conservative observation for presumed Spice consumption View source Lack of meaningful training in self-induced intoxication and new psychoactive substances View source Partial, incomplete and unverifiable record keeping by Discipline and healthcare staff View source Inadequate access, review, storage and retrieval of CCTV footage View source Failure to appreciate, record or actively seek co-detainee concerns View source Inaccurate, irregular and unavailable records of incapacitated detainees View source Failure to consult Illicit Substance Misuse Programme information View source Inadequate knowledge and training in diagnosis, treatment and care of new psychoactive substance intoxication View source Lack of diversity awareness training for dealing with Afro-Caribbean detainees View source Lack of escalation pathways for drug-related incidents developing into medical emergencies View source Lack of escalation protocols recognising healthcare primacy in ongoing detainee care View source Confusion and uncertainty over emergency alarm activation View source Failure to challenge, test or verify presumed drug intoxication View source Failure to consider differential diagnoses and exacerbation of pre-existing co-morbidities View source Failure to clinically verify presumed recent drug consumption View source See 15 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Carlington Maurice Spencer · 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
Carlington Maurice Spencer, a detainee at Morton Hall IRC, suffered a right middle cerebral artery infarction after being found unwell and was later confirmed deceased on 3 October 2017. The report identifies concerns about confirmation bias relating to presumed drug use, inadequate monitoring and record keeping, poor communication and escalation between discipline and healthcare staff, failures to recognise stroke symptoms, and delays in emergency treatment.
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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training on confirmation bias affecting staff decision making
Wider context from the report “4. Training is needed to enable staff to appreciate the potential for their decision making to be affected by "confirmation bias" in addition to the need for diversity awareness training when dealing with detainees of Afro-Caribbean heritage;
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear escalation pathways for presumed Spice-related incidents
Wider context from the report “1. The case demonstrated the failures of existing systems, management and working practices within the Discipline staff employed by Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with detainees with a known history of recreational use of drugs in such a way that when a detainee presents in a manner that is interpreted as being presumed and/or assumed to be under the influence of drugs, this presumption and/or assumption is not challenged or tested or verified (as an example, by meaningful searches of the detainee or his room; review of CCTV evidence or escalation for advice from healthcare personnel);
b. Concerns of co-detainees are not appreciated or noted or actively sought;
c. Record keeping and purported observations of detainees who are incapacitated by reason of presumed self-induced intoxication are inaccurate, irregular and unavailable for inspection by health care personnel;
d. Discipline staff have no meaningful training on the categories of self-induced intoxication and in particular "new psychoactive substances" such as the synthetic cannabinoid known as "Spice";
e. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with a presumed "Spice" related incident ;
f. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with an incident that may have commenced as a drug related incident but develops into a potential medical emergency;
g. Access, review, storage and retrieval of CCTV footage is inadequate and unsatisfactory;
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish the timing, quantity and potency of drug consumption
Wider context from the report “2. The case demonstrated the failures of existing systems, management and working practices within the healthcare provision for detainees at Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with a detainee with a known history of recreational drug use in such a way that when a detainee presents in a manner that is interpreted as being presumed or assumed to be attributable to recent self-induced intoxication, this assumption or presumption is not clinically evaluated by reference to a verification of evidence supporting of recent drug consumption (such evidence being available either from the patient, from Discipline staff, from other detainees, physical evidence in the room);
b. In cases where a diagnosis of recent self-induced intoxication has been reasonably made, a differential diagnosis is not considered to evaluate the potential exacerbations of the patients pre-existing co-morbidities;
c. No appreciation exists of the importance of establishing when the detainee had last consumed drugs and in what quantity and at what potency ;
d. Failure to consult information contained on the Illicit Substance Misuse Programme;
e. An absence of protocols or clear instructions/expectations from healthcare staff to Discipline staff that in the event a conservative pathway of treatment is considered appropriate (the detainee being allowed to "sleep off" the effects of the drugs) how long this should be permitted in a case of presumed "Spice" consumption;
f. An absence of protocols or clear escalation pathways or working practices between healthcare staff and Discipline staff that recognises the primacy of the role of healthcare staff in any case involving ongoing care for a detainee, in particular in a scenario of a detainee with relevant co-morbidities who is recovering from a presumed "Spice" incident;
g. Inadequacy of knowledge and training in the diagnosis, treatment and care in cases of self-induced intoxication by reason of "new psychoactive substances";
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of instructions on duration of conservative observation for presumed Spice consumption
Wider context from the report “2. The case demonstrated the failures of existing systems, management and working practices within the healthcare provision for detainees at Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with a detainee with a known history of recreational drug use in such a way that when a detainee presents in a manner that is interpreted as being presumed or assumed to be attributable to recent self-induced intoxication, this assumption or presumption is not clinically evaluated by reference to a verification of evidence supporting of recent drug consumption (such evidence being available either from the patient, from Discipline staff, from other detainees, physical evidence in the room);
b. In cases where a diagnosis of recent self-induced intoxication has been reasonably made, a differential diagnosis is not considered to evaluate the potential exacerbations of the patients pre-existing co-morbidities;
c. No appreciation exists of the importance of establishing when the detainee had last consumed drugs and in what quantity and at what potency;
d. Failure to consult information contained on the Illicit Substance Misuse Programme;
e. An absence of protocols or clear instructions/expectations from healthcare staff to Discipline staff that in the event a conservative pathway of treatment is considered appropriate (the detainee being allowed to "sleep off" the effects of the drugs) how long this should be permitted in a case of presumed "Spice" consumption ;
f. An absence of protocols or clear escalation pathways or working practices between healthcare staff and Discipline staff that recognises the primacy of the role of healthcare staff in any case involving ongoing care for a detainee, in particular in a scenario of a detainee with relevant co-morbidities who is recovering from a presumed "Spice" incident;
g. Inadequacy of knowledge and training in the diagnosis, treatment and care in cases of self-induced intoxication by reason of "new psychoactive substances";
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of meaningful training in self-induced intoxication and new psychoactive substances
Wider context from the report “1. The case demonstrated the failures of existing systems, management and working practices within the Discipline staff employed by Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with detainees with a known history of recreational use of drugs in such a way that when a detainee presents in a manner that is interpreted as being presumed and/or assumed to be under the influence of drugs, this presumption and/or assumption is not challenged or tested or verified (as an example, by meaningful searches of the detainee or his room; review of CCTV evidence or escalation for advice from healthcare personnel);
b. Concerns of co-detainees are not appreciated or noted or actively sought;
c. Record keeping and purported observations of detainees who are incapacitated by reason of presumed self-induced intoxication are inaccurate, irregular and unavailable for inspection by health care personnel;
d. Discipline staff have no meaningful training on the categories of self-induced intoxication and in particular "new psychoactive substances" such as the synthetic cannabinoid known as "Spice" ;
e. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with a presumed "Spice" related incident;
f. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with an incident that may have commenced as a drug related incident but develops into a potential medical emergency;
g. Access, review, storage and retrieval of CCTV footage is inadequate and unsatisfactory;
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Partial, incomplete and unverifiable record keeping by Discipline and healthcare staff
Wider context from the report “5. Record keeping, both for Discipline and healthcare staff was established in this case to be partial, incomplete and undertaken in circumstances where the provenance of such records is unverifiable ;
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate access, review, storage and retrieval of CCTV footage
Wider context from the report “1. The case demonstrated the failures of existing systems, management and working practices within the Discipline staff employed by Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with detainees with a known history of recreational use of drugs in such a way that when a detainee presents in a manner that is interpreted as being presumed and/or assumed to be under the influence of drugs, this presumption and/or assumption is not challenged or tested or verified (as an example, by meaningful searches of the detainee or his room; review of CCTV evidence or escalation for advice from healthcare personnel);
b. Concerns of co-detainees are not appreciated or noted or actively sought;
c. Record keeping and purported observations of detainees who are incapacitated by reason of presumed self-induced intoxication are inaccurate, irregular and unavailable for inspection by health care personnel;
d. Discipline staff have no meaningful training on the categories of self-induced intoxication and in particular "new psychoactive substances" such as the synthetic cannabinoid known as "Spice";
e. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with a presumed "Spice" related incident;
f. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with an incident that may have commenced as a drug related incident but develops into a potential medical emergency;
g. Access, review, storage and retrieval of CCTV footage is inadequate and unsatisfactory ;
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appreciate, record or actively seek co-detainee concerns
Wider context from the report “1. The case demonstrated the failures of existing systems, management and working practices within the Discipline staff employed by Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with detainees with a known history of recreational use of drugs in such a way that when a detainee presents in a manner that is interpreted as being presumed and/or assumed to be under the influence of drugs, this presumption and/or assumption is not challenged or tested or verified (as an example, by meaningful searches of the detainee or his room; review of CCTV evidence or escalation for advice from healthcare personnel);
b. Concerns of co-detainees are not appreciated or noted or actively sought ;
c. Record keeping and purported observations of detainees who are incapacitated by reason of presumed self-induced intoxication are inaccurate, irregular and unavailable for inspection by health care personnel;
d. Discipline staff have no meaningful training on the categories of self-induced intoxication and in particular "new psychoactive substances" such as the synthetic cannabinoid known as "Spice";
e. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with a presumed "Spice" related incident;
f. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with an incident that may have commenced as a drug related incident but develops into a potential medical emergency;
g. Access, review, storage and retrieval of CCTV footage is inadequate and unsatisfactory;
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate, irregular and unavailable records of incapacitated detainees
Wider context from the report “1. The case demonstrated the failures of existing systems, management and working practices within the Discipline staff employed by Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with detainees with a known history of recreational use of drugs in such a way that when a detainee presents in a manner that is interpreted as being presumed and/or assumed to be under the influence of drugs, this presumption and/or assumption is not challenged or tested or verified (as an example, by meaningful searches of the detainee or his room; review of CCTV evidence or escalation for advice from healthcare personnel);
b. Concerns of co-detainees are not appreciated or noted or actively sought;
c. Record keeping and purported observations of detainees who are incapacitated by reason of presumed self-induced intoxication are inaccurate, irregular and unavailable for inspection by health care personnel ;
d. Discipline staff have no meaningful training on the categories of self-induced intoxication and in particular "new psychoactive substances" such as the synthetic cannabinoid known as "Spice";
e. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with a presumed "Spice" related incident;
f. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with an incident that may have commenced as a drug related incident but develops into a potential medical emergency;
g. Access, review, storage and retrieval of CCTV footage is inadequate and unsatisfactory;
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consult Illicit Substance Misuse Programme information
Wider context from the report “2. The case demonstrated the failures of existing systems, management and working practices within the healthcare provision for detainees at Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with a detainee with a known history of recreational drug use in such a way that when a detainee presents in a manner that is interpreted as being presumed or assumed to be attributable to recent self-induced intoxication, this assumption or presumption is not clinically evaluated by reference to a verification of evidence supporting of recent drug consumption (such evidence being available either from the patient, from Discipline staff, from other detainees, physical evidence in the room);
b. In cases where a diagnosis of recent self-induced intoxication has been reasonably made, a differential diagnosis is not considered to evaluate the potential exacerbations of the patients pre-existing co-morbidities;
c. No appreciation exists of the importance of establishing when the detainee had last consumed drugs and in what quantity and at what potency;
d. Failure to consult information contained on the Illicit Substance Misuse Programme ;
e. An absence of protocols or clear instructions/expectations from healthcare staff to Discipline staff that in the event a conservative pathway of treatment is considered appropriate (the detainee being allowed to "sleep off" the effects of the drugs) how long this should be permitted in a case of presumed "Spice" consumption;
f. An absence of protocols or clear escalation pathways or working practices between healthcare staff and Discipline staff that recognises the primacy of the role of healthcare staff in any case involving ongoing care for a detainee, in particular in a scenario of a detainee with relevant co-morbidities who is recovering from a presumed "Spice" incident;
g. Inadequacy of knowledge and training in the diagnosis, treatment and care in cases of self-induced intoxication by reason of "new psychoactive substances";
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate knowledge and training in diagnosis, treatment and care of new psychoactive substance intoxication
Wider context from the report “2. The case demonstrated the failures of existing systems, management and working practices within the healthcare provision for detainees at Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with a detainee with a known history of recreational drug use in such a way that when a detainee presents in a manner that is interpreted as being presumed or assumed to be attributable to recent self-induced intoxication, this assumption or presumption is not clinically evaluated by reference to a verification of evidence supporting of recent drug consumption (such evidence being available either from the patient, from Discipline staff, from other detainees, physical evidence in the room);
b. In cases where a diagnosis of recent self-induced intoxication has been reasonably made, a differential diagnosis is not considered to evaluate the potential exacerbations of the patients pre-existing co-morbidities;
c. No appreciation exists of the importance of establishing when the detainee had last consumed drugs and in what quantity and at what potency;
d. Failure to consult information contained on the Illicit Substance Misuse Programme;
e. An absence of protocols or clear instructions/expectations from healthcare staff to Discipline staff that in the event a conservative pathway of treatment is considered appropriate (the detainee being allowed to "sleep off" the effects of the drugs) how long this should be permitted in a case of presumed "Spice" consumption;
f. An absence of protocols or clear escalation pathways or working practices between healthcare staff and Discipline staff that recognises the primacy of the role of healthcare staff in any case involving ongoing care for a detainee, in particular in a scenario of a detainee with relevant co-morbidities who is recovering from a presumed "Spice" incident;
g. Inadequacy of knowledge and training in the diagnosis, treatment and care in cases of self-induced intoxication by reason of "new psychoactive substances" ;
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of diversity awareness training for dealing with Afro-Caribbean detainees
Wider context from the report “4. Training is needed to enable staff to appreciate the potential for their decision making to be affected by "confirmation bias" in addition to the need for diversity awareness training when dealing with detainees of Afro-Caribbean heritage ;
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of escalation pathways for drug-related incidents developing into medical emergencies
Wider context from the report “1. The case demonstrated the failures of existing systems, management and working practices within the Discipline staff employed by Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with detainees with a known history of recreational use of drugs in such a way that when a detainee presents in a manner that is interpreted as being presumed and/or assumed to be under the influence of drugs, this presumption and/or assumption is not challenged or tested or verified (as an example, by meaningful searches of the detainee or his room; review of CCTV evidence or escalation for advice from healthcare personnel);
b. Concerns of co-detainees are not appreciated or noted or actively sought;
c. Record keeping and purported observations of detainees who are incapacitated by reason of presumed self-induced intoxication are inaccurate, irregular and unavailable for inspection by health care personnel;
d. Discipline staff have no meaningful training on the categories of self-induced intoxication and in particular "new psychoactive substances" such as the synthetic cannabinoid known as "Spice";
e. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with a presumed "Spice" related incident;
f. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with an incident that may have commenced as a drug related incident but develops into a potential medical emergency ;
g. Access, review, storage and retrieval of CCTV footage is inadequate and unsatisfactory;
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of escalation protocols recognising healthcare primacy in ongoing detainee care
Wider context from the report “2. The case demonstrated the failures of existing systems, management and working practices within the healthcare provision for detainees at Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with a detainee with a known history of recreational drug use in such a way that when a detainee presents in a manner that is interpreted as being presumed or assumed to be attributable to recent self-induced intoxication, this assumption or presumption is not clinically evaluated by reference to a verification of evidence supporting of recent drug consumption (such evidence being available either from the patient, from Discipline staff, from other detainees, physical evidence in the room);
b. In cases where a diagnosis of recent self-induced intoxication has been reasonably made, a differential diagnosis is not considered to evaluate the potential exacerbations of the patients pre-existing co-morbidities;
c. No appreciation exists of the importance of establishing when the detainee had last consumed drugs and in what quantity and at what potency;
d. Failure to consult information contained on the Illicit Substance Misuse Programme;
e. An absence of protocols or clear instructions/expectations from healthcare staff to Discipline staff that in the event a conservative pathway of treatment is considered appropriate (the detainee being allowed to "sleep off" the effects of the drugs) how long this should be permitted in a case of presumed "Spice" consumption;
f. An absence of protocols or clear escalation pathways or working practices between healthcare staff and Discipline staff that recognises the primacy of the role of healthcare staff in any case involving ongoing care for a detainee , in particular in a scenario of a detainee with relevant co-morbidities who is recovering from a presumed "Spice" incident;
g. Inadequacy of knowledge and training in the diagnosis, treatment and care in cases of self-induced intoxication by reason of "new psychoactive substances";
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Confusion and uncertainty over emergency alarm activation
Wider context from the report “3. In this case, a "general alarm" was called and in evidence from both Discipline and Healthcare staff, there exists on-going confusion and uncertainty as to the calling of a general alarm or a "Code 1" or "Code 2" alarm or "Code Red" or "Code Blue" (the replacement codification) confirming the need for training or re-training on this issue.
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to challenge, test or verify presumed drug intoxication
Wider context from the report “1. The case demonstrated the failures of existing systems, management and working practices within the Discipline staff employed by Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with detainees with a known history of recreational use of drugs in such a way that when a detainee presents in a manner that is interpreted as being presumed and/or assumed to be under the influence of drugs, this presumption and/or assumption is not challenged or tested or verified (as an example, by meaningful searches of the detainee or his room; review of CCTV evidence or escalation for advice from healthcare personnel);
b. Concerns of co-detainees are not appreciated or noted or actively sought;
c. Record keeping and purported observations of detainees who are incapacitated by reason of presumed self-induced intoxication are inaccurate, irregular and unavailable for inspection by health care personnel;
d. Discipline staff have no meaningful training on the categories of self-induced intoxication and in particular "new psychoactive substances" such as the synthetic cannabinoid known as "Spice";
e. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with a presumed "Spice" related incident;
f. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with an incident that may have commenced as a drug related incident but develops into a potential medical emergency;
g. Access, review, storage and retrieval of CCTV footage is inadequate and unsatisfactory;
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider differential diagnoses and exacerbation of pre-existing co-morbidities
Wider context from the report “2. The case demonstrated the failures of existing systems, management and working practices within the healthcare provision for detainees at Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with a detainee with a known history of recreational drug use in such a way that when a detainee presents in a manner that is interpreted as being presumed or assumed to be attributable to recent self-induced intoxication, this assumption or presumption is not clinically evaluated by reference to a verification of evidence supporting of recent drug consumption (such evidence being available either from the patient, from Discipline staff, from other detainees, physical evidence in the room);
b. In cases where a diagnosis of recent self-induced intoxication has been reasonably made, a differential diagnosis is not considered to evaluate the potential exacerbations of the patients pre-existing co-morbidities ;
c. No appreciation exists of the importance of establishing when the detainee had last consumed drugs and in what quantity and at what potency;
d. Failure to consult information contained on the Illicit Substance Misuse Programme;
e. An absence of protocols or clear instructions/expectations from healthcare staff to Discipline staff that in the event a conservative pathway of treatment is considered appropriate (the detainee being allowed to "sleep off" the effects of the drugs) how long this should be permitted in a case of presumed "Spice" consumption;
f. An absence of protocols or clear escalation pathways or working practices between healthcare staff and Discipline staff that recognises the primacy of the role of healthcare staff in any case involving ongoing care for a detainee, in particular in a scenario of a detainee with relevant co-morbidities who is recovering from a presumed "Spice" incident;
g. Inadequacy of knowledge and training in the diagnosis, treatment and care in cases of self-induced intoxication by reason of "new psychoactive substances";
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clinically verify presumed recent drug consumption
Wider context from the report “2. The case demonstrated the failures of existing systems, management and working practices within the healthcare provision for detainees at Morton Hall IRC namely:
a. The existence of "confirmation bias" or "confirmatory bias" when dealing with a detainee with a known history of recreational drug use in such a way that when a detainee presents in a manner that is interpreted as being presumed or assumed to be attributable to recent self-induced intoxication, this assumption or presumption is not clinically evaluated by reference to a verification of evidence supporting of recent drug consumption (such evidence being available either from the patient, from Discipline staff, from other detainees, physical evidence in the room);
b. In cases where a diagnosis of recent self-induced intoxication has been reasonably made, a differential diagnosis is not considered to evaluate the potential exacerbations of the patients pre-existing co-morbidities;
c. No appreciation exists of the importance of establishing when the detainee had last consumed drugs and in what quantity and at what potency;
d. Failure to consult information contained on the Illicit Substance Misuse Programme;
e. An absence of protocols or clear instructions/expectations from healthcare staff to Discipline staff that in the event a conservative pathway of treatment is considered appropriate (the detainee being allowed to "sleep off" the effects of the drugs) how long this should be permitted in a case of presumed "Spice" consumption;
f. An absence of protocols or clear escalation pathways or working practices between healthcare staff and Discipline staff that recognises the primacy of the role of healthcare staff in any case involving ongoing care for a detainee, in particular in a scenario of a detainee with relevant co-morbidities who is recovering from a presumed "Spice" incident;
g. Inadequacy of knowledge and training in the diagnosis, treatment and care in cases of self-induced intoxication by reason of "new psychoactive substances";
” Open source report
28 Dec 2017 Michael Richard Drewry · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Failure to promptly report or escalate matters of concern to senior staff View source Failure to ensure consistency and continuity of care View source Failure to make accurate and prompt records of consultations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Michael Richard Drewry · 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 Richard Drewry had a history of anxiety and low mood, with deteriorating mental health and episodes involving knives shortly before he was found with a ligature around his neck on 3 April 2017. He sustained fatal injuries, suffered an unsurvivable hypoxic brain injury, and died in hospital on 8 April 2017. The substantive concerns were failures by the Crisis Team to provide consistent and continuous care, make accurate and prompt records, and escalate concerns appropriately and promptly.
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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly report or escalate matters of concern to senior staff
Wider context from the report “(3) The failure of the Crisis Team promptly to report/escalate any matters of concern to senior members of staff so that appropriate and timely steps could be taken in relation to the management of the deceased’s care including, if necessary, hospitalisation;
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure consistency and continuity of care
Wider context from the report “(1) The failure of the Crisis Team to ensure consistency and continuity of care for the deceased, in particular the changing personnel who visited the deceased ;
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make accurate and prompt records of consultations
Wider context from the report “(2) The failure of the Crisis Team to make accurate and prompt records of all consultations with the deceased ;
” 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 Introduce the Modified Modified Continuity Index into routine reporting, trial it in one team, and then implement it across Crisis Teams.
Verbatim wording from the response “The Trust is shortly to introduce the Modified Modified Continuity Index (MMCI) into its routine reporting systems, at both individual and team levels. This is a measure calculated using the total number of patient visits and the number of different clinical staff visiting the patients and gives a resulting score between 0 and 1, the more staff providing care to the patient the lower the score will be.” Source location 2017-0386-Response-by-Nottinghamshire-Healthcare-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 Monitor compliance with timely RiO recording through monthly managerial supervision.
Verbatim wording from the response “On occasion, staff do have to return to base due to the intermittent availability of the telecom service signal/network therefore delaying the entry on the RiO system. Staff have been reminded of the importance of this in team meetings (held 31/01/2018) and will be monitored ongoing in managerial supervision on a monthly basis.” Source location 2017-0386-Response-by-Nottinghamshire-Healthcare-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 Train and instruct Crisis Team staff, and provide software and devices, to support contemporaneous recording of consultations in RiO.
Verbatim wording from the response “Crisis Team staff are fully aware that contemporaneous notes must be recorded about the patient and must be written at the time of the event or as soon afterwards on the Trust Patient Information System (RiO).” Source location 2017-0386-Response-by-Nottinghamshire-Healthcare-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 Remind staff of escalation procedures and the importance of timely input during team meetings and monthly managerial supervision.
Verbatim wording from the response “When staff are concerned following a contact with a patient, these concerns must be escalated to senior members of staff. This can be done through the daily handover of patients who are on RED in the RAG rating alongside any other patients causing concern and a doctor is present at these meetings. There is also a line management structure through which issues can be escalated to senior managers and staff have been reminded of this process which is included in the operational procedure.” Source location 2017-0386-Response-by-Nottinghamshire-Healthcare-NHS-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 Existing handover, line-management escalation, and multidisciplinary meeting arrangements are relied upon to manage and escalate patient concerns safely.
Verbatim wording from the response “Crisis Team staff are fully aware the need to escalate any concerns regarding a difference in presentation of any patient.” Source location 2017-0386-Response-by-Nottinghamshire-Healthcare-NHS-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 Continuity of staff cannot always be provided because 24-hour crisis response requirements and high-intensity care create operational constraints.
Verbatim wording from the response “Continuity of care is a challenge within our Crisis Resolution and Home Treatment Teams due to the service operating 24 hours a day, 7 days a week. Staff work 12 hour shifts and need to be able to respond swiftly to urgent referrals, within 4 hours and 24 hours whilst also maintaining robust care and treatment for those patients already on their caseload.” Source location 2017-0386-Response-by-Nottinghamshire-Healthcare-NHS-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 Prompt recording can be delayed when intermittent telecommunications signals prevent staff from entering notes remotely.
Verbatim wording from the response “Crisis Team staff are fully aware that contemporaneous notes must be recorded about the patient and must be written at the time of the event or as soon afterwards on the Trust Patient Information System (RiO).” Source location 2017-0386-Response-by-Nottinghamshire-Healthcare-NHS-Trust
Open published response
6 Nov 2017 RYAN JAMES VOUT · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Inability to pre-arrange ambulance attendance during execution of a s.135 (1) MHA Act 1983 warrant View source Failure to inform family before discharge View source Failure of hospital and community professionals to liaise before discharge View source Lack of a formal briefing or risk assessment before entry under a s.135 (1) MHA Act 1983 warrant 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
RYAN JAMES VOUT · 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
Ryan James Vout, who had paranoid schizophrenia and was apparently unmedicated, stabbed himself in the chest during an attempt by police officers to execute a section 135 warrant on 10 August 2016. He died despite emergency first aid and hospital treatment. The principal concerns were inadequate coordination before his discharge from psychiatric care, the inability to pre-arrange an ambulance for section 135 warrant attendances, and the lack of a formal briefing or risk assessment before officers entered the premises.
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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inability to pre-arrange ambulance attendance during execution of a s.135 (1) MHA Act 1983 warrant
Wider context from the report “(2) The inability to pre-arrange attendance of an ambulance when police officers exercise a s.135 (1) MHA Act 1983 warrant;
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform family before discharge
Wider context from the report “(1) The lack of a co-ordinated discharge from in-patient psychiatric care into the community, in particular the failure of appropriate professionals from hospital and community to liaise and for family to be informed as a pre-requisite for discharge ;
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital and community professionals to liaise before discharge
Wider context from the report “(1) The lack of a co-ordinated discharge from in-patient psychiatric care into the community, in particular the failure of appropriate professionals from hospital and community to liaise and for family to be informed as a pre-requisite for discharge;
” 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 Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal briefing or risk assessment before entry under a s.135 (1) MHA Act 1983 warrant
Wider context from the report “(3) The lack of a formality to the ‘briefing’ or risk assessment exercise before officers enter premises with a view to exercising a s.135 (1) MHA Act 1983 warrant.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations