12 Oct 2016 Rohid SHERGILL · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 7 Failure of information-sharing between trusts View source Unclear responsibility for ensuring parental competence in NGT feeding View source Lack of parental competence for first use of NGT feeding View source Repeated use of syringes for NGT aspirate pH testing View source Lack of staff training on information to record in shared care records View source Failure of clinicians visiting sick children at home to perform or confirm pH testing before medication administration View source Lack of clear allocation of a named keyworker or lead nurse for community care coordination View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Rohid SHERGILL · 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
Rohid Shergill, who had Duchenne’s muscular dystrophy and was fed through a nasogastric tube, died on 14 March 2016 after the tube was inserted into his lung and was used for feeding and medication. The principal concerns included inadequate checking of the tube position, uncertainty about parental understanding of pH testing, insufficient information-sharing between trusts, unclear care coordination, and possible contamination from repeated syringe use.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of information-sharing between trusts
Wider context from the report “2. Information-sharing between the two trusts – by way of shared IT and / or the use of shared care folders kept in the family home – with clear training to staff on what information should be recorded there.
” Open source report × Source evidence
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 ensuring parental competence in NGT feeding
Wider context from the report “1. Ensuring that parents of children fed in this way are completely happy with what they have to do, and understand the significance of it. There was clear confusion about whether this was the responsibility of the school nurse or the community nurses (then working separately). Urgent consideration should be given to an agreed protocol to ensure parental competence whenever an NGT is first used – in the community or in hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of parental competence for first use of NGT feeding
Wider context from the report “1. Ensuring that parents of children fed in this way are completely happy with what they have to do, and understand the significance of it. There was clear confusion about whether this was the responsibility of the school nurse or the community nurses (then working separately). Urgent consideration should be given to an agreed protocol to ensure parental competence whenever an NGT is first used – in the community or in hospital .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Repeated use of syringes for NGT aspirate pH testing
Wider context from the report “5. There should be a review of the policy of syringes being used multiple times for pH testing aspirate from NGTs – and whether this results in a risk of contamination and therefore falsely reassuring results .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training on information to record in shared care records
Wider context from the report “2. Information-sharing between the two trusts – by way of shared IT and / or the use of shared care folders kept in the family home – with clear training to staff on what information should be recorded there .
” Open source report × Source evidence
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 clinicians visiting sick children at home to perform or confirm pH testing before medication administration
Wider context from the report “4. Training to physiotherapy teams regarding the importance of pH testing (or at least confirming this has been done) before administration of medication. This should be considered for other disciplines who routinely visit sick children at home and prescribe medication – such as occupational therapists / speech and language therapists.
” Open source report × Source evidence
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 allocation of a named keyworker or lead nurse for community care coordination
Wider context from the report “3. Clear guidance on a named keyworker / lead nurse who is responsible for coordinating the care of children cared for in the community.
” Open source report
3 May 2016 Shalan Blackwood · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 6 Lack of proper provision for care and supervision of prisoners with complex physical and/or mental health needs View source Insufficient prison staffing for proper regimes and unlocking of prisoners requiring four person unlocks in the Segregation Unit View source Rife use of New Psychoactive Substances within the prison View source Insufficient staffing of the Substance Misuse Team View source Failure of healthcare staff to recognise urgent physical symptoms obscured by mental health issues View source Unclear or unavailable documentary tool for decisions about prisoners remaining in Segregation View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Shalan Blackwood · 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
Shalan Blackwood died at HMP Nottingham on 5 August 2015 as a result of bleeding from a duodenal ulcer. The report identified concerns about inadequate care and supervision for prisoners with complex physical or mental health needs, insufficient staffing for prisoners in segregation requiring a four-person unlock, unclear decision-making tools, widespread use of New Psychoactive Substances, and insufficient recognition of urgent physical symptoms obscured by mental health issues.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of proper provision for care and supervision of prisoners with complex physical and/or mental health needs
Wider context from the report “1. That there is no proper provision for the care and supervision of prisoners who present with complex physical and/or mental health needs . It is understood that such a provision could be provided by means of an inpatient unit within the prison, such as for example is the case at HMP Liverpool.
” Open source report × Source evidence
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 prison staffing for proper regimes and unlocking of prisoners requiring four person unlocks in the Segregation Unit
Wider context from the report “2. That at present, if a prisoner is assessed as needing a four person unlock, and is within the Segregation Unit, there are insufficient prison staff to provide him with a proper regime and to unlock him after lunchtime , for example to allow
” Open source report × Source evidence
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 Rife use of New Psychoactive Substances within the prison
Wider context from the report “3. That the use of New Psychoactive Substances (NPS) remains rife within the prison , and presentations such as Mr Blackwood’s are not diminishing , and that the Substance Misuse Team requires further staff to be effective in future.
” Open source report × Source evidence
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 of the Substance Misuse Team
Wider context from the report “3. That the use of New Psychoactive Substances (NPS) remains rife within the prison, and presentations such as Mr Blackwood’s are not diminishing, and that the Substance Misuse Team requires further staff to be effective in future .
” Open source report × Source evidence
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 healthcare staff to recognise urgent physical symptoms obscured by mental health issues
Wider context from the report “5. That healthcare staff are insufficiently alert to the issue that physical symptoms which require urgent medical attention may be occluded by mental health issues .
” Open source report × Source evidence
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 or unavailable documentary tool for decisions about prisoners remaining in Segregation
Wider context from the report “4. That the documentary tool for decision making between prison staff and healthcare staff , as to whether a prisoner is fit to remain in Segregation and should do so , is unclear in or in use .
” Open source report
16 Mar 2016 Steven James May · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 10 Inadequate First Aid training for prison staff View source Selective emergency First Aid training among prison staff View source Lack of mental health experience and/or training among reception nursing staff View source Involvement of prison staff lacking relevant training or appropriate rank in the ACCT process View source Hesitancy to enter a cell during an emergency because of an instruction not to enter cells alone View source Failure to ensure medical professional attendance at First Care Reviews View source Failure of reception nursing staff to consult historical medical notes during reception interviews View source Limited accessibility of health and/or mental health care during weekends and Bank Holidays View source Reliance on verbal handovers rather than written records for prisoner information View source Failure to prepare sufficiently full ACCT assessment notes View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Steven James May · 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
Steven James May died by hanging at HMP Ranby on 25 May 2015 at 01:45, after previously expressing suicidal intent and being placed on the ACCT programme. The report identified concerns about failures in reception health screening, ACCT documentation and reviews, information handovers, staff training and involvement, emergency first aid, cell-entry procedures, and access to health and mental health care.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate First Aid training for prison staff
Wider context from the report “(9) The inadequacy of First Aid training provided to prison staff in any event (namely, the administration of CPR by prison staff whilst the deceased was lying on a bed );
” Open source report × Source evidence
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 Selective emergency First Aid training among prison staff
Wider context from the report “(7) The selective training of prison staff in emergency First Aid (namely the first member of prison staff on the scene of the death was not trained in the administration of CPR and was ignorant of the location of and method of use of defibrillators );
” Open source report × Source evidence
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 mental health experience and/or training among reception nursing staff
Wider context from the report “(2) The lack of experience and/or training of reception nursing staff in the field of mental health ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Involvement of prison staff lacking relevant training or appropriate rank in the ACCT process
Wider context from the report “(5) The involvement in the ACCT process of prison staff possessing neither relevant training nor the appropriate rank ;
” Open source report × Source evidence
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 Hesitancy to enter a cell during an emergency because of an instruction not to enter cells alone
Wider context from the report “(8) The hesitancy of the first member of prison staff on the scene to enter the deceased’s cell in apparent adherence to an instruction not to enter cells alone ;
” Open source report × Source evidence
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 medical professional attendance at First Care Reviews
Wider context from the report “(6) The failure of prison staff to ensure the attendance of a medical professional at the First Care Review ;
” Open source report × Source evidence
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 reception nursing staff to consult historical medical notes during reception interviews
Wider context from the report “(1) The failure of reception nursing staff , by reason of lack of training and/or instruction or lack of staff and/or time , to consult the deceased’s historical medical notes prior to or during the reception interview ;
” Open source report × Source evidence
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 accessibility of health and/or mental health care during weekends and Bank Holidays
Wider context from the report “(10) The accessibility of health and/or mental health care to inmates at weekends and during Bank Holidays .
” Open source report × Source evidence
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 verbal handovers rather than written records for prisoner information
Wider context from the report “(4) Reliance by prison staff on verbal and/or oral handovers of information, rather than written records , regarding 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 prepare sufficiently full ACCT assessment notes
Wider context from the report “(3) The failure of prison staff when preparing the ACCT document to prepare as full a note as possible . For example, to follow the subject areas suggested in the narrative accompanying sections 1-8 of the Assessment Interview ;
” 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 Remind reception staff to review patient notes for key information during reception health screening.
Verbatim wording from the response “In response to this recommendation all staff were reminded via primary care team meetings (minutes of the meeting have been emailed to all staff members) and during one to one sessions with their line manager of the importance of reviewing patient notes for key information during the reception health screen.” Source location 2016-0109-Response-by-Nottingham-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 Provide a designated reception nurse to reduce time constraints during reception screening.
Verbatim wording from the response “In addition to this, I understand that ████████ gave evidence at the inquest that in November 2015 the Trust submitted a business case to NHS England (the Trust’s commissioner) seeking recurrent funding for further healthcare staff. This document was provided to you by the Trust’s solicitors after the conclusion of the inquest. The funding requested was secured, with the exception of that for a paramedic post, which the Trust may bid for again in future. As a result, the Trust is now able to provide a designated reception nurse, so that nurses on reception do not experience the time constraints that ████████ would have experienced in May 2015 due to her other duties.” Source location 2016-0109-Response-by-Nottingham-Healthcare-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a keyword search facility to identify relevant entries in patients’ SystmOne medical histories quickly.
Verbatim wording from the response “As set out in ████████ statement and oral evidence, in recognition of the fact that there is a limited time a nurse on reception can spend with each individual prisoner, the Trust introduced a key word search facility (i.e. nurses can search key words, such as ‘mental health’ or ‘self-harm’). This enables nurses to identify key entries in a patient’s SystmOne medical history (which can be extensive if an individual is serving a long sentence) very quickly.” Source location 2016-0109-Response-by-Nottingham-Healthcare-NHS-Trust
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 Existing reception nursing processes, training, mental-health referral arrangements and access to specialist advice address concerns about staff experience and training.
Verbatim wording from the response “Individuals arriving into HMP Ranby can have a history of physical illness, mental illness, substance misuse or a combination of these. All healthcare needs must be considered, not purely mental health in isolation. Reception nurses are generally primary health nurses.” Source location 2016-0109-Response-by-Nottingham-Healthcare-NHS-Trust
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 remaining seven concerns were matters for HM Prison Service and other parties, so the Trust could not respond to them.
Verbatim wording from the response “The Trust cannot respond to the other 7 concerns highlighted in the Prevent Future Death report as they are matters for HM Prison Service and/or other parties.” Source location 2016-0109-Response-by-Nottingham-Healthcare-NHS-Trust
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 Weekend mental-health cover was limited because the service was not commissioned and Trust resources were constrained by its NHS England contract.
Verbatim wording from the response “The Trust’s resources are of course limited in accordance with its contract with NHS England. In May 2015, the Trust was not commissioned to provide mental health services at HMP Ranby at a weekend. Despite this service not being commissioned, the Trust had identified a need for weekend mental health cover and was providing limited cover by transferring resources from elsewhere (which is why ████████ was available on Sunday 24 May 2015).” Source location 2016-0109-Response-by-Nottingham-Healthcare-NHS-Trust
Open published response
16 Feb 2016 Philip Anthony Denning · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 6 Risk of future deaths from fragmented provision by a separate substance misuse organisation View source Unclear remit of CRI in managing patients with co-occurring substance misuse and mental health problems View source Failure to establish consent arrangements and information-sharing between CRI and Nottinghamshire Healthcare View source Lack of primary care understanding of access routes and service roles for patients with co-occurring substance misuse and mental health problems View source Failure of CRI to provide or arrange additional psychological support for patients with co-occurring substance misuse and mental health problems View source Lack of CRI access to Nottinghamshire Healthcare electronic patient 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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Philip Anthony Denning · 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
Philip Anthony Denning, who had a history of substance misuse and mental health problems, died from diamorphine intoxication on 23 July 2015 after using heroin. The report raised concerns about fragmented services, limited psychology provision, poor information-sharing between organisations, and a lack of clarity in primary care about accessing appropriate support for people with both substance misuse and mental health needs.
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 Risk of future deaths from fragmented provision by a separate substance misuse organisation
Wider context from the report “6. Even aside from the question of shared access to key records held by Nottinghamshire Healthcare and CRI, I am concerned that the current approach of having a separate organisation dealing only with substance misuse carries a risk of future deaths . Commissioners and providers will need to consider these matters carefully.
” Open source report × Source evidence
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 remit of CRI in managing patients with co-occurring substance misuse and mental health problems
Wider context from the report “2. Since the introduction of the CRI in October 2014, patients with both categories of problem, have, in the county, been managed by CRI. They are not equipped or commissioned to deal with the additional psychology needs of their patients. We were told that the only way that they can try to arrange this for their patients is via their GPs. It appears that, on the facts of this tragic case, even an employee of CRI itself may have mistaken their remit .
” Open source report × Source evidence
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 consent arrangements and information-sharing between CRI and Nottinghamshire Healthcare
Wider context from the report “5. As I understand it, the question of patients giving their consent for access to the records by CRI (and indeed for Nottinghamshire Healthcare to have access to CRI records) has not been considered by either organisation. Aside from potential cost and governance issues, none of the senior clinicians involved could tell me any disadvantage to such access being considered. It appears not to have been considered at all to date. There appears to be very little currently by way of joint working or information-sharing between CRI and Nottinghamshire Healthcare.
” Open source report × Source evidence
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 primary care understanding of access routes and service roles for patients with co-occurring substance misuse and mental health problems
Wider context from the report “7. It is also clear that there is a significant lack of understanding in primary care about how to access help for patients like Philip . The respective roles of CRI, Nottinghamshire Healthcare and primary care talking therapies appear to be widely misunderstood. I have included reference to GPs and primary care largely with a view to raising awareness in this area.
” Open source report × Source evidence
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 CRI to provide or arrange additional psychological support for patients with co-occurring substance misuse and mental health problems
Wider context from the report “2. Since the introduction of the CRI in October 2014, patients with both categories of problem, have, in the county, been managed by CRI. They are not equipped or commissioned to deal with the additional psychology needs of their patients. We were told that the only way that they can try to arrange this for their patients is via their GPs. It appears that, on the facts of this tragic case, even an employee of CRI itself may have mistaken their remit.
” Open source report × Source evidence
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 CRI access to Nottinghamshire Healthcare electronic patient records
Wider context from the report “4. The CRI is an entirely separate entity from Nottinghamshire Healthcare and has no access to RiO, Nottingham Healthcare’s electronic record-keeping system . If, for instance, one of their patients had been seen regularly by Nottinghamshire Healthcare following overdoses, they would not be aware of this unless their patient told them about this.
” Open source report
22 Oct 2015 Glenda Day · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 8 Lack of clear written home leave requirements View source Lack of defined recency requirements for risk assessment review before home leave View source Lack of auditing of home leave policy adherence View source Lack of defined recency requirements for doctor review before home leave View source Failure to ensure doctor review before granting home leave View source Failure to review risk assessments before granting home leave View source Failure to communicate home leave requirements to relevant staff across the trust View source Failure to establish home leave requirements trustwide View source See 5 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
Glenda Day · 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
Glenda Day, who had a history of mental health problems, was admitted following an overdose and later took a fatal overdose after being granted home leave on 12 March 2015. She died on 13 March 2015; the inquest recorded opiate toxicity as the cause of death and suicide as the conclusion. The principal concerns were that home leave was granted without an adequate contemporaneous medical review and updated risk assessment, and that requirements for home leave were not clearly established, communicated, and monitored across the trust.
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 clear written home leave requirements
Wider context from the report “3. I remain concerned however for patients across the wider trust and indeed for this ward when new staff are taken on, who may not be familiar with this tragic case. It seems to me very important to have these requirements enshrined in written policies . I understand that some work has already gone into this.
4. I was advised that a Home Leave Policy does exist for the Ward B2, but neither the ward manager ████████ nor the most senior nurse ████████ was able to tell me with any certainty whether these were in fact new requirements, or requirements that were already contained with the existing policy, which had been overlooked .
” Open source report × Source evidence
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 defined recency requirements for risk assessment review before home leave
Wider context from the report “7. It is also concerning that there appears to be no timescale for the two requirements referred to above – ie how contemporary does a doctor review and risk assessment review need to be before the patient can be granted home leave ?
” Open source report × Source evidence
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 auditing of home leave policy adherence
Wider context from the report “8. I am also concerned to know about the trust’s plan in terms of staff awareness of home leave policies, across the trust, as well as auditing, to ensure that the policy is being adhered to .
” Open source report × Source evidence
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 defined recency requirements for doctor review before home leave
Wider context from the report “7. It is also concerning that there appears to be no timescale for the two requirements referred to above – ie how contemporary does a doctor review and risk assessment review need to be before the patient can be granted home leave ?
” Open source report × Source evidence
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 doctor review before granting home leave
Wider context from the report “1. It would appear that ████████ twice granted Glenda home leave by telephone, without seeing the patient himself . On the first occasion (5 March), he did ask a trainee to see her first. On the second (12 March), he appears simply to have repeated his view of 9 March (when he last saw Glenda) without seeing her first, or asking a colleague to see her , despite the significant events which had occurred between 9 and 12 March. Her risk assessment had also not been updated since her overdose on 10 March.
” Open source report × Source evidence
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 review risk assessments before granting home leave
Wider context from the report “1. It would appear that ████████ twice granted Glenda home leave by telephone, without seeing the patient himself. On the first occasion (5 March), he did ask a trainee to see her first. On the second (12 March), he appears simply to have repeated his view of 9 March (when he last saw Glenda) without seeing her first, or asking a colleague to see her, despite the significant events which had occurred between 9 and 12 March. Her risk assessment had also not been updated since her overdose on 10 March.
” Open source report × Source evidence
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 home leave requirements to relevant staff across the trust
Wider context from the report “5. I was also concerned that the focus was very much on this ward, rather than the trust as a whole. Whilst I was advised that a trustwide review is ongoing (dealing with involuntary patients as well), no witness could tell me whether these requirements are likely to be included in a trustwide policy, and when this review will be completed.
6. I remain concerned that the focus of this investigation has been too narrow. It is clearly important that these requirements are included in the written Home Leave Policy, and communicated to all relevant staff, across 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 Failure to establish home leave requirements trustwide
Wider context from the report “5. I was also concerned that the focus was very much on this ward, rather than the trust as a whole . Whilst I was advised that a trustwide review is ongoing (dealing with involuntary patients as well), no witness could tell me whether these requirements are likely to be included in a trustwide policy , and when this review will be completed.
6. I remain concerned that the focus of this investigation has been too narrow. It is clearly important that these requirements are included in the written Home Leave Policy, and communicated to all relevant staff, across the trust.
” Open source report
1 Apr 2015 John Lowe · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 1 Inaccurate nursing staff belief that 1:1 nursing care is unavailable for falls risk or physical care needs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
John Lowe · 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
John Lowe was an inpatient receiving mental health assessment and care after suffering a stroke. After a series of falls, his final fall on 18 February 2014 caused a fractured left neck of femur, which materially contributed to his death from bronchopneumonia on 26 February 2014. Concerns related to nursing staff beliefs that 1:1 nursing could not be provided solely for falls risk or physical care needs.
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 Inaccurate nursing staff belief that 1:1 nursing care is unavailable for falls risk or physical care needs
Wider context from the report “1. That there was a belief amongst members of the Trust’s nursing staff that they were unable as a matter of policy to provide 1:1 nursing care for a patient in respect of that patient’s falls risk assessment alone, no matter what that assessment might be.
2. That there was a belief amongst members of the Trust’s nursing staff that 1:1 nursing could only be provided on the basis of a patient’s particular mental health needs, and not in respect of his or her physical care needs.
” Open source report
4 Feb 2015 Paul Hardy · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 3 Failure to act on clinical instructions to obtain and process blood and urine samples for investigation of possible urological cancer View source Failure to conduct a Significant Event Analysis when recommended View source Failure to act on recommendations for obtaining blood samples for INR monitoring View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Paul Hardy · 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 Hardy was a serving prisoner at HMP Lowdham Grange when his local hospital confirmed that he had urological cancer, which was not the immediate cause of his death. The report identified failures to obtain and process blood and urine samples, to facilitate INR monitoring, and to conduct a Significant Event Analysis, with delays and errors causing unnecessary suffering and distress.
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 act on clinical instructions to obtain and process blood and urine samples for investigation of possible urological cancer
Wider context from the report “1. That there was a clear failure by Healthcare Staff to act upon instruction given by a visiting Advanced Nurse Practitioner to obtain and process blood and urine samples for the investigation of possible urological cancer .
” Open source report × Source evidence
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 conduct a Significant Event Analysis when recommended
Wider context from the report “3. There was a failure to act upon a clear recommendation made by the Clinical Reviewer that there should be a Significant Event Analysis of the events surrounding the death of Paul Hardy.
” Open source report × Source evidence
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 on recommendations for obtaining blood samples for INR monitoring
Wider context from the report “2. There was a failure to act upon a clear recommendation made by the Prison and Probation Ombudsman's Clinical Reviewer for facilitating the effective obtaining of blood samples for INR monitoring .
” Open source report
18 Dec 2014 John Derek Stabler · Prevention of Future Deaths report Central Lincolnshire
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Concerns raised 2 Inadequacy of the Prisoner Escort Record View source Unavailability of System 1 medical records in specified reception units View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
John Derek Stabler · 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
John Derek Stabler was found hanging in a cell at HMP Lincoln on 4 March 2013 and died in Lincoln County Hospital on 6 March 2013. The substantive concerns were the need to review and redesign the Prisoner Escort Record and to ensure medical records were available at HMP North Sea Camp and HMP Lincoln.
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 Inadequacy of the Prisoner Escort Record
Wider context from the report “(i) That there is a need for the Prisoner Escort Record to be reviewed and redesigned
” Open source report × Source evidence
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 System 1 medical records in specified reception units
Wider context from the report “(II) The requirements for System 1 (Medical Records) to be made available in Reception at HMP North Sea Camp and in The Care and Reception Unit at HMP Lincoln
” 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