12 Feb 2026 James Fitzpatrick · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 3 Failure to ensure accurate and complete handover information View source Lack of written national guidance for handovers across healthcare settings View source Lack of written local guidance for undertaking and recording handovers View source
Responses linked to these concerns
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AI-generated summary
James Fitzpatrick · 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 Fitzpatrick, an 89-year-old man with decompensated heart failure and respiratory illness, became unresponsive after coughing and was found with food material in his mouth; his death was confirmed on 14 February 2024. The principal concerns were the lack of written national and local guidance for care handovers, and the risk that incomplete or incorrect handover information could affect patient care and contribute to a future death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure accurate and complete handover information
Wider context from the report “(4) Two weeks prior to his death, Jim was moved to another ward within Alderney Hospital. There was a verbal handover undertaken which was recorded in the electronic patient records. No written handover was provided. The patient records referred to him being a “high risk of choking” and “on an unofficial soft diet”. This information was not true and was not recorded anywhere else in his records or risk assessments.
(5) Further evidence was given that at the time of Jim’s death there were a number of agency workers at Alderney Hospital, and they would rely on information provided to them at the start of their shift during the handover as they would not have time to go through each patient’s records to appraise themselves of the patient’s history and risks. A daily written handover sheet was provided at the beginning of each shift which would be updated during the day, however from the daily handover sheet provided to the Court for the day of Jim’s death, pertinent general information about Jim was missing from that handover sheet .
(6) The lack of written local and national guidance on the handover of a patient’s care creates a risk that incorrect or incomplete information can be passed to those caring for an individual which may impact upon the patient’s care and may lead to a 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of written national guidance for handovers across healthcare settings
Wider context from the report “(1) There is a lack of written national guidance on how handovers between Doctors, Nurses and support staff should be undertaken either when a patient is moved between wards or hospitals, or when there is the handover to staff starting a shift who will be taking over the care of the person. Whilst it is acknowledged that each Trust has different policies and procedures in place, there is no generic national guidance to assist in ensuring relevant, pertinent and critical information is passed on to those who will be caring for the patient .
(2) Evidence was provided that national guidance currently exists in England and Wales for handovers relating to emergency care in acute hospitals, however there is no other guidance for other healthcare settings as to what a handover should include or how it should be undertaken .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of written local guidance for undertaking and recording handovers
Wider context from the report “(3) Within DHUFT there is a lack of written guidance or policy as to how handovers should be undertaken and recorded by those working within the Trust .
” Open source report
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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 professional standards adequately address communication, handover, record keeping, risk escalation and safe transfer of care.
Verbatim wording from the response “While we recognise the concerns raised, we consider that communication, handover, record keeping, escalation of risk, and the safe transfer of responsibility for care are already addressed adequately within the Nursing and Midwifery Council’s professional standards, including The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates and the Standards of proficiency for registered nurses.” Source location 2026-0087 - Response from Nursing and Midwifery Council
Open published response
Concerns raised 2 Lack of defined boundaries and guidance for doula interactions with maternity services View source Lack of regulation of doula care 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
Matilda Pomfret Thomas · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Matilda Pomfret Thomas died aged 15 days from hypoxic ischaemic encephalopathy after a difficult home labour in which fetal distress and meconium were observed, but transfer to hospital did not occur until later. The principal concern was the lack of regulation, registration, training and guidance for doulas, including how their role should interact with midwifery services.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of defined boundaries and guidance for doula interactions with maternity services
Wider context from the report “Doulas provide continuity of care and give emotional, informational and practical support throughout pregnancy, labour and after the birth of a baby: those words come from Doula UK’s website. Doula UK is the largest representative body for Doulas, but it is not a regulatory body, it does not represent all doulas, indeed many doulas are not members of Doula UK. Doula UK have put in place membership requirements, training offers and much guidance, but the role of a doula is clearly diffuse in practical terms and capable of multiple understandings not just by doulas but their clients and midwives .
It appears that doulas have been increasingly used and increasingly offer services - as here - on a paid basis.
As MNSI (Maternity & Newborn Safety Investigations - formerly HSIB) put it in their report into this birth, “MNSI acknowledges that there is no regulation of doula care or any guidance on how the two services interact with each other . MNSI considers the dynamics of a situation, where a third party are involved can provide additional challenges for staff, such as making clinical recommendations against personal recommendations or views and providing usual care that could be viewed as interference rather than surveillance.”
MNSI have identified 12 cases in which there was evidence that doulas worked outside of the defined boundaries of their role and in which the care or advice provided by the doula was considered to have potentially had an influence on the poor outcome for the family.
There was evidence given at the inquest by experienced midwifery professionals highlighting that provision of guidance would be helpful for all involved with a birth at which a doula was present .
The issues of doula registration, regulation and training are therefore points of concern I would commend for 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of regulation of doula care
Wider context from the report “Doulas provide continuity of care and give emotional, informational and practical support throughout pregnancy, labour and after the birth of a baby: those words come from Doula UK’s website. Doula UK is the largest representative body for Doulas, but it is not a regulatory body , it does not represent all doulas, indeed many doulas are not members of Doula UK. Doula UK have put in place membership requirements, training offers and much guidance, but the role of a doula is clearly diffuse in practical terms and capable of multiple understandings not just by doulas but their clients and midwives.
It appears that doulas have been increasingly used and increasingly offer services - as here - on a paid basis.
As MNSI (Maternity & Newborn Safety Investigations - formerly HSIB) put it in their report into this birth, “MNSI acknowledges that there is no regulation of doula care or any guidance on how the two services interact with each other. MNSI considers the dynamics of a situation, where a third party are involved can provide additional challenges for staff, such as making clinical recommendations against personal recommendations or views and providing usual care that could be viewed as interference rather than surveillance.”
MNSI have identified 12 cases in which there was evidence that doulas worked outside of the defined boundaries of their role and in which the care or advice provided by the doula was considered to have potentially had an influence on the poor outcome for the family.
There was evidence given at the inquest by experienced midwifery professionals highlighting that provision of guidance would be helpful for all involved with a birth at which a doula was present.
The issues of doula registration, regulation and training are therefore points of concern I would commend for review.
” 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 Continue working with others to provide information clarifying doula and midwife roles and expected standards of care.
Verbatim wording from the response “Doulas are not a regulated profession and do not fall within the remit of the Nursing and Midwifery Council. We therefore cannot set standards of training or produce guidance on the role of doulas and other unregistered birth workers. However, as the regulator of midwives we will continue working with others to provide information which supports both the public’s and professionals’ understanding of these different roles and the standards of care people should expect from registered midwives.” Source location Response from Nursing and Midwifery Council
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 publish maternity principles, webinar materials and frequently asked questions supporting midwives and organisations to provide personalised care when doulas are involved.
Verbatim wording from the response “In August 2025, we launched our “Principles for supporting women’s choices in maternity care” webinar, with supporting frequently asked questions from our launch webinar factsheet. This all sets out a series of principles that have been developed to support midwives and organisations providing personalised care for women during pregnancy, birth and the postnatal period, wherever the care takes place. We have addressed the following points:” Source location Response from Nursing and Midwifery Council
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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 with Doula UK to provide a video clarifying the distinct roles of midwives and doulas and how they can work together.
Verbatim wording from the response “The NMC has also worked with Doula UK to launch a video resource intended to clarify the distinct roles that midwives and doulas play for women and families, in addition to setting out how the professions can work together to support positive maternity experiences. The maternity principles and video are available at: https://www.nmc.org.uk/standards/guidance/principles-for-supporting-womens-choices-in-maternity-care/.” Source location Response from Nursing and Midwifery Council
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 Doula registration, regulation and training are not being addressed because they fall beyond the Council’s remit and are matters of government policy.
Verbatim wording from the response “We are not taking any action in respect of the issue of doula registration, regulation and training as this is beyond the remit of the Nursing and Midwifery Council and is a matter for government policy.” Source location Response from Nursing and Midwifery Council
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 Council cannot set training standards or produce guidance for doulas because they are unregulated and outside its remit.
Verbatim wording from the response “Doulas are not a regulated profession and do not fall within the remit of the Nursing and Midwifery Council. We therefore cannot set standards of training or produce guidance on the role of doulas and other unregistered birth workers. However, as the regulator of midwives we will continue working with others to provide information which supports both the public’s and professionals’ understanding of these different roles and the standards of care people should expect from registered midwives.” Source location Response from Nursing and Midwifery Council
Open published response
5 Nov 2025 Jennifer Cahill and Agnes Cahill · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 15 Lack of specialist commissioning of home birth services View source Failure to personalise and individualise pregnancy and birth risk assessment View source Failure to routinely provide women with community midwives’ delivery experience View source Unavailability or significant delay of required interventions during high-risk home births View source Lack of national data collection on home birth transfers, outcomes and out-of-guidance care View source Omission of maternal death risk from intrapartum guidance View source Inconsistent models of home birth care View source Failure to discuss maternal and neonatal death risk with women considering home birth View source Lack of national guidance on home birth care View source Lack of a national framework for safe home birth eligibility and midwifery practice View source Lack of mandated delivery experience requirements for midwives maintaining registration View source Lack of national guidance on staffing, training and experience for home birth midwives View source Use of pregnancy terminology that obscures stage-specific risk View source Lack of bespoke training needs analysis for home birth team midwives View source Lack of national guidance on the ethical responsibility and proportionality of offering home birth under the NHS View source See 12 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
Jennifer Cahill and Agnes Cahill · 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
Jennifer Cahill died in hospital on 4 June 2024 after post-partum haemorrhage, a fourth-degree perineal tear and cardiac arrest following a home birth. Her daughter, Agnes Cahill, was born on 2 June 2024, required resuscitation after complications during birth, and died in neonatal intensive care on 7 June 2024. The report identified concerns including failures in antenatal planning, fetal monitoring, resuscitation and post-birth care, as well as the absence of national guidance and a robust framework for supporting higher-risk home births.
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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of specialist commissioning of home birth services
Wider context from the report “3. The lack of national guidance means there are differing models of care and unlike other specialities home births are not a specialist commissioned service . There is no national guidance considering the ethical responsibility and proportionality of offering a home birth model under the NHS framework.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to personalise and individualise pregnancy and birth risk assessment
Wider context from the report “6. Terminology around pregnancies describes them as ‘high’ or ‘low risk pregnancy’ and leads women to consider that pregnancy encompasses all stages through to delivery of a child. Practice does not personalise or individualise risk so women can fully understand what the level of risk is for them in actually being pregnant, or what the level of risk is for them in giving birth .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely provide women with community midwives’ delivery experience
Wider context from the report “7. In order to maintain their skills, there is no set number of deliveries a community midwife must conduct following qualification. There is no mandated number of deliveries that any midwife (irrespective of the settings in which they are working) must complete once they have qualified as a midwife in order to maintain their registration. The level of experience of community midwives in conducting deliveries is not information routinely provided to women to inform their decision whether to have a homebirth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability or significant delay of required interventions during high-risk home births
Wider context from the report “2. There is an increase in the number of women with ‘high risk pregnancies’ requesting home births where required interventions cannot take place or would be significantly delayed and there is no robust framework for midwives supporting home birth care. There is no national guidance to support consistent practice across the country including, for example, details of clinical scenarios where women, following robust assessment, have been considered too high risk to safely receive care in a home-setting.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of national data collection on home birth transfers, outcomes and out-of-guidance care
Wider context from the report “9. The lack of national data collection means there is no data to evidence the number of women who are transferred in during labour or after birth, maternal or neonatal outcomes, number of women who are considered out of guidance .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Omission of maternal death risk from intrapartum guidance
Wider context from the report “5. NICE guidance on intrapartum care (2023 updated June 2025) Section 1.3.3 only refers to the potential risk of death to a baby . There is no mention in the guidance of risk to the mother .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Inconsistent models of home birth care
Wider context from the report “3. The lack of national guidance means there are differing models of care and unlike other specialities home births are not a specialist commissioned service. There is no national guidance considering the ethical responsibility and proportionality of offering a home birth model under the NHS framework.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss maternal and neonatal death risk with women considering home birth
Wider context from the report “4. Even though there is a very small risk of death, this is not something which is discussed with women particularly in relation to maternal death , even if the woman has a recognised risk such as a post-partum haemorrhage. There is no guidance to ensure the risk of death to both mother and baby is discussed with any woman considering a home birth irrespective of being considered high or low 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on home birth care
Wider context from the report “1. There is no national guidance in respect of home births . Specifically, robust evidenced based guidance on home birth care , similar to that which is in place for intrapartum care in a hospital setting.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a national framework for safe home birth eligibility and midwifery practice
Wider context from the report “2. There is an increase in the number of women with ‘high risk pregnancies’ requesting home births where required interventions cannot take place or would be significantly delayed and there is no robust framework for midwives supporting home birth care . There is no national guidance to support consistent practice across the country including, for example, details of clinical scenarios where women, following robust assessment, have been considered too high risk to safely receive care in a home-setting .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of mandated delivery experience requirements for midwives maintaining registration
Wider context from the report “7. In order to maintain their skills, there is no set number of deliveries a community midwife must conduct following qualification . There is no mandated number of deliveries that any midwife (irrespective of the settings in which they are working) must complete once they have qualified as a midwife in order to maintain their registration. The level of experience of community midwives in conducting deliveries is not information routinely provided to women to inform their decision whether to have a homebirth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on staffing, training and experience for home birth midwives
Wider context from the report “10. The no national guidance on the model of staffing, training and experience for midwives providing home birth care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Use of pregnancy terminology that obscures stage-specific risk
Wider context from the report “6. Terminology around pregnancies describes them as ‘high’ or ‘low risk pregnancy’ and leads women to consider that pregnancy encompasses all stages through to delivery of a child . Practice does not personalise or individualise risk so women can fully understand what the level of risk is for them in actually being pregnant, or what the level of risk is for them in giving birth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of bespoke training needs analysis for home birth team midwives
Wider context from the report “8. No bespoke training needs analysis has been conducted focusing on midwives practicing in home birth teams .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on the ethical responsibility and proportionality of offering home birth under the NHS
Wider context from the report “3. The lack of national guidance means there are differing models of care and unlike other specialities home births are not a specialist commissioned service. There is no national guidance considering the ethical responsibility and proportionality of offering a home birth model under the NHS framework .
” 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 Contribute to the task and finish group on national homebirth guidance, frameworks, ethical proportionality, informed risk discussions, maternal risks, terminology and training needs.
Verbatim wording from the response “As the professional regulator for midwives in the UK, the NMC plans to play an active role in the group in line with our regulatory role. More specifically, we propose to take the following actions in response to the matters of concern detailed in your report as follows:” Source location Response from Nursing & Midwifery Council
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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 Participate in the joint safety stakeholder work that developed a task and finish group for national homebirth pathways.
Verbatim wording from the response “On 8 December, we participated in a joint safety stakeholder meeting to discuss the specific matters of concerns identified. This meeting was attended by senior maternity and neonatal leaders from NHS England, Maternity and Neonatal transformation programme at NHS England, the Royal College of Midwives (RCM), NHS Resolution (NHSR), the National Institute for Health and Care Excellence (NICE), the General Medical Council, Maternity and Neonatal Safety Investigations” Source location Response from Nursing & Midwifery Council
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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 No mandated number of post-registration deliveries will be introduced because midwives work across varied roles and settings.
Verbatim wording from the response “We are not proposing to take action to introduce a mandated number of deliveries post-registration. There is currently no requirement for post registration confirmation of competence in any area of midwifery because midwives work in various areas and can transfer across roles regularly if they choose to do so.” Source location Response from Nursing & Midwifery Council
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 Workforce modelling for staffing, training and experience in home birth care is outside the regulator’s functions.
Verbatim wording from the response “10. There is no national guidance on the model of staffing, training and experience for midwives providing home birth care.” Source location Response from Nursing & Midwifery Council
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 No action can be taken on national clinical data collection because the organisation neither holds nor mandates such data.
Verbatim wording from the response “9. The lack of national data collection means there is no data to evidence the number of women who are transferred in during labour or after birth, maternal or neonatal outcomes, number of women who are considered out of guidance.” Source location Response from Nursing & Midwifery Council
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 Midwives and their employers are responsible for ensuring the skills, knowledge and capabilities needed to provide care.
Verbatim wording from the response “As the regulator of midwives, we do not contribute to workforce modelling. However, our standards are clear regarding our expectations that midwives should be able to care for women in all birth settings. Midwives, with support from their employers are responsible for ensuring they have the skills, knowledge and capabilities to provide care.” Source location Response from Nursing & Midwifery Council
Open published response
25 Jun 2024 James Reginald Capstick · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 5 Failure to provide consistently good quality care View source Failure to maintain reliable clinical records View source Failure to perform and respond appropriately to basic checks and signs of life during resuscitation View source Unavailability of a defibrillator for attempted resuscitation in the care home View source Failure to retain and apply basic resuscitation training View source See 2 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
James Reginald Capstick · 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 Reginald Capstick died in hospital on 1 October 2022 after sustaining multiple rib fractures during more than 20 minutes of chest compressions when he was not in cardiac arrest, followed by respiratory insufficiency and pneumonia. The report raised concerns about the quality of care at Westmorland Court, the reliability of care records, the absence of a defibrillator at the time, and the failure to recognise signs of life during the resuscitation attempt.
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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide consistently good quality care
Wider context from the report “(1) To Westmorland Court. The General Practitioner who came to give evidence said that care had improved since Reg's death but he still had concerns about care given and had to visit regularly every week to check residents -the only one of six homes he covers that requires this level of support. He said it was a struggle to provide good quality care and felt this report would be helpful -as I stated at inquest it is not intended in any way to be punitive but to put focus on areas that may be improved. A particular concern was clear evidence that examinations entered into Reg's notes were made at times when this was impossible because he was in hospital -this puts into question the reliability of notes generally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain reliable clinical records
Wider context from the report “(1) To Westmorland Court. The General Practitioner who came to give evidence said that care had improved since Reg's death but he still had concerns about care given and had to visit regularly every week to check residents -the only one of six homes he covers that requires this level of support. He said it was a struggle to provide good quality care and felt this report would be helpful -as I stated at inquest it is not intended in any way to be punitive but to put focus on areas that may be improved. A particular concern was clear evidence that examinations entered into Reg's notes were made at times when this was impossible because he was in hospital -this puts into question the reliability of notes generally .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to perform and respond appropriately to basic checks and signs of life during resuscitation
Wider context from the report “(3) To Nursing and Midwifery Council. A Registered nurse was in charge of the home on the night of Reg's injury. Her statement told us that she forgot her basic training and had never had to attempt CPR before. Despite clear signs of breathing and resistance to her efforts she continued to be guided by the call handler at NWAS who had been confused by her inconsistent responses to his questions . Basic checks and signs of life were ignored. I was told at inquest that after being stepped down from nursing duty for a while she had had further training and was back in position. I was told that a referral to yourselves had been made and acknowledged but nothing further had been heard, has the referral been closed?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a defibrillator for attempted resuscitation in the care home
Wider context from the report “(2) To Care Quality Commission. You requested a note of the outcome of this case and please accept this report as such. I imagine you will be making further enquiries. There was no defibrillator in the home at the time of this incident although I am told one has now been installed. I was told that it is not a requirement for care homes to have one. If staff in these homes are expected to attempt resuscitation should provision be 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to retain and apply basic resuscitation training
Wider context from the report “(3) To Nursing and Midwifery Council. A Registered nurse was in charge of the home on the night of Reg's injury. Her statement told us that she forgot her basic training and had never had to attempt CPR before . Despite clear signs of breathing and resistance to her efforts she continued to be guided by the call handler at NWAS who had been confused by her inconsistent responses to his questions. Basic checks and signs of life were ignored. I was told at inquest that after being stepped down from nursing duty for a while she had had further training and was back in position. I was told that a referral to yourselves had been made and acknowledged but nothing further had been heard, has the referral been closed?
” 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 Refer concerns about care at Westmorland Court and inaccurate healthcare records to the Employer Link Service and New Referrals team for enquiries.
Verbatim wording from the response “We have also considered whether the PFD raises any other concerns which we need to act on. We have noted that concerns were raised about the care provided to Mr Capstick generally at Westmorland Court and a specific issue relating to inaccurate entries made within healthcare records. We have noted that at the time of the inquest one safeguarding referral remained open.” Source location Response from NMC
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 Keep the decision not to impose an interim order under review pending new information.
Verbatim wording from the response “We also carried out a risk assessment upon receipt of the referral to establish whether urgent interim action needed to be taken to suspend or restrict the individual’s practice. We concluded an interim order was not necessary for public protection and was not otherwise in the public interest. We continue to keep this under review pending receipt of new information.” Source location Response from NMC
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 risk assessment to determine whether urgent interim restrictions or suspension are required to protect the public.
Verbatim wording from the response “We also carried out a risk assessment upon receipt of the referral to establish whether urgent interim action needed to be taken to suspend or restrict the individual’s practice. We concluded an interim order was not necessary for public protection and was not otherwise in the public interest. We continue to keep this under review pending receipt of new information.” Source location Response from NMC
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 the fitness-to-practise investigation into the registered nurse and decide whether to progress or close the case for public-protection reasons.
Verbatim wording from the response “We can confirm that our investigations in relation to the concerns raised about the registered nurse in charge of the home on the night of Mr Capstick’s injury are ongoing. We have shared your concerns as set out in the PFD with the investigating team. We have also contacted Westmorland Court for further information and obtained details about the registered nurse’s current practice. We have contacted the registered nurse to give them the ability to comment on the concerns and are waiting for their response. We expect to make a decision in the next two to three weeks on whether to progress our investigations on the basis that we need to take action to protect the public or whether we can close the case on the basis that there are no public protection issues.” Source location Response from NMC
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 An interim order restricting or suspending the nurse’s practice was not considered necessary for public protection or otherwise in the public interest.
Verbatim wording from the response “We also carried out a risk assessment upon receipt of the referral to establish whether urgent interim action needed to be taken to suspend or restrict the individual’s practice. We concluded an interim order was not necessary for public protection and was not otherwise in the public interest. We continue to keep this under review pending receipt of new information.” Source location Response from NMC
Open published response
Concerns raised 3 Lack of awareness of hyponatremia developing in birthing women View source Failure to recognise the risk of hyponatremia when giving intravenous fluids View source Failure to keep accurate records of fluid input and output View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Orlando NOVA DAVIS · 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
Orlando Nova DAVIS suffered an irreversible brain injury after his mother developed unrecognised hyponatremia and seizures during labour, restricting oxygen before his birth. He died aged 14 days on 24 September 2021; the principal concerns were a lack of recognition and understanding of hyponatremia among midwives and clinicians, and inaccurate recording of fluid input and output despite additional fluids being given.
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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of hyponatremia developing in birthing women
Wider context from the report “Orlando was caused an irreversible brain injury when his mother suffered a seizure having developed hyponatremia during her labour. The concern is that the midwifes (in the community and in the hosptial, who had cared for Orlando’s mother) were completely unaware of this potential condition developing in birthing women .
In this case due to Orlando developing a tachicardia during labour Orlando’s mothers was actively encouraged to take in more fluid yet there was no accurate record kept of either input or output of fluid. Again when in hospital further fluids were given intravenously with no recognition of any potential risk of hyponatremia developing by the midwives or the Doctor on duty.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the risk of hyponatremia when giving intravenous fluids
Wider context from the report “Orlando was caused an irreversible brain injury when his mother suffered a seizure having developed hyponatremia during her labour. The concern is that the midwifes (in the community and in the hosptial, who had cared for Orlando’s mother) were completely unaware of this potential condition developing in birthing women.
In this case due to Orlando developing a tachicardia during labour Orlando’s mothers was actively encouraged to take in more fluid yet there was no accurate record kept of either input or output of fluid. Again when in hospital further fluids were given intravenously with no recognition of any potential risk of hyponatremia developing by the midwives or the Doctor on duty .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to keep accurate records of fluid input and output
Wider context from the report “Orlando was caused an irreversible brain injury when his mother suffered a seizure having developed hyponatremia during her labour. The concern is that the midwifes (in the community and in the hosptial, who had cared for Orlando’s mother) were completely unaware of this potential condition developing in birthing women.
In this case due to Orlando developing a tachicardia during labour Orlando’s mothers was actively encouraged to take in more fluid yet there was no accurate record kept of either input or output of fluid . Again when in hospital further fluids were given intravenously with no recognition of any potential risk of hyponatremia developing by the midwives or the Doctor on duty.
” 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 information about the doctor’s potential failure to recognise hyponatraemia with the General Medical Council.
Verbatim wording from the response “2. We have shared the PFD report with the General Medical Council (GMC) so they can take appropriate action which falls within their remit.” Source location Response from NMC
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 Investigate the concerns about the incident through fitness-to-practise processes to determine whether regulatory action is needed.
Verbatim wording from the response “1. We are carrying out Fitness to Practise (FtP) investigations and will take appropriate action to protect the public and uphold standards where we identify concerns relating to professionals on our register.” Source location Response from NMC
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 publish a hyponatraemia scenario for student midwives and midwives, and raise awareness of it with education colleagues before the next academic year.
Verbatim wording from the response “3. We will develop and publish a scenario to inform student midwives and midwives about hyponatraemia for the start of the next academic year and raise awareness with our education colleagues.” Source location Response from NMC
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 GMC is responsible for considering whether further investigation or action is required concerning the doctor involved.
Verbatim wording from the response “The PFD report mentions that there was also a doctor on duty who failed to recognise the potential risk of hyponatraemia. Whilst our statutory remit does not extend to doctors, we have shared this information with the GMC in accordance with our fitness” Source location Response from NMC
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 Hyponatraemia need not be specified in NMC standards because high-level standards and provider curricula are considered sufficient, although a scenario will be developed.
Verbatim wording from the response “We do not specify a list of diseases or conditions that professionals need to know or be able to provide care in respect of. This is because it would not be possible to keep such a list up to date and complete. We rely on our Approved Education Institutions (AEIs) to develop evidence-based curricula which reflect local practice contexts and the population.” Source location Response from NMC
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 statutory remit does not extend to doctors, so the NMC cannot take regulatory action concerning the doctor involved.
Verbatim wording from the response “The PFD report mentions that there was also a doctor on duty who failed to recognise the potential risk of hyponatraemia. Whilst our statutory remit does not extend to doctors, we have shared this information with the GMC in accordance with our fitness” Source location Response from NMC
Open published response
9 Mar 2024 Linda Heath · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 4 Insufficient inquiry into the parameters of care provided by private domiciliary carers View source Failure of immediate discharge summaries to include relevant and sufficient community treatment and nursing information View source Absence of GP follow-up triggers for recently discharged patients with worsening conditions and missed routine appointments View source Failure to make post-discharge referrals for patients needing district nursing care 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
Linda Heath · 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
Linda Heath was discharged from hospital with a sacral sore, but the discharge information did not include a required district nursing referral and no referral was made. Her condition worsened, she was admitted to hospital, and she died on 31 March 2022 from sepsis caused by an infected sacral sore. The substantive concerns included inadequate discharge information, failure to arrange district nursing care, insufficient follow-up after discharge, and over-reliance on private domiciliary carers without sufficient enquiry into their remit.
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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient inquiry into the parameters of care provided by private domiciliary carers
Wider context from the report “(4) An over reliance upon private hygiene care packages with insufficient inquiry into the parameters of care provided by the private domiciliary carers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure of immediate discharge summaries to include relevant and sufficient community treatment and nursing information
Wider context from the report “(1) The Immediate Discharge Summary did not include relevant or sufficient information about treatment in the community needs or a nursing summary .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Absence of GP follow-up triggers for recently discharged patients with worsening conditions and missed routine appointments
Wider context from the report “(3) No trigger appears to exist whereby GPs conduct follow up enquiries or visits to patients who have recently been discharged from hospital and who are complaining of a condition which may worsen and failing to attend routine appointments due to a worsening of their 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to make post-discharge referrals for patients needing district nursing care
Wider context from the report “(2) Despite the presence of a difficult sacral sore which would have benefitted from district nursing care, no referral was made post discharge by the GP surgery .
” Open source report
19 May 2023 Emilia Watson · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 1 Lack of specific requirements for midwives’ training and ongoing exposure to home births 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
Emilia Watson · 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
Emilia Watson was delivered by Caesarean section on 5 April 2021 after concerns about fetal wellbeing and fetal heart rate; she died shortly after birth despite resuscitation attempts. The report raised concerns about the limited home-birth experience of the two attending midwives and the lack of specific regulatory requirements for training or ongoing exposure to home-birth practice.
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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of specific requirements for midwives’ training and ongoing exposure to home births
Wider context from the report “1. I am concerned that the two midwives who attended Emilia’s mother at home had limited experience of home births . One was a newly-qualified midwife who actually had more experience in home births than the other midwife; despite decades of midwifery experience she had never attended a home birth before.
I heard evidence that there is no specific regulatory requirement regarding midwifery experience at home births and that training to become a midwife requires attendance at 40 births of unspecified type. During the inquest it was set out that home births occur relatively infrequently and that it can be difficult to ensure involvement in such births during training .
I also heard that some midwives tend to focus on specific areas of practice, such as low-risk or high-risk births and that their experience in other areas can therefore be limited . This is despite the potential need for any midwife to attend low-risk births and the regulatory requirement that midwives ensure competency in all areas of practice.
I asked the hospital Trust involved for information as to how they ensure that midwives have appropriate experience in home birthing. They have set out as follows:
The lead midwife has previous experience (gained knowledge and skills through direct observation and participation) of attending and facilitating a home birth or birth in a low risk setting
The lead midwife normally works in a low risk birth setting i.e Community midwife or Bluebell birth centre midwife
The lead midwife is competent and up to date with their mandatory training within a home birth or low risk birth setting thus demonstrating the knowledge and skills required.
However, the concern remains that there is seemingly no specific regulatory requirement for training or ongoing exposure to areas of practice that midwives may encounter, in particular the unique issues that can arise during home births .
” Open source report
23 Mar 2022 Robert George MURRAY · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 1 Lack of understanding of circumstances when DNACPR should not be applied View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Robert George 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
Robert George MURRAY, who had mild dementia and lived in a nursing home, choked on food at breakfast on 10 June 2021 and died. An ambulance was not sent because he had a DNACPR in place; the concern was that those involved did not understand when a DNACPR should not be applied, indicating a need for further training and clarification.
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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of circumstances when DNACPR should not be applied
Wider context from the report “From listening to the 999 call between the registered nurse at the care home and the call operator, and also from evidence heard at the inquest, it is apparent that no one involved understood that there are circumstances when the DNACPR should not be applied . I am concerned that this may potentially be an issue elsewhere in the country and further training and clarification is therefore necessary.
” 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 Monitor approved education institutions and their delivery of nursing education programmes through quality assurance activities.
Verbatim wording from the response “Nursing and midwifery professionals can demonstrate that they have met these standards of proficiency by completing approved qualifications as part of a pre-registration education programmes that have been approved by us in the UK. We set wider standards for nursing and midwifery education and programme standards⁴ which enable our approved education institutions to deliver programmes related to the relevant standards of proficiency. The approved education institutions will design their curricula to be able to meet our standards. We approve programmes and monitor the education institutions and their programme delivery as part of our Quality Assurance” Source location Response from Nursing Midwifery Council
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 Approve all UK pre-registration nursing programmes against the Future Nurse standards.
Verbatim wording from the response “The Future Nurse standards were approved by our Council following extensive consultation and engagement over a two year period. All pre-registration programmes in the UK have been approved against the new Future Nurse standards. We expect the first nurses will graduate under these new standards in 2022.” Source location Response from Nursing Midwifery Council
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 and establish Future Nurse standards of proficiency, including requirements covering end-of-life care and DNACPR decisions.
Verbatim wording from the response “In 2016 we embarked on a significant programme of change in relation to all of our education and training standards, which has included revising our standards of proficiency for registered nurses and midwives to strengthen public protection and continue to make sure that they are fit for purpose. We introduced new standards of proficiency for registered nurses in 2018 (described as the Future Nurse standards⁶).” Source location Response from Nursing Midwifery Council
Open published response
20 Apr 2021 Ella Adoo-Kissi-Debrah · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Insufficient undergraduate teaching on the health effects of air pollution View source Insufficient postgraduate education on the health effects of air pollution View source Insufficient detail and monitoring capacity for air quality information View source Insufficient professional guidance on communicating the health effects of air pollution View source Low public awareness of sources of national and local pollution information View source National Particulate Matter limits exceeding WHO guideline levels 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
Ella Adoo-Kissi-Debrah · 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
Ella Adoo-Kissi-Debrah died aged 9 after an asthmatic episode led to cardiac arrest on 15 February 2013. The report states that air pollution, including exposure to nitrogen dioxide and particulate matter from traffic emissions, significantly contributed to her asthma and death. It also identifies concerns about pollution limits, public access to pollution information, and communication of air-pollution health risks by healthcare professionals.
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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient undergraduate teaching on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient postgraduate education on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail and monitoring capacity for air quality information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government. The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient professional guidance on communicating the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Low public awareness of sources of national and local pollution information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government . The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation National Particulate Matter limits exceeding WHO guideline levels
Wider context from the report “(1) The national limits for Particulate Matter are set at a level far higher than the WHO guidelines. The evidence at the inquest was that there is no safe level for Particulate Matter and that the WHO guidelines should be seen as minimum requirements. Legally binding targets based on WHO guidelines would reduce the number of deaths from air pollution in the UK.
” 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 Identify further activity to ensure registered professionals understand their obligations to communicate evidence about preventing and managing ill health.
Verbatim wording from the response “• We will identify if there is further activity that we can do to make sure that the professionals on our register understand their obligations to communicate clearly to their patients and their families about evidence related to the management and prevention of ill-health, and help prevent tragic cases such as Ella’s from occurring again.” Source location 2021-0113-Response-from-Nursing-and-Midwifery-Council-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 communication skills requirements covering evidence-based communication and sharing health information with patients, families and carers.
Verbatim wording from the response “In addition to the Platform itself, we have also developed a detailed list of communication skills that we expect our nursing professionals to demonstrate at point of registration. The communication skills draw together the communication techniques and skills required to communicate effectively, taking into account best practice and evidence the management of ill-health. Here is an excerpt from Paragraph 2 of the communication skills annexe to the standards:” Source location 2021-0113-Response-from-Nursing-and-Midwifery-Council-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 Consider whether post-registration community nursing standards should strengthen proficiencies addressing prevention, management and communication of ill health.
Verbatim wording from the response “• We will consider the concerns that you have raised as part of our current consultation on post-registration standards, to ensure that the parts of our new Post Registration Standards for specialist community public health nursing and specialist practice qualifications for community nursing which relate to the prevention and management of ill health will reduce the risk of information not being communicated clearly.” Source location 2021-0113-Response-from-Nursing-and-Midwifery-Council-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 Approve UK undergraduate programmes against the Future Nurse standards.
Verbatim wording from the response “The Future Nurse standards were approved by our Council, following extensive consultation and engagement over a two year period. All undergraduate programmes in the UK have been approved against the new Future Nurse standards. We expect the first nurses to graduate under these new standards in 2022.” Source location 2021-0113-Response-from-Nursing-and-Midwifery-Council-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 Evaluate whether the Future Nurse standards support safe practice and are properly implemented to reduce communication-related risks.
Verbatim wording from the response “• We will consider the concerns that you have raised in our evaluation of our new Future Nurse pre-registration standards, focussing on whether those standards are continuing to meet the requirements of what is necessary for safe and effective practice. Moreover, whether the proper implementation of the standards by education institutions will play a part to reduce the risk of cases such as Ella’s arising again in the future.” Source location 2021-0113-Response-from-Nursing-and-Midwifery-Council-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 Introduce Future Nurse standards of proficiency for registered nurses.
Verbatim wording from the response “In 2016, we embarked on a significant programme of change in relation to all of our education and training standards, which has included revising our standards of proficiency for nurses and midwives. We introduced new standards of proficiency for registered nurses in 2018, (described as the Future Nurse standards⁶), and midwives in 2019, (described as the Future Midwife standards⁷).” Source location 2021-0113-Response-from-Nursing-and-Midwifery-Council-Redacted
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 regulator does not set requirements for all postgraduate education of nursing professionals.
Verbatim wording from the response “Nurses and midwives who are initially registered with us may pursue additional qualifications that can also be registered with us. We describe these as post-registration qualifications. We do not set the requirements for all postgraduate education of nursing professionals.” Source location 2021-0113-Response-from-Nursing-and-Midwifery-Council-Redacted
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 nursing standards cover environmental factors affecting health through their reference to the wider determinants of health, despite not expressly mentioning them.
Verbatim wording from the response “While the standards do not expressly refer to environmental factors affecting health, we believe that these would be covered by the reference to “wider determinants of health” expressed in the standards.” Source location 2021-0113-Response-from-Nursing-and-Midwifery-Council-Redacted
Open published response
14 Jan 2020 John David Long · Prevention of Future Deaths report London Inner (West)
View report summary
Concerns raised 4 Failure to provide safe break and relief arrangements during 1:1 care View source Failure to implement, administer and communicate 1:1 care training View source Bed rails allowing patients to fall from their beds View source Lack of clear definitions and operational rules for 1:1 care 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
John David Long · 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 David Long suffered an unwitnessed fall from his bed in Benjamin Weir Ward at St. George’s Hospital on 4 May 2019, sustaining a head injury that led to his death. The concerns identified relate to the design and suitability of bed rails, the definition and administration of one-to-one care, provision of breaks without leaving the patient alone, and training for one-to-one 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide safe break and relief arrangements during 1:1 care
Wider context from the report “2. A review is required into the use of 1:1 (one to one) care in hospital wards and in particular a review into the definition of what 1:1 (one to one) care actually means. In addition a review on how it is administered on the ward and what rules there are for those nurses and Carers to comply with when carrying out such care for a patient. Furthermore there needs to be very clear rules about how Carer or nurse carrying out such care ensures they have sufficient breaks from providing such care and how they are relieved from their duties in such circumstances but ensuring the Patient is not left alone at any time .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to implement, administer and communicate 1:1 care training
Wider context from the report “3.A review is required on how training of 1: 1 (one to one) care is implemented
And administered on a hospital ward and also how such training is communicated to nurses and Carers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Bed rails allowing patients to fall from their beds
Wider context from the report “1. The bed rails affixed to patients beds allow a patient to fall easily from the patient’s bed and the make and manufacture of bed rails should be reviewed to ensure they are fit for purpose and act to ensure the patient is secure in their bed and also prevent a patient accidentally falling from their 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clear definitions and operational rules for 1:1 care
Wider context from the report “2. A review is required into the use of 1:1 (one to one) care in hospital wards and in particular a review into the definition of what 1:1 (one to one) care actually means . In addition a review on how it is administered on the ward and what rules there are for those nurses and Carers to comply with when carrying out such care for a patient . Furthermore there needs to be very clear rules about how Carer or nurse carrying out such care ensures they have sufficient breaks from providing such care and how they are relieved from their duties in such circumstances but ensuring the Patient is not left alone at any time.
” Open source report
16 Oct 2019 Victor James Hall · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 5 Failure of pharmacy-to-ward medication transfer procedures to require receipt checks against packaging, labelling and prescription charts View source Failure to contemporaneously document medication packaging, labelling and prescription checks View source Failure to check medication packaging and labelling against the prescription chart before administration View source Phosphate Polyfusor product design failing to distinguish the medication clearly View source Insufficient training, auditing, supervision and monitoring of nursing and pharmacy staff on medication checking controls 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
Victor James Hall · 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
Victor James Hall died at Salford Royal Hospital on 29 June 2018 after being admitted with shortness of breath and an exacerbation of chronic obstructive pulmonary disease. He was mistakenly administered Phosphate Polyfusor instead of prescribed sodium bicarbonate after dispensing, pharmacy checking and ward checking errors, although the post-mortem and toxicology evidence concluded that the medication error played no role in his death. Concerns were raised about the similar Polyfusor product design and about medication-checking, recording, dispensing, training and supervision procedures.
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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure of pharmacy-to-ward medication transfer procedures to require receipt checks against packaging, labelling and prescription charts
Wider context from the report “During the Inquest, evidence was heard that:-
1.Salford Royal Hospital had undertaken an internal investigation and concluded that one of the root causes for the medication error, was the Phosphate Polyfusor product design.
i. The Pharmacy and Nursing Matron Lead, concurred that the staff involved in the incident had relied on the word Polyfusor, without actually checking the medication packaging against the prescription chart and label. Salford Royal Hospital, wrote to the Medicines and Healthcare products Regulatory Agency (MHRA) in 2018, requesting the word Polyfusor be removed from the Phosphate design product packaging to prevent future medication errors. Despite repeated requests from Salford Royal Hospital for an MHRA update, the product design for Phosphate Polyfusor remains the same.
2. I request that The Chief Executive, Medicines and Healthcare products Regulatory Agency (MHRA) reviews the:
i. Product design on the Polyfusors in question
3.The Chief Executive, Nursing & Midwifery Council, 23 Portland Place, London W1B 1PZ reviews the:
i.Guidance given to their members in relation to the administration of medication to consider and include the simplest of steps, namely that a Healthcare Professional should check the name of the medication on the prescription chart against the name of the medication on the packaging and labelling of the medication at the time of each administration of medication to ensure that the correct medication is always administered to a patient.
ii.Guidance given to their members in relation to their duties, to accurately record and contemporaneously document the packaging, label an prescription checks they have undertaken to ensure the correct medication is always administered to a patient.
4.The Chief Executive, Salford Royal Hospital, NHS Trust Hospital, Stott Lane, Salford M6 8HD reviews the:
i.Guidance and procedures in relation to the dispensing and transfer of medications from the Pharmacy Department to a ward, to include a system of checking medications against the packaging, labelling and prescription chart at the time of receipt by the ward . Furthermore, to consider documentary evidence of the fact that the medication packaging has been checked against the prescription chart and an acknowledgement of receipt of the correct medication by the pharmacy and ward staff, evidenced by a signature of the recipient.
ii.Training, Auditing, Supervision and monitoring of all staff, particularly Nursing and Pharmacy staff, in relation to the above 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to contemporaneously document medication packaging, labelling and prescription checks
Wider context from the report “During the Inquest, evidence was heard that:-
1.Salford Royal Hospital had undertaken an internal investigation and concluded that one of the root causes for the medication error, was the Phosphate Polyfusor product design.
i. The Pharmacy and Nursing Matron Lead, concurred that the staff involved in the incident had relied on the word Polyfusor, without actually checking the medication packaging against the prescription chart and label. Salford Royal Hospital, wrote to the Medicines and Healthcare products Regulatory Agency (MHRA) in 2018, requesting the word Polyfusor be removed from the Phosphate design product packaging to prevent future medication errors. Despite repeated requests from Salford Royal Hospital for an MHRA update, the product design for Phosphate Polyfusor remains the same.
2. I request that The Chief Executive, Medicines and Healthcare products Regulatory Agency (MHRA) reviews the:
i. Product design on the Polyfusors in question
3.The Chief Executive, Nursing & Midwifery Council, 23 Portland Place, London W1B 1PZ reviews the:
i.Guidance given to their members in relation to the administration of medication to consider and include the simplest of steps, namely that a Healthcare Professional should check the name of the medication on the prescription chart against the name of the medication on the packaging and labelling of the medication at the time of each administration of medication to ensure that the correct medication is always administered to a patient.
ii.Guidance given to their members in relation to their duties, to accurately record and contemporaneously document the packaging, label an prescription checks they have undertaken to ensure the correct medication is always administered to a patient.
4.The Chief Executive, Salford Royal Hospital, NHS Trust Hospital, Stott Lane, Salford M6 8HD reviews the:
i.Guidance and procedures in relation to the dispensing and transfer of medications from the Pharmacy Department to a ward, to include a system of checking medications against the packaging, labelling and prescription chart at the time of receipt by the ward. Furthermore, to consider documentary evidence of the fact that the medication packaging has been checked against the prescription chart and an acknowledgement of receipt of the correct medication by the pharmacy and ward staff, evidenced by a signature of the recipient.
ii.Training, Auditing, Supervision and monitoring of all staff, particularly Nursing and Pharmacy staff, in relation to the above 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to check medication packaging and labelling against the prescription chart before administration
Wider context from the report “During the Inquest, evidence was heard that:-
1.Salford Royal Hospital had undertaken an internal investigation and concluded that one of the root causes for the medication error, was the Phosphate Polyfusor product design.
i. The Pharmacy and Nursing Matron Lead, concurred that the staff involved in the incident had relied on the word Polyfusor, without actually checking the medication packaging against the prescription chart and label . Salford Royal Hospital, wrote to the Medicines and Healthcare products Regulatory Agency (MHRA) in 2018, requesting the word Polyfusor be removed from the Phosphate design product packaging to prevent future medication errors. Despite repeated requests from Salford Royal Hospital for an MHRA update, the product design for Phosphate Polyfusor remains the same.
2. I request that The Chief Executive, Medicines and Healthcare products Regulatory Agency (MHRA) reviews the:
i. Product design on the Polyfusors in question
3.The Chief Executive, Nursing & Midwifery Council, 23 Portland Place, London W1B 1PZ reviews the:
i.Guidance given to their members in relation to the administration of medication to consider and include the simplest of steps, namely that a Healthcare Professional should check the name of the medication on the prescription chart against the name of the medication on the packaging and labelling of the medication at the time of each administration of medication to ensure that the correct medication is always administered to a patient.
ii.Guidance given to their members in relation to their duties, to accurately record and contemporaneously document the packaging, label an prescription checks they have undertaken to ensure the correct medication is always administered to a patient.
4.The Chief Executive, Salford Royal Hospital, NHS Trust Hospital, Stott Lane, Salford M6 8HD reviews the:
i.Guidance and procedures in relation to the dispensing and transfer of medications from the Pharmacy Department to a ward, to include a system of checking medications against the packaging, labelling and prescription chart at the time of receipt by the ward. Furthermore, to consider documentary evidence of the fact that the medication packaging has been checked against the prescription chart and an acknowledgement of receipt of the correct medication by the pharmacy and ward staff, evidenced by a signature of the recipient.
ii.Training, Auditing, Supervision and monitoring of all staff, particularly Nursing and Pharmacy staff, in relation to the above 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Phosphate Polyfusor product design failing to distinguish the medication clearly
Wider context from the report “During the Inquest, evidence was heard that:-
1.Salford Royal Hospital had undertaken an internal investigation and concluded that one of the root causes for the medication error, was the Phosphate Polyfusor product design .
i. The Pharmacy and Nursing Matron Lead, concurred that the staff involved in the incident had relied on the word Polyfusor, without actually checking the medication packaging against the prescription chart and label. Salford Royal Hospital, wrote to the Medicines and Healthcare products Regulatory Agency (MHRA) in 2018, requesting the word Polyfusor be removed from the Phosphate design product packaging to prevent future medication errors. Despite repeated requests from Salford Royal Hospital for an MHRA update, the product design for Phosphate Polyfusor remains the same .
2. I request that The Chief Executive, Medicines and Healthcare products Regulatory Agency (MHRA) reviews the:
i. Product design on the Polyfusors in question
3.The Chief Executive, Nursing & Midwifery Council, 23 Portland Place, London W1B 1PZ reviews the:
i.Guidance given to their members in relation to the administration of medication to consider and include the simplest of steps, namely that a Healthcare Professional should check the name of the medication on the prescription chart against the name of the medication on the packaging and labelling of the medication at the time of each administration of medication to ensure that the correct medication is always administered to a patient.
ii.Guidance given to their members in relation to their duties, to accurately record and contemporaneously document the packaging, label an prescription checks they have undertaken to ensure the correct medication is always administered to a patient.
4.The Chief Executive, Salford Royal Hospital, NHS Trust Hospital, Stott Lane, Salford M6 8HD reviews the:
i.Guidance and procedures in relation to the dispensing and transfer of medications from the Pharmacy Department to a ward, to include a system of checking medications against the packaging, labelling and prescription chart at the time of receipt by the ward. Furthermore, to consider documentary evidence of the fact that the medication packaging has been checked against the prescription chart and an acknowledgement of receipt of the correct medication by the pharmacy and ward staff, evidenced by a signature of the recipient.
ii.Training, Auditing, Supervision and monitoring of all staff, particularly Nursing and Pharmacy staff, in relation to the above 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient training, auditing, supervision and monitoring of nursing and pharmacy staff on medication checking controls
Wider context from the report “During the Inquest, evidence was heard that:-
1.Salford Royal Hospital had undertaken an internal investigation and concluded that one of the root causes for the medication error, was the Phosphate Polyfusor product design.
i. The Pharmacy and Nursing Matron Lead, concurred that the staff involved in the incident had relied on the word Polyfusor, without actually checking the medication packaging against the prescription chart and label. Salford Royal Hospital, wrote to the Medicines and Healthcare products Regulatory Agency (MHRA) in 2018, requesting the word Polyfusor be removed from the Phosphate design product packaging to prevent future medication errors. Despite repeated requests from Salford Royal Hospital for an MHRA update, the product design for Phosphate Polyfusor remains the same.
2. I request that The Chief Executive, Medicines and Healthcare products Regulatory Agency (MHRA) reviews the:
i. Product design on the Polyfusors in question
3.The Chief Executive, Nursing & Midwifery Council, 23 Portland Place, London W1B 1PZ reviews the:
i.Guidance given to their members in relation to the administration of medication to consider and include the simplest of steps, namely that a Healthcare Professional should check the name of the medication on the prescription chart against the name of the medication on the packaging and labelling of the medication at the time of each administration of medication to ensure that the correct medication is always administered to a patient.
ii.Guidance given to their members in relation to their duties, to accurately record and contemporaneously document the packaging, label an prescription checks they have undertaken to ensure the correct medication is always administered to a patient.
4.The Chief Executive, Salford Royal Hospital, NHS Trust Hospital, Stott Lane, Salford M6 8HD reviews the:
i.Guidance and procedures in relation to the dispensing and transfer of medications from the Pharmacy Department to a ward, to include a system of checking medications against the packaging, labelling and prescription chart at the time of receipt by the ward. Furthermore, to consider documentary evidence of the fact that the medication packaging has been checked against the prescription chart and an acknowledgement of receipt of the correct medication by the pharmacy and ward staff, evidenced by a signature of the recipient.
ii.Training, Auditing, Supervision and monitoring of all staff, particularly Nursing and Pharmacy staff, in relation to the above issues .
” Open source report
29 Jul 2019 Mr Alex Blake · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Failure to perform required patient observations View source Failure to maintain accurate and truthful patient observation records and reports View source Failure to conduct timely and adequate observations of patients whose condition is uncertain 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
Mr Alex Blake · 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 Alex Blake died from a self-administered heroin overdose while a sectioned in-patient at Lambeth Hospital, sometime before 04.13 on 24 June 2018. The jury found that inadequate observations, unsuitable record sheets, ineffective observations and poor communication meant his death went unnoticed for several hours. Concerns were also raised about unreliable or potentially false accounts and records by staff regarding observations of him before he was found dead.
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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to perform required patient observations
Wider context from the report “The first was RMN T, who gave evidence that the deceased was half out of bed, wearing pyjamas and assumed to be asleep at 05.00. When asked whether he could have been dead, the nurse said she did not know, but it was too dark to see and no torch was used. She chose to wait until 06.00 to conduct a proper observation. She could not answer the question why she had not gone to get a torch or returned before 06.00. When found in the same position an hour later, she says she was concerned and asked Health Care assistant K if he was breathing as he had been in the same position for an hour. HCA K denies that this conversation took place before he was found dead. RMN T on finding the deceased said that it still did not occur to her that he might be dead. Her evidence to the court that he was wearing pyjamas at 05.00 is in contrast to the electronic patient journal, which confirms that when he was found dead he was topless.
The second was RMN E, whose evidence was read due to his unavailability. He made an entry in the electronic journal at 05.59, which is about the time which he was found dead, that “he went to his bedroom and was observed asleep from 23.00 hrs. Alex remains asleep and was observed breathing regularly at the time of this entry (05.52).” The deceased was already dead at the time this entry claims to have been written. RMN T told the court that she had no communication with RMN E about his observations and RMN E was not one of those who found him dead at about 06.10 hours. This raises concern about what prompted the unusual entry at 05.59.
The third was health care assistant K, whose evidence in court was that the deceased was observed at 03.00 and he held his phone in his hand which was lit up, and so assumed to be watching a film. The witness was unable to answer why he had then recorded the deceased as being asleep, as it would be likely then that the light of the phone would not be visible.
The evidence of these three witnesses cannot be said to be reliable. The evidence of the two nurses would seem to go beyond that of poorly conducted observations. It would be reasonable to suspect that either the two nurses did not perform the observations at all or that they have provided false evidence to the Trust and to the court.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate and truthful patient observation records and reports
Wider context from the report “The first was RMN T, who gave evidence that the deceased was half out of bed, wearing pyjamas and assumed to be asleep at 05.00. When asked whether he could have been dead, the nurse said she did not know, but it was too dark to see and no torch was used. She chose to wait until 06.00 to conduct a proper observation. She could not answer the question why she had not gone to get a torch or returned before 06.00. When found in the same position an hour later, she says she was concerned and asked Health Care assistant K if he was breathing as he had been in the same position for an hour. HCA K denies that this conversation took place before he was found dead. RMN T on finding the deceased said that it still did not occur to her that he might be dead. Her evidence to the court that he was wearing pyjamas at 05.00 is in contrast to the electronic patient journal, which confirms that when he was found dead he was topless.
The second was RMN E, whose evidence was read due to his unavailability. He made an entry in the electronic journal at 05.59, which is about the time which he was found dead, that “he went to his bedroom and was observed asleep from 23.00 hrs. Alex remains asleep and was observed breathing regularly at the time of this entry (05.52).” The deceased was already dead at the time this entry claims to have been written. RMN T told the court that she had no communication with RMN E about his observations and RMN E was not one of those who found him dead at about 06.10 hours. This raises concern about what prompted the unusual entry at 05.59.
The third was health care assistant K, whose evidence in court was that the deceased was observed at 03.00 and he held his phone in his hand which was lit up, and so assumed to be watching a film. The witness was unable to answer why he had then recorded the deceased as being asleep, as it would be likely then that the light of the phone would not be visible .
The evidence of these three witnesses cannot be said to be reliable . The evidence of the two nurses would seem to go beyond that of poorly conducted observations. It would be reasonable to suspect that either the two nurses did not perform the observations at all or that they have provided false evidence to the Trust and to the court .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct timely and adequate observations of patients whose condition is uncertain
Wider context from the report “The first was RMN T, who gave evidence that the deceased was half out of bed, wearing pyjamas and assumed to be asleep at 05.00. When asked whether he could have been dead, the nurse said she did not know, but it was too dark to see and no torch was used . She chose to wait until 06.00 to conduct a proper observation . She could not answer the question why she had not gone to get a torch or returned before 06.00. When found in the same position an hour later, she says she was concerned and asked Health Care assistant K if he was breathing as he had been in the same position for an hour. HCA K denies that this conversation took place before he was found dead. RMN T on finding the deceased said that it still did not occur to her that he might be dead . Her evidence to the court that he was wearing pyjamas at 05.00 is in contrast to the electronic patient journal, which confirms that when he was found dead he was topless.
The second was RMN E, whose evidence was read due to his unavailability. He made an entry in the electronic journal at 05.59, which is about the time which he was found dead, that “he went to his bedroom and was observed asleep from 23.00 hrs. Alex remains asleep and was observed breathing regularly at the time of this entry (05.52).” The deceased was already dead at the time this entry claims to have been written. RMN T told the court that she had no communication with RMN E about his observations and RMN E was not one of those who found him dead at about 06.10 hours. This raises concern about what prompted the unusual entry at 05.59.
The third was health care assistant K, whose evidence in court was that the deceased was observed at 03.00 and he held his phone in his hand which was lit up, and so assumed to be watching a film. The witness was unable to answer why he had then recorded the deceased as being asleep, as it would be likely then that the light of the phone would not be visible.
The evidence of these three witnesses cannot be said to be reliable. The evidence of the two nurses would seem to go beyond that of poorly conducted observations. It would be reasonable to suspect that either the two nurses did not perform the observations at all or that they have provided false evidence to the Trust and to the court.
” Open source report
2 May 2019 Mr Royston Kemp · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 4 Failure to escalate to medical care or refer View source Failure to establish relevant care assistant concerns and their timing View source Failure to measure vital signs View source Failure to act on abnormal limb findings 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
Mr Royston Kemp · 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 Royston Kemp, an 85-year-old care home resident with dementia and a history of fractures and falls, suffered an unwitnessed traumatic fracture of his left femur in February 2016. He was not referred to hospital until two days after signs of injury and died on 20 March 2016 from pneumonia, aspiration and advanced dementia, with the fracture-related immobility identified as a key contributor. Concerns included failure by a nurse to act on leg swelling and temperature differences, establish the care assistant’s concerns, measure vital signs, or escalate for medical assessment and referral.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate to medical care or refer
Wider context from the report “A nurse working at Marlborough Court Care Home, who has already been referred to the NMC assessed this frail elderly resident whose leg caused concern to care assistants. In doing so her evidence concerned the coroner was:
1) She found one leg more swollen than the other and of a different temperature
but took no action
2) She failed to establish the care assistant’s concern or whether she had met the
concern before or after her assessment
3) She failed to measure Vital Signs
4) She failed to escalate to medical care or refer , in the process failed to enable a
diagnosis of fractured femur to be made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to establish relevant care assistant concerns and their timing
Wider context from the report “A nurse working at Marlborough Court Care Home, who has already been referred to the NMC assessed this frail elderly resident whose leg caused concern to care assistants. In doing so her evidence concerned the coroner was:
1) She found one leg more swollen than the other and of a different temperature
but took no action
2) She failed to establish the care assistant’s concern or whether she had met the
concern before or after her assessment
3) She failed to measure Vital Signs
4) She failed to escalate to medical care or refer, in the process failed to enable a
diagnosis of fractured femur to be made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to measure vital signs
Wider context from the report “A nurse working at Marlborough Court Care Home, who has already been referred to the NMC assessed this frail elderly resident whose leg caused concern to care assistants. In doing so her evidence concerned the coroner was:
1) She found one leg more swollen than the other and of a different temperature
but took no action
2) She failed to establish the care assistant’s concern or whether she had met the
concern before or after her assessment
3) She failed to measure Vital Signs
4) She failed to escalate to medical care or refer, in the process failed to enable a
diagnosis of fractured femur to be made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to act on abnormal limb findings
Wider context from the report “A nurse working at Marlborough Court Care Home, who has already been referred to the NMC assessed this frail elderly resident whose leg caused concern to care assistants. In doing so her evidence concerned the coroner was:
1) She found one leg more swollen than the other and of a different temperature
but took no action
2) She failed to establish the care assistant’s concern or whether she had met the
concern before or after her assessment
3) She failed to measure Vital Signs
4) She failed to escalate to medical care or refer, in the process failed to enable a
diagnosis of fractured femur to be made.
” Open source report
15 Jan 2019 John Preece · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 4 Risk to medically unwell mental health patients View source Failure to plan and maintain required continued observations View source Lack of staff knowledge and understanding of falls management and head injury recognition View source Lack of staff training and knowledge in conducting neuro observations 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
John Preece · 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 Preece, who had early onset dementia and was prone to seizures, suffered a witnessed seizure and fall on 9 September 2015, sustaining a serious head injury. He was not closely monitored and received incomplete and inappropriate physical and neurological observations before being admitted to hospital, where he died in the early hours of 10 September 2015. The principal concerns were inadequate falls management and neuro-observation knowledge and training, lack of forward planning and monitoring, and delayed medical assistance for medically unwell mental health patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Risk to medically unwell mental health patients
Wider context from the report “(5) Evidence given at the inquest showed that the health board had considered the introduction of the NEWS scoring system (National Early Warning System) for the Mental Health Directorate but felt unable to introduce it as the mental health unit did not sit within/alongside a district general hospital. The obvious concern being that against a background of poor training and poor management medically unwell mental health patients are at 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to plan and maintain required continued observations
Wider context from the report “(2) There was a clear lack of knowledge amongst all staff, both registered nurses and support workers as to how to conduct neuro observations despite the evidence showing that guidance in the form of health board policy and also a “wall chart” was available to be consulted.
(3) There was no forward planning for the continued observations of Mr Preece throughout the day on 9th September 2015 and as a result he was simply put to bed and not closely monitored as the circumstances required .
(4) The evidence revealed that none of the registered nursing staff were trained either during their basic nurse training or subsequently upon employment within the health board, on how to conduct neuro observations and that together with a failure to appreciate an obvious head injury meant that not only observations conducted but that no medical assistance was sought for at least ten hours.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge and understanding of falls management and head injury recognition
Wider context from the report “(1) There was a clear lack of understanding and basic knowledge of falls management by both trained nurses and support workers in circumstances in which it should have been obvious that Mr Preece sustained a head injury . The evidence clearly revealed that there was knowledge of a head injury following his seizure and fall. Even if that were not the case a head injury should have been suspected .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training and knowledge in conducting neuro observations
Wider context from the report “(2) There was a clear lack of knowledge amongst all staff, both registered nurses and support workers as to how to conduct neuro observations despite the evidence showing that guidance in the form of health board policy and also a “wall chart” was available to be consulted.
(3) There was no forward planning for the continued observations of Mr Preece throughout the day on 9th September 2015 and as a result he was simply put to bed and not closely monitored as the circumstances required.
(4) The evidence revealed that none of the registered nursing staff were trained either during their basic nurse training or subsequently upon employment within the health board, on how to conduct neuro observations and that together with a failure to appreciate an obvious head injury meant that not only observations conducted but that no medical assistance was sought for at least ten hours.
” 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 Pursue appropriate regulatory concerns concerning the nurses through fitness-to-practise procedures.
Verbatim wording from the response “In appropriate circumstances, we enforce the standards set out in the Code through our fitness to practise proceedings. Depending on the seriousness of the case, our fitness to practise (FtP) proceedings can result in us providing advice or a warning, accepting undertakings, imposing a caution or conditions of practice order or suspending or removing a nurse from our register.” Source location 2019-0019-Response-by-NMC
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 health board is responsible for explaining nurses’ relevant training and any steps taken to learn from the incident.
Verbatim wording from the response “We note that you have also written to the Cardiff and Vale University Health Board. They will no doubt explain in their response the relevant training, if any, which nurses in this unit had received, and any relevant steps they are taking to learn from this tragic incident. I can confirm that we will be drawing the concerns you have raised to the attention of the Healthcare Inspectorate Wales, so that they are aware of the issues (if they are not already) and can take any appropriate action.” Source location 2019-0019-Response-by-NMC
Open published response
9 Oct 2018 Tom Cribley · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 12 Failure to document important clinical findings View source Insufficient clinical staff training in identifying and treating sepsis View source Failure to escalate monitoring and management after grossly abnormal blood results View source Failure of senior leadership ownership of training programme implementation and review View source Failure to maintain systematic and monitored ongoing sepsis training View source Failure to complete full PIT STOP reviews View source Failure to hand over clinical concerns to relevant clinical staff View source Failure to escalate and convey the severity of deterioration to the Critical Care Team View source Failure to review an initial diagnosis when the patient deteriorates View source Delays in escalating NEWS to medical staff View source Delays in administering antibiotic therapy during clinical deterioration View source Failure to repeat observations hourly in accordance with the NEWS policy View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Tom Cribley · 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
Tom Cribley attended Aintree hospital on 18 February 2017 with vomiting, diarrhoea and a rash, and was later diagnosed with meningococcal sepsis. The report identifies concerns including failures to document and escalate the rash and deteriorating observations, inadequate handovers and reassessment, delayed recognition of abnormal blood results, and delayed antibiotic treatment. Tom did not recover and died on 20 February 2017.
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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to document important clinical findings
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage . The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient clinical staff training in identifying and treating sepsis
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate monitoring and management after grossly abnormal blood results
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results , the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure of senior leadership ownership of training programme implementation and review
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board . This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain systematic and monitored ongoing sepsis training
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness .
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to complete full PIT STOP reviews
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review , the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to hand over clinical concerns to relevant clinical staff
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers , the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate and convey the severity of deterioration to the Critical Care Team
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team , who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to review an initial diagnosis when the patient deteriorates
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate , the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Delays in escalating NEWS to medical staff
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Delays in administering antibiotic therapy during clinical deterioration
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to repeat observations hourly in accordance with the NEWS policy
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy . The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report
16 Jun 2017 Mrs Macrae · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 2 Failure to seek attendance by the attending spinal surgeon for postoperative instability View source Failure to consider internal haemorrhage as a cause of instability after elective spinal surgery 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
Mrs Macrae · 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
Mrs Macrae was admitted for elective lumbar spinal surgery and experienced intermittent drops in blood pressure during recovery. The report raises concern that internal haemorrhage was not considered as a possible cause of her instability and that this rare but recognised complication should be understood after similar surgery.
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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to seek attendance by the attending spinal surgeon for postoperative instability
Wider context from the report “1) Mrs Macrae was admitted to the Woodlands Hospital Kettering on 11th June 2016 for routine left lumbar L4/L5 decompression and discectomy under the care of a specialist neurosurgeon. Whilst in recovery her blood pressure dropped on occasion. She was cared for by attending anaesthetists but her attending spinal surgeon was not asked to attend . Those caring for Mrs Macrae did not consider internal haemorrhage as a cause of her instability.
2) All persons having care for a patient having undergone a similar elective spinal surgery should be aware that internal haemorrhage is a rare but recognised complication of this surgery.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to consider internal haemorrhage as a cause of instability after elective spinal surgery
Wider context from the report “1) Mrs Macrae was admitted to the Woodlands Hospital Kettering on 11th June 2016 for routine left lumbar L4/L5 decompression and discectomy under the care of a specialist neurosurgeon. Whilst in recovery her blood pressure dropped on occasion. She was cared for by attending anaesthetists but her attending spinal surgeon was not asked to attend. Those caring for Mrs Macrae did not consider internal haemorrhage as a cause of her instability .
2) All persons having care for a patient having undergone a similar elective spinal surgery should be aware that internal haemorrhage is a rare but recognised complication of this surgery .
” 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 finalise education standards incorporating standards on patient assessment, management of deterioration, and surgery-related complications.
Verbatim wording from the response “We are currently undertaking a wholesale review of our education standards, including the pre-registration standards of proficiency that nurses must meet before being registered with us. We intend that these new standards of proficiency for registered nurses will include specific standards relating to patient assessment and the management of patient deterioration. We are undertaking a full public consultation on the draft standards, which is due to conclude on 12 September 2017, following which we will carefully review the feedback we receive from our stakeholders before finalising the standards. We will also take into account the concerns you have raised in your report about complications of surgery.” Source location 2017-0193-Response-by-NMC
Open published response
9 Mar 2017 Billy Wilson · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 5 Failure to provide management review and pass-or-fail assessment of midwives' CTG refresher training View source Lack of CTG tracing interpretation training in undergraduate midwifery degree syllabuses View source Failure to make CTG tracing interpretation training compulsory and pass-or-fail assessed before midwife registration View source Failure to verify newly qualified midwives' CTG tracing interpretation proficiency before recruitment View source Lack of formal annual CTG tracing and interpretation refresher training for practising midwives 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
Billy Wilson · 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
Billy Wilson was born at Pinderfields Hospital and died aged three days after suffering hypoxic-ischaemic brain injury and perinatal asphyxia. The report describes continued use and increased dosing of syntocinon despite abnormal foetal monitoring, hyperstimulation and signs of foetal distress. It raises concerns about inadequate training and assessment in cardiotocograph interpretation for student, newly qualified and practising midwives.
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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide management review and pass-or-fail assessment of midwives' CTG refresher training
Wider context from the report “(1) I request that you ensure that training on CTG tracing interpretation is contained in the Undergraduate Syllabus for all Midwifery Degree Courses throughout the country.
(2) That this is compulsory and that it has to be assessed on a pass or fail basis, and that a student Midwife cannot seek registration until this vital element in training is undertaken.
(3) That Hospital Trusts should not recruit newly qualified Midwives until they can demonstrate their understanding and proficiency in CTG tracing interpretation.
(4) There should be formal refresher training for all practising Midwives in CTG tracing and interpretation done on a yearly basis, and that this should be assessed on a pass or fail basis , and not merely left to the responsibility of the individual Midwife to complete an E-learning package without Management Review and 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of CTG tracing interpretation training in undergraduate midwifery degree syllabuses
Wider context from the report “(1) I request that you ensure that training on CTG tracing interpretation is contained in the Undergraduate Syllabus for all Midwifery Degree Courses throughout the country.
(2) That this is compulsory and that it has to be assessed on a pass or fail basis, and that a student Midwife cannot seek registration until this vital element in training is undertaken.
(3) That Hospital Trusts should not recruit newly qualified Midwives until they can demonstrate their understanding and proficiency in CTG tracing interpretation.
(4) There should be formal refresher training for all practising Midwives in CTG tracing and interpretation done on a yearly basis, and that this should be assessed on a pass or fail basis, and not merely left to the responsibility of the individual Midwife to complete an E-learning package without Management Review and 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to make CTG tracing interpretation training compulsory and pass-or-fail assessed before midwife registration
Wider context from the report “(1) I request that you ensure that training on CTG tracing interpretation is contained in the Undergraduate Syllabus for all Midwifery Degree Courses throughout the country.
(2) That this is compulsory and that it has to be assessed on a pass or fail basis , and that a student Midwife cannot seek registration until this vital element in training is undertaken .
(3) That Hospital Trusts should not recruit newly qualified Midwives until they can demonstrate their understanding and proficiency in CTG tracing interpretation.
(4) There should be formal refresher training for all practising Midwives in CTG tracing and interpretation done on a yearly basis, and that this should be assessed on a pass or fail basis, and not merely left to the responsibility of the individual Midwife to complete an E-learning package without Management Review and 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to verify newly qualified midwives' CTG tracing interpretation proficiency before recruitment
Wider context from the report “(1) I request that you ensure that training on CTG tracing interpretation is contained in the Undergraduate Syllabus for all Midwifery Degree Courses throughout the country.
(2) That this is compulsory and that it has to be assessed on a pass or fail basis, and that a student Midwife cannot seek registration until this vital element in training is undertaken.
(3) That Hospital Trusts should not recruit newly qualified Midwives until they can demonstrate their understanding and proficiency in CTG tracing interpretation .
(4) There should be formal refresher training for all practising Midwives in CTG tracing and interpretation done on a yearly basis, and that this should be assessed on a pass or fail basis, and not merely left to the responsibility of the individual Midwife to complete an E-learning package without Management Review and 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of formal annual CTG tracing and interpretation refresher training for practising midwives
Wider context from the report “(1) I request that you ensure that training on CTG tracing interpretation is contained in the Undergraduate Syllabus for all Midwifery Degree Courses throughout the country.
(2) That this is compulsory and that it has to be assessed on a pass or fail basis, and that a student Midwife cannot seek registration until this vital element in training is undertaken.
(3) That Hospital Trusts should not recruit newly qualified Midwives until they can demonstrate their understanding and proficiency in CTG tracing interpretation.
(4) There should be formal refresher training for all practising Midwives in CTG tracing and interpretation done on a yearly basis , and that this should be assessed on a pass or fail basis, and not merely left to the responsibility of the individual Midwife to complete an E-learning package without Management Review and assessment.
” Open source report
3 Feb 2017 ROBERT ENTENMAN · Prevention of Future Deaths report London Inner (South)
View report summary
Concerns raised 4 Delays in communicating suction catheter difficulties to doctors View source Delays in identifying and replacing blocked endotracheal tubes View source Failure to monitor humidifier operation and temperature View source Lack of a humidifier alarm indicating when the machine is turned off 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
ROBERT ENTENMAN · 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
Robert Entenman was an intubated intensive care patient whose humidifier was turned off from around 12.00pm on 22 May 2015 until 6.00am on 23 May 2015. A mucus plug blocked his endotracheal tube, leading to cardiac arrest shortly after 6.00am; he died on 30 May 2015. Concerns included failures to observe that the humidifier was off, the absence of an alarm on the humidifier, delays in identifying and replacing the blocked tube, and possible delays in communicating suction difficulties to doctors.
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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Delays in communicating suction catheter difficulties to doctors
Wider context from the report “(3) There were delays in identifying that the endotracheal tube had become blocked between 5.32 and 6.00am on 23 May 2015, and thus replacing it earlier. There may have been further such delays after 6.00 am. There may have been a delay by the nursing staff in providing information about difficulties with the suction catheter to the doctors who arrived after the cardiac arrest call was put out.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Delays in identifying and replacing blocked endotracheal tubes
Wider context from the report “(3) There were delays in identifying that the endotracheal tube had become blocked between 5.32 and 6.00am on 23 May 2015, and thus replacing it earlier . There may have been further such delays after 6.00 am . There may have been a delay by the nursing staff in providing information about difficulties with the suction catheter to the doctors who arrived after the cardiac arrest call was put out.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor humidifier operation and temperature
Wider context from the report “(1) Three nurses cared for Mr Entenman between 12.00pm on 22 May 2015 and 6.00am on 23 May 2015. During that time they did not observe that the humidifier had been turned off , either handovers that took place between them or each hour when they should have recorded the temperature reading from the humidifier .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a humidifier alarm indicating when the machine is turned off
Wider context from the report “(2) The humidifier machine does not have an alarm on it, to indicate when the machine has been turned off .
” 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 Investigate the nursing-care concerns in accordance with statutory functions.
Verbatim wording from the response “We are aware of the particular issues raised about the registered nurse who reviewed Mr Entenman in the time leading up to his death. We are currently investigating this matter and are considering the concerns in accordance with our statutory functions.” Source location 2017-0011-Response-by-NMC
Open published response
Concerns raised 3 Failure to subject advanced nurse practitioners to stringent appraisal and revalidation processes View source Lack of direct employer responsibility and supervision for some advanced nurse practitioners View source Lack of regulatory oversight for advanced nurse practitioners 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
Benjamin Orrill · 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
Benjamin Orrill died on 12 June 2016 following a fall from Lee Circle NCP car park, Leicester; the inquest concluded that the death was suicide. He had been reviewed by an advanced nurse practitioner after feeling suicidal, and the report identified concerns about the lack of a regulatory body and appraisal or revalidation processes for advanced nurse practitioners, with potential implications for patient safety.
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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to subject advanced nurse practitioners to stringent appraisal and revalidation processes
Wider context from the report “During the course of the Inquest it came to my attention that there is no regulatory body for advanced nurse practitioners. It would appear they are not subject to the same stringent appraisal and revalidation processes such that GPs currently are , despite the fact that they may perform similar duties and can have parallel roles.
I also became aware that some advance nurse practitioners may independently buy into a partnership and may not have an employer directly responsible for their appraisal. Therefore some may potentially be operating as independent practitioners without any supervision or regulation. I am concerned that this may have a significant impact on patient safety.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of direct employer responsibility and supervision for some advanced nurse practitioners
Wider context from the report “During the course of the Inquest it came to my attention that there is no regulatory body for advanced nurse practitioners. It would appear they are not subject to the same stringent appraisal and revalidation processes such that GPs currently are, despite the fact that they may perform similar duties and can have parallel roles.
I also became aware that some advance nurse practitioners may independently buy into a partnership and may not have an employer directly responsible for their appraisal . Therefore some may potentially be operating as independent practitioners without any supervision or regulation . I am concerned that this may have a significant impact on patient safety.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of regulatory oversight for advanced nurse practitioners
Wider context from the report “During the course of the Inquest it came to my attention that there is no regulatory body for advanced nurse practitioners . It would appear they are not subject to the same stringent appraisal and revalidation processes such that GPs currently are, despite the fact that they may perform similar duties and can have parallel roles.
I also became aware that some advance nurse practitioners may independently buy into a partnership and may not have an employer directly responsible for their appraisal. Therefore some may potentially be operating as independent practitioners without any supervision or regulation. I am concerned that this may have a significant impact on patient safety.
” Open source report
×
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 statutory regulation and revalidation are considered sufficient to protect the public against risks associated with advanced nursing practice.
Verbatim wording from the response “We will not be taking any further action in relation to the concerns you have raised because, for the reasons we summarise in the enclosed document, we believe that our statutory framework and the process of revalidation are sufficient to protect the public in respect of advanced practice.” Source location 2016-0367-Response-by-NMC
Open published response
22 Apr 2015 Laurence Boyens · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 12 Failure to recognise appropriate indications for Naloxone administration View source Failure to communicate and define reporting parameters for pre-administration blood-pressure readings View source Failure to record respiratory rates when monitoring controlled-drug patients View source Failure to cancel discontinued medication prescriptions in the computerised record View source Failure to record blood-pressure readings promptly in medical records View source Failure to identify and act on drowsiness before controlled-drug administration View source Failure to stop medicines when Methadone toxicity is considered View source Failure to review blood-pressure trends before controlled-drug administration View source Failure to suspend controlled drugs and escalate low blood pressure View source Lack of defined criteria and recording requirements for lowering blood pressure View source Prescribing multiple medicines without a sufficiently complete clinical assessment and medication history View source Failure to assess drug interactions and cumulative effects before prescribing View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Laurence Boyens · 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
Laurence Boyens died in prison on 15 November 2012 from Methadone, Tramadol and Diazepam intoxication. The jury identified concerns about the combination and interaction of prescribed drugs, failures to monitor intoxication symptoms and blood pressure, and failures to suspend or withhold Methadone and Tramadol when signs of toxicity were present.
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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise appropriate indications for Naloxone administration
Wider context from the report “4. ████████
████████ was represented at the inquest and the following evidence gave rise to concerns:
• He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him, although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison.
• When he saw the patient on 13th he failed to consider the interactions between Citalopram and Tramadol and between Citalopram and Methadone, both of which the prison expert ████████ said were contraindicated, nor the summative effects of combining Methadone, Tramadol and Diazepam.
• He said that he was not aware whether withdrawal can cause low BP and thought the BP was measured to see if the patient was withdrawing.
• He said that he did not know whether he should stop Methadone if the BP was low.
• Mr Boyens was seen by the doctor on 13th, the day after another witness found him drowsy with “pinned eyes” and a few hours before another witness found him unsteady and drowsy. He made no record of the state of the pupils, but did record him as unusually drowsy.
• At that examination, according to his 2013 statement he considered the patient was drowsy due to lack of sleep; in a 2015 statement he considered use of illicit drugs and was aware of the possibility of Methadone toxicity. But he failed to stop these drugs from continuing to be administered.
• At this assessment on 13th he recorded an intention to stop the Citalopram on the request of the patient, but did not take the simple steps to cancel the prescription on the computerised record and if he told a nurse about this instruction it was not recalled or noted by them, and continued to be administered.
• He gave evidence that he would not administer Naloxone to a patient unless the patient was blue and unconscious and known to have taken opiates and did not know any disadvantages of doing so . ████████ gave evidence that this was not correct and that Naloxone properly administered had the potential to save lives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate and define reporting parameters for pre-administration blood-pressure readings
Wider context from the report “1. There appeared to be a general misunderstanding how health care professionals should comply with DH Clinical Management of Drug Dependence in Adult Prison Settings Guidelines 12.3 and 12.4. In particular this relates to the requirement to ensure that patients who are undergoing Methadone or Buprenorphine stabilization have not experienced a lowering of blood pressure or drowsiness before administration of the controlled drug.
• Health care assistants routinely took the blood pressure before administration but did not inform the nurse of the reading and may not have had instruction when to report the reading
• The evidence of six nurses and a health care assistant showed that previous blood pressure recordings were not sought or examined to determine if there had been a lowering of BP
• The record of blood pressure was often written on paper and not usually entered in the medical records at the time and sometimes not at all
• A health care assistant who did record a BP of 93/68 was asked by a nurse to repeat it and reported back to the medication hatch that it was still low. No apparent action was taken by nurses to suspend the medication or escalate the concern to a doctor on 11th.
• One nurse, who did not see the BP of 93/58 recorded in the records and administered Methadone, did not know what she would do if he had discovered a previous higher BP.
• One nurse was surprised that a BP of 105/60 having a reading of 128/68 and 93/68 the previous day and 121/81 the day before that, should trigger withholding Methadone and escalating to the doctor.
• The expert GP, who had been clinical director in the health care team provided to the prison, identified a sequence of seven BP recordings over 4 days, six of which (the second was considered rogue) should have triggered suspension of administration of drugs and escalation to the doctor, but in no case did this occur.
• The head of health care at the time, who was an inexperienced nurse, did not accept that advice and asserted it would be impractical to implement it, as it would lead to significant delays.
• In a local policy on Buprenorphine a threshold triggering suspension of drug and escalation was defined as 90/60 without reference to the trend. None was found in a section on Methadone and no definition of lowering of blood pressure or how to record it was found in any local policies.
• No nurse saw the entry in the medical records by a doctor at 18.56 on 13th November which read: “Unusually drowsy. Eyelids close when not engaged. communicative alert. no sadness or dsh. Plan stop Citalopram and monitor for signs of overdose.. may req further urine test before further Methadone testing...”.
• At 17.57 on 13th, one hour from the doctor’s assessment, when he must have been unusually drowsy, no nurse found him drowsy when he presented at the hatch for medication, and he was given Methadone and Tramadol.
• On the morning of 14th he was given further Methadone and Tramadol, without measuring the blood pressure, or testing, as the previous day was last day of his Methadone titration regime and his 5 day 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record respiratory rates when monitoring controlled-drug patients
Wider context from the report “3. Nurse ████████ was called during the course of the inquest, and although given the opportunity, did not have legal representation in the proceedings.
The evidence from Nurse ████████ herself that caused concern about risks to future patients included:
• She did not record a BP at 18.35 on 10th, or at 09.25 on 11th, prior to administration of Methadone.
• She did not notice a BP of 93/68 recorded on “System One” at 15.27, before she administered Methadone at 17.50 on 11th.
• She expected the health care assistant to inform her of an abnormal blood pressure, but has not set any parameters, prior to Methadone
• She never looked at previous blood pressures prior to administering Methadone.
• She never makes respiratory rate recordings in monitoring patients on controlled drugs
• If she had seen the blood pressure of 134/113 that was recorded at 09.21 on 12th November, she would not do anything different.
• Given that her drug administration clinics were very busy (60 people per session), she was asked whether it would make any difference to what she did, if she saw half as many patients, but she said she would still not look at the blood pressures.
• Asked if she had changed her practice in any way since the incident, she said that she had not.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to cancel discontinued medication prescriptions in the computerised record
Wider context from the report “4. ████████
████████ was represented at the inquest and the following evidence gave rise to concerns:
• He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him, although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison.
• When he saw the patient on 13th he failed to consider the interactions between Citalopram and Tramadol and between Citalopram and Methadone, both of which the prison expert ████████ said were contraindicated, nor the summative effects of combining Methadone, Tramadol and Diazepam.
• He said that he was not aware whether withdrawal can cause low BP and thought the BP was measured to see if the patient was withdrawing.
• He said that he did not know whether he should stop Methadone if the BP was low.
• Mr Boyens was seen by the doctor on 13th, the day after another witness found him drowsy with “pinned eyes” and a few hours before another witness found him unsteady and drowsy. He made no record of the state of the pupils, but did record him as unusually drowsy.
• At that examination, according to his 2013 statement he considered the patient was drowsy due to lack of sleep; in a 2015 statement he considered use of illicit drugs and was aware of the possibility of Methadone toxicity. But he failed to stop these drugs from continuing to be administered.
• At this assessment on 13th he recorded an intention to stop the Citalopram on the request of the patient, but did not take the simple steps to cancel the prescription on the computerised record and if he told a nurse about this instruction it was not recalled or noted by them, and continued to be administered .
• He gave evidence that he would not administer Naloxone to a patient unless the patient was blue and unconscious and known to have taken opiates and did not know any disadvantages of doing so. ████████ gave evidence that this was not correct and that Naloxone properly administered had the potential to save lives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record blood-pressure readings promptly in medical records
Wider context from the report “1. There appeared to be a general misunderstanding how health care professionals should comply with DH Clinical Management of Drug Dependence in Adult Prison Settings Guidelines 12.3 and 12.4. In particular this relates to the requirement to ensure that patients who are undergoing Methadone or Buprenorphine stabilization have not experienced a lowering of blood pressure or drowsiness before administration of the controlled drug.
• Health care assistants routinely took the blood pressure before administration but did not inform the nurse of the reading and may not have had instruction when to report the reading
• The evidence of six nurses and a health care assistant showed that previous blood pressure recordings were not sought or examined to determine if there had been a lowering of BP
• The record of blood pressure was often written on paper and not usually entered in the medical records at the time and sometimes not at all
• A health care assistant who did record a BP of 93/68 was asked by a nurse to repeat it and reported back to the medication hatch that it was still low. No apparent action was taken by nurses to suspend the medication or escalate the concern to a doctor on 11th.
• One nurse, who did not see the BP of 93/58 recorded in the records and administered Methadone, did not know what she would do if he had discovered a previous higher BP.
• One nurse was surprised that a BP of 105/60 having a reading of 128/68 and 93/68 the previous day and 121/81 the day before that, should trigger withholding Methadone and escalating to the doctor.
• The expert GP, who had been clinical director in the health care team provided to the prison, identified a sequence of seven BP recordings over 4 days, six of which (the second was considered rogue) should have triggered suspension of administration of drugs and escalation to the doctor, but in no case did this occur.
• The head of health care at the time, who was an inexperienced nurse, did not accept that advice and asserted it would be impractical to implement it, as it would lead to significant delays.
• In a local policy on Buprenorphine a threshold triggering suspension of drug and escalation was defined as 90/60 without reference to the trend. None was found in a section on Methadone and no definition of lowering of blood pressure or how to record it was found in any local policies.
• No nurse saw the entry in the medical records by a doctor at 18.56 on 13th November which read: “Unusually drowsy. Eyelids close when not engaged. communicative alert. no sadness or dsh. Plan stop Citalopram and monitor for signs of overdose.. may req further urine test before further Methadone testing...”.
• At 17.57 on 13th, one hour from the doctor’s assessment, when he must have been unusually drowsy, no nurse found him drowsy when he presented at the hatch for medication, and he was given Methadone and Tramadol.
• On the morning of 14th he was given further Methadone and Tramadol, without measuring the blood pressure, or testing, as the previous day was last day of his Methadone titration regime and his 5 day 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and act on drowsiness before controlled-drug administration
Wider context from the report “1. There appeared to be a general misunderstanding how health care professionals should comply with DH Clinical Management of Drug Dependence in Adult Prison Settings Guidelines 12.3 and 12.4. In particular this relates to the requirement to ensure that patients who are undergoing Methadone or Buprenorphine stabilization have not experienced a lowering of blood pressure or drowsiness before administration of the controlled drug.
• Health care assistants routinely took the blood pressure before administration but did not inform the nurse of the reading and may not have had instruction when to report the reading
• The evidence of six nurses and a health care assistant showed that previous blood pressure recordings were not sought or examined to determine if there had been a lowering of BP
• The record of blood pressure was often written on paper and not usually entered in the medical records at the time and sometimes not at all
• A health care assistant who did record a BP of 93/68 was asked by a nurse to repeat it and reported back to the medication hatch that it was still low. No apparent action was taken by nurses to suspend the medication or escalate the concern to a doctor on 11th.
• One nurse, who did not see the BP of 93/58 recorded in the records and administered Methadone, did not know what she would do if he had discovered a previous higher BP.
• One nurse was surprised that a BP of 105/60 having a reading of 128/68 and 93/68 the previous day and 121/81 the day before that, should trigger withholding Methadone and escalating to the doctor.
• The expert GP, who had been clinical director in the health care team provided to the prison, identified a sequence of seven BP recordings over 4 days, six of which (the second was considered rogue) should have triggered suspension of administration of drugs and escalation to the doctor, but in no case did this occur.
• The head of health care at the time, who was an inexperienced nurse, did not accept that advice and asserted it would be impractical to implement it, as it would lead to significant delays.
• In a local policy on Buprenorphine a threshold triggering suspension of drug and escalation was defined as 90/60 without reference to the trend. None was found in a section on Methadone and no definition of lowering of blood pressure or how to record it was found in any local policies.
• No nurse saw the entry in the medical records by a doctor at 18.56 on 13th November which read: “Unusually drowsy. Eyelids close when not engaged. communicative alert. no sadness or dsh. Plan stop Citalopram and monitor for signs of overdose.. may req further urine test before further Methadone testing...”.
• At 17.57 on 13th, one hour from the doctor’s assessment, when he must have been unusually drowsy, no nurse found him drowsy when he presented at the hatch for medication , and he was given Methadone and Tramadol.
• On the morning of 14th he was given further Methadone and Tramadol, without measuring the blood pressure, or testing, as the previous day was last day of his Methadone titration regime and his 5 day 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to stop medicines when Methadone toxicity is considered
Wider context from the report “4. ████████
████████ was represented at the inquest and the following evidence gave rise to concerns:
• He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him, although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison.
• When he saw the patient on 13th he failed to consider the interactions between Citalopram and Tramadol and between Citalopram and Methadone, both of which the prison expert ████████ said were contraindicated, nor the summative effects of combining Methadone, Tramadol and Diazepam.
• He said that he was not aware whether withdrawal can cause low BP and thought the BP was measured to see if the patient was withdrawing.
• He said that he did not know whether he should stop Methadone if the BP was low.
• Mr Boyens was seen by the doctor on 13th, the day after another witness found him drowsy with “pinned eyes” and a few hours before another witness found him unsteady and drowsy. He made no record of the state of the pupils, but did record him as unusually drowsy.
• At that examination, according to his 2013 statement he considered the patient was drowsy due to lack of sleep; in a 2015 statement he considered use of illicit drugs and was aware of the possibility of Methadone toxicity. But he failed to stop these drugs from continuing to be administered .
• At this assessment on 13th he recorded an intention to stop the Citalopram on the request of the patient, but did not take the simple steps to cancel the prescription on the computerised record and if he told a nurse about this instruction it was not recalled or noted by them, and continued to be administered.
• He gave evidence that he would not administer Naloxone to a patient unless the patient was blue and unconscious and known to have taken opiates and did not know any disadvantages of doing so. ████████ gave evidence that this was not correct and that Naloxone properly administered had the potential to save lives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to review blood-pressure trends before controlled-drug administration
Wider context from the report “1. There appeared to be a general misunderstanding how health care professionals should comply with DH Clinical Management of Drug Dependence in Adult Prison Settings Guidelines 12.3 and 12.4. In particular this relates to the requirement to ensure that patients who are undergoing Methadone or Buprenorphine stabilization have not experienced a lowering of blood pressure or drowsiness before administration of the controlled drug.
• Health care assistants routinely took the blood pressure before administration but did not inform the nurse of the reading and may not have had instruction when to report the reading
• The evidence of six nurses and a health care assistant showed that previous blood pressure recordings were not sought or examined to determine if there had been a lowering of BP
• The record of blood pressure was often written on paper and not usually entered in the medical records at the time and sometimes not at all
• A health care assistant who did record a BP of 93/68 was asked by a nurse to repeat it and reported back to the medication hatch that it was still low. No apparent action was taken by nurses to suspend the medication or escalate the concern to a doctor on 11th.
• One nurse, who did not see the BP of 93/58 recorded in the records and administered Methadone, did not know what she would do if he had discovered a previous higher BP.
• One nurse was surprised that a BP of 105/60 having a reading of 128/68 and 93/68 the previous day and 121/81 the day before that, should trigger withholding Methadone and escalating to the doctor.
• The expert GP, who had been clinical director in the health care team provided to the prison, identified a sequence of seven BP recordings over 4 days, six of which (the second was considered rogue) should have triggered suspension of administration of drugs and escalation to the doctor, but in no case did this occur.
• The head of health care at the time, who was an inexperienced nurse, did not accept that advice and asserted it would be impractical to implement it, as it would lead to significant delays.
• In a local policy on Buprenorphine a threshold triggering suspension of drug and escalation was defined as 90/60 without reference to the trend. None was found in a section on Methadone and no definition of lowering of blood pressure or how to record it was found in any local policies.
• No nurse saw the entry in the medical records by a doctor at 18.56 on 13th November which read: “Unusually drowsy. Eyelids close when not engaged. communicative alert. no sadness or dsh. Plan stop Citalopram and monitor for signs of overdose.. may req further urine test before further Methadone testing...”.
• At 17.57 on 13th, one hour from the doctor’s assessment, when he must have been unusually drowsy, no nurse found him drowsy when he presented at the hatch for medication, and he was given Methadone and Tramadol.
• On the morning of 14th he was given further Methadone and Tramadol, without measuring the blood pressure, or testing, as the previous day was last day of his Methadone titration regime and his 5 day 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to suspend controlled drugs and escalate low blood pressure
Wider context from the report “1. There appeared to be a general misunderstanding how health care professionals should comply with DH Clinical Management of Drug Dependence in Adult Prison Settings Guidelines 12.3 and 12.4. In particular this relates to the requirement to ensure that patients who are undergoing Methadone or Buprenorphine stabilization have not experienced a lowering of blood pressure or drowsiness before administration of the controlled drug.
• Health care assistants routinely took the blood pressure before administration but did not inform the nurse of the reading and may not have had instruction when to report the reading
• The evidence of six nurses and a health care assistant showed that previous blood pressure recordings were not sought or examined to determine if there had been a lowering of BP
• The record of blood pressure was often written on paper and not usually entered in the medical records at the time and sometimes not at all
• A health care assistant who did record a BP of 93/68 was asked by a nurse to repeat it and reported back to the medication hatch that it was still low. No apparent action was taken by nurses to suspend the medication or escalate the concern to a doctor on 11th.
• One nurse, who did not see the BP of 93/58 recorded in the records and administered Methadone, did not know what she would do if he had discovered a previous higher BP.
• One nurse was surprised that a BP of 105/60 having a reading of 128/68 and 93/68 the previous day and 121/81 the day before that, should trigger withholding Methadone and escalating to the doctor.
• The expert GP, who had been clinical director in the health care team provided to the prison, identified a sequence of seven BP recordings over 4 days, six of which (the second was considered rogue) should have triggered suspension of administration of drugs and escalation to the doctor, but in no case did this occur .
• The head of health care at the time, who was an inexperienced nurse, did not accept that advice and asserted it would be impractical to implement it, as it would lead to significant delays.
• In a local policy on Buprenorphine a threshold triggering suspension of drug and escalation was defined as 90/60 without reference to the trend. None was found in a section on Methadone and no definition of lowering of blood pressure or how to record it was found in any local policies.
• No nurse saw the entry in the medical records by a doctor at 18.56 on 13th November which read: “Unusually drowsy. Eyelids close when not engaged. communicative alert. no sadness or dsh. Plan stop Citalopram and monitor for signs of overdose.. may req further urine test before further Methadone testing...”.
• At 17.57 on 13th, one hour from the doctor’s assessment, when he must have been unusually drowsy, no nurse found him drowsy when he presented at the hatch for medication, and he was given Methadone and Tramadol.
• On the morning of 14th he was given further Methadone and Tramadol, without measuring the blood pressure, or testing, as the previous day was last day of his Methadone titration regime and his 5 day 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of defined criteria and recording requirements for lowering blood pressure
Wider context from the report “1. There appeared to be a general misunderstanding how health care professionals should comply with DH Clinical Management of Drug Dependence in Adult Prison Settings Guidelines 12.3 and 12.4. In particular this relates to the requirement to ensure that patients who are undergoing Methadone or Buprenorphine stabilization have not experienced a lowering of blood pressure or drowsiness before administration of the controlled drug.
• Health care assistants routinely took the blood pressure before administration but did not inform the nurse of the reading and may not have had instruction when to report the reading
• The evidence of six nurses and a health care assistant showed that previous blood pressure recordings were not sought or examined to determine if there had been a lowering of BP
• The record of blood pressure was often written on paper and not usually entered in the medical records at the time and sometimes not at all
• A health care assistant who did record a BP of 93/68 was asked by a nurse to repeat it and reported back to the medication hatch that it was still low. No apparent action was taken by nurses to suspend the medication or escalate the concern to a doctor on 11th.
• One nurse, who did not see the BP of 93/58 recorded in the records and administered Methadone, did not know what she would do if he had discovered a previous higher BP.
• One nurse was surprised that a BP of 105/60 having a reading of 128/68 and 93/68 the previous day and 121/81 the day before that, should trigger withholding Methadone and escalating to the doctor.
• The expert GP, who had been clinical director in the health care team provided to the prison, identified a sequence of seven BP recordings over 4 days, six of which (the second was considered rogue) should have triggered suspension of administration of drugs and escalation to the doctor, but in no case did this occur.
• The head of health care at the time, who was an inexperienced nurse, did not accept that advice and asserted it would be impractical to implement it, as it would lead to significant delays.
• In a local policy on Buprenorphine a threshold triggering suspension of drug and escalation was defined as 90/60 without reference to the trend. None was found in a section on Methadone and no definition of lowering of blood pressure or how to record it was found in any local policies .
• No nurse saw the entry in the medical records by a doctor at 18.56 on 13th November which read: “Unusually drowsy. Eyelids close when not engaged. communicative alert. no sadness or dsh. Plan stop Citalopram and monitor for signs of overdose.. may req further urine test before further Methadone testing...”.
• At 17.57 on 13th, one hour from the doctor’s assessment, when he must have been unusually drowsy, no nurse found him drowsy when he presented at the hatch for medication, and he was given Methadone and Tramadol.
• On the morning of 14th he was given further Methadone and Tramadol, without measuring the blood pressure, or testing, as the previous day was last day of his Methadone titration regime and his 5 day 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Prescribing multiple medicines without a sufficiently complete clinical assessment and medication history
Wider context from the report “4. ████████
████████ was represented at the inquest and the following evidence gave rise to concerns:
• He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him , although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison .
• When he saw the patient on 13th he failed to consider the interactions between Citalopram and Tramadol and between Citalopram and Methadone, both of which the prison expert ████████ said were contraindicated, nor the summative effects of combining Methadone, Tramadol and Diazepam.
• He said that he was not aware whether withdrawal can cause low BP and thought the BP was measured to see if the patient was withdrawing.
• He said that he did not know whether he should stop Methadone if the BP was low.
• Mr Boyens was seen by the doctor on 13th, the day after another witness found him drowsy with “pinned eyes” and a few hours before another witness found him unsteady and drowsy. He made no record of the state of the pupils, but did record him as unusually drowsy.
• At that examination, according to his 2013 statement he considered the patient was drowsy due to lack of sleep; in a 2015 statement he considered use of illicit drugs and was aware of the possibility of Methadone toxicity. But he failed to stop these drugs from continuing to be administered.
• At this assessment on 13th he recorded an intention to stop the Citalopram on the request of the patient, but did not take the simple steps to cancel the prescription on the computerised record and if he told a nurse about this instruction it was not recalled or noted by them, and continued to be administered.
• He gave evidence that he would not administer Naloxone to a patient unless the patient was blue and unconscious and known to have taken opiates and did not know any disadvantages of doing so. ████████ gave evidence that this was not correct and that Naloxone properly administered had the potential to save lives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to assess drug interactions and cumulative effects before prescribing
Wider context from the report “4. ████████
████████ was represented at the inquest and the following evidence gave rise to concerns:
• He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him, although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison.
• When he saw the patient on 13th he failed to consider the interactions between Citalopram and Tramadol and between Citalopram and Methadone , both of which the prison expert ████████ said were contraindicated, nor the summative effects of combining Methadone, Tramadol and Diazepam .
• He said that he was not aware whether withdrawal can cause low BP and thought the BP was measured to see if the patient was withdrawing.
• He said that he did not know whether he should stop Methadone if the BP was low.
• Mr Boyens was seen by the doctor on 13th, the day after another witness found him drowsy with “pinned eyes” and a few hours before another witness found him unsteady and drowsy. He made no record of the state of the pupils, but did record him as unusually drowsy.
• At that examination, according to his 2013 statement he considered the patient was drowsy due to lack of sleep; in a 2015 statement he considered use of illicit drugs and was aware of the possibility of Methadone toxicity. But he failed to stop these drugs from continuing to be administered.
• At this assessment on 13th he recorded an intention to stop the Citalopram on the request of the patient, but did not take the simple steps to cancel the prescription on the computerised record and if he told a nurse about this instruction it was not recalled or noted by them, and continued to be administered.
• He gave evidence that he would not administer Naloxone to a patient unless the patient was blue and unconscious and known to have taken opiates and did not know any disadvantages of doing so. ████████ gave evidence that this was not correct and that Naloxone properly administered had the potential to save lives.
” Open source report
26 Feb 2014 Bertram Theophilus HAMILTON · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 2 Failure to provide frank and open evidence supported by contemporaneous documentation View source Failure to withhold insulin when blood sugars are dangerously low 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
Bertram Theophilus HAMILTON · 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
Bertram Theophilus HAMILTON was a long-term care-home resident who died shortly after receiving insulin despite a recorded blood sugar level of 1.6. Concerns included the nurse appearing not to know that insulin should not be given when blood sugar was so low, and concerns about the nurse's account of events not being supported by contemporaneous documentation.
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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide frank and open evidence supported by contemporaneous documentation
Wider context from the report “I am concerned that the nurse in question appeared not to know that insulin should not be given to a person whose blood sugars were so low. In addition, I was concerned that the nurse was not frank and open in giving evidence to me and claimed that she had given Mr. Hamilton a sugary solution, that she had re-checked his blood sugar and gave the insulin only after the blood sugar level was high . None of the contemporaneous documentation, including documentation completed by the nurse herself, supported such a contention .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to withhold insulin when blood sugars are dangerously low
Wider context from the report “I am concerned that the nurse in question appeared not to know that insulin should not be given to a person whose blood sugars were so low . In addition, I was concerned that the nurse was not frank and open in giving evidence to me and claimed that she had given Mr. Hamilton a sugary solution, that she had re-checked his blood sugar and gave the insulin only after the blood sugar level was high. None of the contemporaneous documentation, including documentation completed by the nurse herself, supported such a contention.
” Open source report
25 Feb 2014 Arthur Brockett-Deakins · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 8 Inadequate governance and oversight of private midwifery-led services across the mixed health economy View source Insufficient CTG interpretation training and competence View source Inconsistent thresholds for review and intervention between private and NHS maternity care View source Maternal pulse being displayed as fetal heart rate on CTG machines View source Unsafe staffing and shift arrangements for private midwifery services View source Failure to document and risk-assess private midwifery-led service arrangements View source Failure to escalate abnormal CTG findings appropriately in slow second-stage labour View source Insufficient specialist and interdisciplinary support for private midwifery-led services View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Arthur Brockett-Deakins · 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
Arthur Brockett-Deakins was born in poor condition on 16 December 2007 after complications during labour and suffered severe disabilities resulting from acute profound perinatal hypoxic-ischaemic encephalopathy. He died at home on 18 October 2011 from respiratory problems. The report identified concerns about failure to escalate an abnormal CTG, administration and monitoring of Syntocinon, CTG interpretation and display of the maternal heart rate, and the organisation and support of a private midwifery-led service.
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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate governance and oversight of private midwifery-led services across the mixed health economy
Wider context from the report “4. Models of private midwifery led services for low risk pregnancy: The private midwifery caseload for low risk pregnancies was managed by a pair of midwives who set up the service to provide continuity of care. The midwife service that was operating when ████████ was pregnant was not adequately documented. No job description was seen by the court and the referral and operational arrangements were discussed, but no documentation was brought to the court. There was no evidence of risk assessment. Although NHS employees were required to be self sufficient in terms of annual leave and sickness cover, on call arrangements and use of NHS personnel except in emergencies. They did not at the outset have a link obstetrician. This led to fear of burn out, a sense of isolation and lack of support and collegiality.
When they transferred babies to the Hospital Birthing Centre, they were expected to refer to a duty obstetric consultant, access to whom was described as variable. The midwife in charge of the NHS unit agreed that she provided a different threshold of care to private and NHS mothers and was reluctant to intervene or review the care plan for augmentation of labour, which she would have done in an NHS patient. The midwives expected her to be involved but did not ask her. In the event no peer senior midwife or obstetrician saw ████████ which was necessary. The reasons for non referral were complex and were not because the midwives thought they could not refer. Misjudgements were made which in part were caused by a 15 hour shift with only a 40 minute break. This would not occur in contexts where there was normal NHS management of staff, but this arrangement continued apparently unknown to the NHS Trust management. The service is no longer operational, the Trust reporting that it was discontinued for economic reasons.
Expert advice considered that the model of service created a risk of deaths, although it was not found to have directly done so in this case. Dr ████████ reported that there were similar units operating elsewhere in the country and that the lessons from the difficulties in operating this one should be disseminated to other such units. The expert midwife, Ms ████████ was particularly concerned about adequate support and Dr. ████████ was particularly concerned about the isolation and professional culture and lack of interdisciplinary peer discussion, in the context of increasingly risks in obstetric and midwifery practice.
The Trust head midwife reported that she expected that the matter would now be dealt with robustly by the statutory supervision system. No evidence was heard about whether this was now effective in this regard , nor how influence and information could be brought to bear on those setting up or managing such midwife led services. It was further reported that not all midwives are members of the College that runs that supervision and that midwives are not necessarily practising within the NHS. Thus is it was not clear how the risks are best identified and managed across a complex mixed health economy , which is why the Secretary of State is an addressee of my report.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient CTG interpretation training and competence
Wider context from the report “2. Training of one midwife in CTG interpretation: Both midwives underwent voluntary further training and supervision, including an expert workshop on CTG interpretation. Both accepted that a number of errors had been made by them and applied the learning to their current practice. However even in retrospect, one of the midwives could not accept that the early CTG trace was pathological , as held by both expert obstetrician and midwife. Although she would refer now, there is doubt about the urgency . She said in court it would be within half an hour but also that 40 minutes was needed to see if it was abnormal. The expert midwife said that she needed further training on CTG interpretation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Inconsistent thresholds for review and intervention between private and NHS maternity care
Wider context from the report “4. Models of private midwifery led services for low risk pregnancy: The private midwifery caseload for low risk pregnancies was managed by a pair of midwives who set up the service to provide continuity of care. The midwife service that was operating when ████████ was pregnant was not adequately documented. No job description was seen by the court and the referral and operational arrangements were discussed, but no documentation was brought to the court. There was no evidence of risk assessment. Although NHS employees were required to be self sufficient in terms of annual leave and sickness cover, on call arrangements and use of NHS personnel except in emergencies. They did not at the outset have a link obstetrician. This led to fear of burn out, a sense of isolation and lack of support and collegiality.
When they transferred babies to the Hospital Birthing Centre, they were expected to refer to a duty obstetric consultant, access to whom was described as variable. The midwife in charge of the NHS unit agreed that she provided a different threshold of care to private and NHS mothers and was reluctant to intervene or review the care plan for augmentation of labour , which she would have done in an NHS patient. The midwives expected her to be involved but did not ask her. In the event no peer senior midwife or obstetrician saw ████████ which was necessary . The reasons for non referral were complex and were not because the midwives thought they could not refer. Misjudgements were made which in part were caused by a 15 hour shift with only a 40 minute break. This would not occur in contexts where there was normal NHS management of staff, but this arrangement continued apparently unknown to the NHS Trust management. The service is no longer operational, the Trust reporting that it was discontinued for economic reasons.
Expert advice considered that the model of service created a risk of deaths, although it was not found to have directly done so in this case. Dr ████████ reported that there were similar units operating elsewhere in the country and that the lessons from the difficulties in operating this one should be disseminated to other such units. The expert midwife, Ms ████████ was particularly concerned about adequate support and Dr. ████████ was particularly concerned about the isolation and professional culture and lack of interdisciplinary peer discussion, in the context of increasingly risks in obstetric and midwifery practice.
The Trust head midwife reported that she expected that the matter would now be dealt with robustly by the statutory supervision system. No evidence was heard about whether this was now effective in this regard, nor how influence and information could be brought to bear on those setting up or managing such midwife led services. It was further reported that not all midwives are members of the College that runs that supervision and that midwives are not necessarily practising within the NHS. Thus is it was not clear how the risks are best identified and managed across a complex mixed health economy, which is why the Secretary of State is an addressee of my report.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Maternal pulse being displayed as fetal heart rate on CTG machines
Wider context from the report “3. Display of MHR as FHR on CTGs: Ms ████████ explained that if the foetus moves out of the range of the ultrasound field or the baby has sadly died, the ultrasound transducer may then pick up the maternal pulse from the aorta, iliac or uterine artery and it is displayed as the FHR and can show reactivity and variability due to MHR changes and muscle contractions can be difficult to distinguish from the FHR. It is known that the rate can be doubled or halved .
The only explanation that both expert midwife and expert obstetrician could reach for the unusual CTG trace after 1pm, in the context of the state of the baby at birth, was that the maternal pulse rate was masquerading as the FHR but it had been multiplied by 1.5 . The CTG machine was not the type that is known rarely to multiply by 2 and the phenomenon of a multiplication by a factor other than 2, being unknown to both experts in their distinguished careers. Evidence was not heard from the manufacturer or the product's regulatory authority. The inquest heard that new CTG machines incorporate maternal ECG or pulse oximetry, which alerts staff to investigate when MHR and FHR appear the same. But it also heard that it will take some time before all old machines are replaced . It needs to be established if multiplying by 1.5 is a possible functional feature of some machines and if so whether either it can be designed away or whether dissemination or guidance or an action by the regulatory authority is needed to prevent it leading to a fatality or child disability.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Unsafe staffing and shift arrangements for private midwifery services
Wider context from the report “4. Models of private midwifery led services for low risk pregnancy: The private midwifery caseload for low risk pregnancies was managed by a pair of midwives who set up the service to provide continuity of care. The midwife service that was operating when ████████ was pregnant was not adequately documented. No job description was seen by the court and the referral and operational arrangements were discussed, but no documentation was brought to the court. There was no evidence of risk assessment. Although NHS employees were required to be self sufficient in terms of annual leave and sickness cover, on call arrangements and use of NHS personnel except in emergencies. They did not at the outset have a link obstetrician. This led to fear of burn out, a sense of isolation and lack of support and collegiality.
When they transferred babies to the Hospital Birthing Centre, they were expected to refer to a duty obstetric consultant, access to whom was described as variable. The midwife in charge of the NHS unit agreed that she provided a different threshold of care to private and NHS mothers and was reluctant to intervene or review the care plan for augmentation of labour, which she would have done in an NHS patient. The midwives expected her to be involved but did not ask her. In the event no peer senior midwife or obstetrician saw ████████ which was necessary. The reasons for non referral were complex and were not because the midwives thought they could not refer. Misjudgements were made which in part were caused by a 15 hour shift with only a 40 minute break . This would not occur in contexts where there was normal NHS management of staff, but this arrangement continued apparently unknown to the NHS Trust management. The service is no longer operational, the Trust reporting that it was discontinued for economic reasons.
Expert advice considered that the model of service created a risk of deaths, although it was not found to have directly done so in this case. Dr ████████ reported that there were similar units operating elsewhere in the country and that the lessons from the difficulties in operating this one should be disseminated to other such units. The expert midwife, Ms ████████ was particularly concerned about adequate support and Dr. ████████ was particularly concerned about the isolation and professional culture and lack of interdisciplinary peer discussion, in the context of increasingly risks in obstetric and midwifery practice.
The Trust head midwife reported that she expected that the matter would now be dealt with robustly by the statutory supervision system. No evidence was heard about whether this was now effective in this regard, nor how influence and information could be brought to bear on those setting up or managing such midwife led services. It was further reported that not all midwives are members of the College that runs that supervision and that midwives are not necessarily practising within the NHS. Thus is it was not clear how the risks are best identified and managed across a complex mixed health economy, which is why the Secretary of State is an addressee of my report.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to document and risk-assess private midwifery-led service arrangements
Wider context from the report “4. Models of private midwifery led services for low risk pregnancy: The private midwifery caseload for low risk pregnancies was managed by a pair of midwives who set up the service to provide continuity of care. The midwife service that was operating when ████████ was pregnant was not adequately documented . No job description was seen by the court and the referral and operational arrangements were discussed, but no documentation was brought to the court . There was no evidence of risk assessment . Although NHS employees were required to be self sufficient in terms of annual leave and sickness cover, on call arrangements and use of NHS personnel except in emergencies. They did not at the outset have a link obstetrician. This led to fear of burn out, a sense of isolation and lack of support and collegiality.
When they transferred babies to the Hospital Birthing Centre, they were expected to refer to a duty obstetric consultant, access to whom was described as variable. The midwife in charge of the NHS unit agreed that she provided a different threshold of care to private and NHS mothers and was reluctant to intervene or review the care plan for augmentation of labour, which she would have done in an NHS patient. The midwives expected her to be involved but did not ask her. In the event no peer senior midwife or obstetrician saw ████████ which was necessary. The reasons for non referral were complex and were not because the midwives thought they could not refer. Misjudgements were made which in part were caused by a 15 hour shift with only a 40 minute break. This would not occur in contexts where there was normal NHS management of staff, but this arrangement continued apparently unknown to the NHS Trust management. The service is no longer operational, the Trust reporting that it was discontinued for economic reasons.
Expert advice considered that the model of service created a risk of deaths, although it was not found to have directly done so in this case. Dr ████████ reported that there were similar units operating elsewhere in the country and that the lessons from the difficulties in operating this one should be disseminated to other such units. The expert midwife, Ms ████████ was particularly concerned about adequate support and Dr. ████████ was particularly concerned about the isolation and professional culture and lack of interdisciplinary peer discussion, in the context of increasingly risks in obstetric and midwifery practice.
The Trust head midwife reported that she expected that the matter would now be dealt with robustly by the statutory supervision system. No evidence was heard about whether this was now effective in this regard, nor how influence and information could be brought to bear on those setting up or managing such midwife led services. It was further reported that not all midwives are members of the College that runs that supervision and that midwives are not necessarily practising within the NHS. Thus is it was not clear how the risks are best identified and managed across a complex mixed health economy, which is why the Secretary of State is an addressee of my report.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate abnormal CTG findings appropriately in slow second-stage labour
Wider context from the report “1. When to escalate concerns about a CTG: With regard to not escalating an abnormal CTG that ran for about half an hour after augmentation of labour, reliance was placed by midwives on a clause of NICE Clinical Guidelines, Intrapartum Care, 2007, which advises that a 40 minutes trace should be studied before concluding if it is abnormal. Expert evidence from Dr ████████ and Ms ████████ suggested that this guidance was appropriate in the first stage of labour, but not in the context in this case, namely a slow second stage .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient specialist and interdisciplinary support for private midwifery-led services
Wider context from the report “4. Models of private midwifery led services for low risk pregnancy: The private midwifery caseload for low risk pregnancies was managed by a pair of midwives who set up the service to provide continuity of care. The midwife service that was operating when ████████ was pregnant was not adequately documented. No job description was seen by the court and the referral and operational arrangements were discussed, but no documentation was brought to the court. There was no evidence of risk assessment. Although NHS employees were required to be self sufficient in terms of annual leave and sickness cover, on call arrangements and use of NHS personnel except in emergencies. They did not at the outset have a link obstetrician . This led to fear of burn out, a sense of isolation and lack of support and collegiality.
When they transferred babies to the Hospital Birthing Centre, they were expected to refer to a duty obstetric consultant, access to whom was described as variable . The midwife in charge of the NHS unit agreed that she provided a different threshold of care to private and NHS mothers and was reluctant to intervene or review the care plan for augmentation of labour, which she would have done in an NHS patient. The midwives expected her to be involved but did not ask her. In the event no peer senior midwife or obstetrician saw ████████ which was necessary. The reasons for non referral were complex and were not because the midwives thought they could not refer. Misjudgements were made which in part were caused by a 15 hour shift with only a 40 minute break. This would not occur in contexts where there was normal NHS management of staff, but this arrangement continued apparently unknown to the NHS Trust management. The service is no longer operational, the Trust reporting that it was discontinued for economic reasons.
Expert advice considered that the model of service created a risk of deaths, although it was not found to have directly done so in this case. Dr ████████ reported that there were similar units operating elsewhere in the country and that the lessons from the difficulties in operating this one should be disseminated to other such units. The expert midwife, Ms ████████ was particularly concerned about adequate support and Dr. ████████ was particularly concerned about the isolation and professional culture and lack of interdisciplinary peer discussion , in the context of increasingly risks in obstetric and midwifery practice.
The Trust head midwife reported that she expected that the matter would now be dealt with robustly by the statutory supervision system. No evidence was heard about whether this was now effective in this regard, nor how influence and information could be brought to bear on those setting up or managing such midwife led services. It was further reported that not all midwives are members of the College that runs that supervision and that midwives are not necessarily practising within the NHS. Thus is it was not clear how the risks are best identified and managed across a complex mixed health economy, which is why the Secretary of State is an addressee of my report.
” 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 Establish policy and training for supervisory investigations.
Verbatim wording from the response “Currently, the local supervisory authority (LSA) would be alerted to serious incidents of this nature via their database system and there is a link to the LSA for every maternity service in London who would provide guidance to a supervisor of midwives when a serious incident occurs. A serious incident of this nature would also trigger a supervisory investigation which would be reported to the local supervisory authority midwifery officer. I understand from the lead supervisor of midwives for the London area that there were no separate supervisory investigations undertaken at the time of Arthur’s birth. Furthermore, there were no guidelines in place at that time for the conduct of supervisory investigations. There is now policy and training in place on supervisory investigations.” Source location 2014-0077-Response-by-Nursing-Midwifery-Council
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 actions of either midwife concerning the death cannot be reconsidered because the referral was previously closed and no legal exception applies.
Verbatim wording from the response “The NMC will not, however, be able to consider the actions of either midwife in relation to the death of Arthur. This is because that aspect of the referral was considered fully, and closed, by our investigating committee (IC) in 2009. Since the case was closed over three years ago, it cannot be reconsidered by the IC under rule 7(1) of the NMC’s Fitness to Practise Rules 2004. There is also no evidence of an error which would allow us to remit the case back to the committee in accordance with case law in this area (R (on the application of B) v NMC [2012] EWHC 1264 (Admin)).” Source location 2014-0077-Response-by-Nursing-Midwifery-Council
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 References concerning private and NHS midwifery care should be addressed to the Department of Health.
Verbatim wording from the response “As the regulatory body for nurse and midwives, the NMC is not in a position to offer a view on the models of midwifery care offered in private and NHS settings and I think that references to this particular area of your report would be more appropriately addressed by colleagues at the Department of Health.” Source location 2014-0077-Response-by-Nursing-Midwifery-Council
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 regulator cannot offer a view on models of private and NHS midwifery care because this falls outside its regulatory role.
Verbatim wording from the response “As the regulatory body for nurse and midwives, the NMC is not in a position to offer a view on the models of midwifery care offered in private and NHS settings and I think that references to this particular area of your report would be more appropriately addressed by colleagues at the Department of Health.” Source location 2014-0077-Response-by-Nursing-Midwifery-Council
Open published response
10 Jan 2014 Mary WALDRON · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 9 Failure of nursing home staff to take appropriate action when aware of low blood pressure View source Inability of the nursing home to address future risks relating to a nurse's training View source Lack of clarity regarding the status of the Care Quality Commission investigation View source Failure of nursing home staff to recognise acutely unwell residents View source Failure of nursing home managers to take action to prevent recurrence View source Failure of nursing home managers to undertake effective incident investigations View source Failure to provide the non-driving paramedic with satellite navigation information for hospital transfer times View source Inaccurate reporting by nursing home managers to the Care Quality Commission View source Lack of ongoing training in recognition and treatment of acutely unwell residents View source See 6 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
Mary WALDRON · 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
Mary Waldron became unwell at St Mary's Nursing Home on 24 August 2013 and was transferred to University Hospital, Coventry, where she died after suffering a cardiac arrest during the transfer. Concerns included failures to recognise and appropriately respond to her acute illness and low blood pressure, inadequate ongoing staff training, shortcomings in the nursing home's investigation and reporting, uncertainty about the CQC investigation, and potential confusion between ambulance drivers and paramedics about transfer times.
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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing home staff to take appropriate action when aware of low blood pressure
Wider context from the report “(2) failure of the nursing home staff to undertake appropriate action when they were aware of the low blood pressure ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Inability of the nursing home to address future risks relating to a nurse's training
Wider context from the report “(7) the nurse primarily involved in this incident is no longer an employee at St Mary's and is working elsewhere. St Mary's nursing home is therefore unable to take action to address potential future risks relating to the training of this nurse ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity regarding the status of the Care Quality Commission investigation
Wider context from the report “(6) lack of clarity as to the investigation that is to be undertaken by the CQC . The nursing home gave evidence that the investigation is closed, whilst the family believe it is ongoing ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing home staff to recognise acutely unwell residents
Wider context from the report “(1) failure of the nursing home staff to recognise an acutely unwell resident ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing home managers to take action to prevent recurrence
Wider context from the report “(4) failure of the nursing home managers to undertake an effective investigation into this incident and to take action to prevent repetition;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing home managers to undertake effective incident investigations
Wider context from the report “(4) failure of the nursing home managers to undertake an effective investigation into this incident and to take action to prevent repetition;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the non-driving paramedic with satellite navigation information for hospital transfer times
Wider context from the report “(8) the potential for further incidents of confusion between driver and paramedic with regard to hospital transfer times , with the possibility of significant adverse consequences. Evidence given was that satellite navigation information (including time to arrival) was only available directly to the ambulance driver . Direct visualisation of a satellite navigation console by the non-driving paramedic could address this 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Inaccurate reporting by nursing home managers to the Care Quality Commission
Wider context from the report “(5) inaccurate reporting by the nursing home managers to the Care Quality Commission (CQC) that internal protocols had been appropriately followed , when evidence given at the inquest was that this was not 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 Nursing and Midwifery Council; that does not assign responsibility.
PFD Monitor interpretation Lack of ongoing training in recognition and treatment of acutely unwell residents
Wider context from the report “(3) a lack of ongoing training with regard to the recognition and treatment of acutely unwell residents ; with reliance solely on initial nursing training ;
” 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