Concerns raised 9 Lack of national guidance for cross-Trust transfer of complex cases View source Commissioning arrangements failing to accommodate overlapping eating and emotional needs View source Lack of training on national guidance for complex case transfers View source Lack of clear escalation procedures during complex case transfers View source Failure to conduct risk assessments at the time of complex case transfer View source Failure to assess and manage overlapping needs using a formulation-led approach View source Lack of a national treatment pathway for co-existing eating disorders and complex emotional needs View source Failure to disseminate learning and address identified concerns nationally View source Lack of senior management oversight of complex case transfers 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
Sunny Elise EYMOND · 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
Sunny Elise EYMOND died at Winchester Hospice on 27 May 2024 after a long history of anorexia nervosa, personality disorder and complex post-traumatic stress disorder, including hospital admissions and periods of forced feeding. The report identified communication and oversight failings during her transfer of care between Hampshire and Bristol services, including the absence of a robust care package, planned 1:1 professional support and a suitable risk management plan. Concerns were raised about the lack of national guidance and treatment pathways for cross-Trust transfers involving people with eating disorders and complex emotional needs.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for cross-Trust transfer of complex cases
Wider context from the report “1. While the two trusts involved in the inquest (Southern Health and Avon & Wiltshire Mental Health Partnership NHS Trust) have undertaken reviews, learned lessons and implemented changes following Sunny’s death, the same has not happened at a national level/England wide Trust level.
2. Firstly, I am concerned that a risk of death may arise in the future if the concerns raised are not addressed more widely and brought to the attention of other Trusts and consideration is not given to the production of national guidance on cross Trust transfer of complex cases, particularly those involving patients with a diagnosis of an eating disorder and complex Post Traumatic Stress Disorder/Emotionally Unstable Personality Disorder/complex emotional needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Commissioning arrangements failing to accommodate overlapping eating and emotional needs
Wider context from the report “5. There is currently no national specified treatment pathway for individuals who present with co-existing eating difficulties and complex emotional needs. This, in turn, impacts how services are commissioned, as commissioning arrangements are largely organised around set, diagnosis-specific pathways . To ensure patient safety and national consistency, there is a need for national guidance addressing:
a) How to develop a pathway/protocol for patients with eating disorders and complex emotional needs
b) When bespoke services (such as the creation of Willow Ward at Parklands Hospital in Sunny's case) are required
c) How patients with overlapping needs should be assessed and managed using a formulation-led approach, where single- diagnosis pathways are not appropriate
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Lack of training on national guidance for complex case transfers
Wider context from the report “4. There is currently no national guidance on how best to manage and plan for Trust to Trust transfers of highly complex cases (in particular those involving patients with both a diagnosed eating disorder such as AN and complex emotional needs). Guidance is therefore required as to the need for:
a) Senior management oversight of the transfer
b) Risk assessments at the time of transfer
c) Clear escalation procedures if concerns are raised during the transfer and
d) Training on any such national 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 Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Lack of clear escalation procedures during complex case transfers
Wider context from the report “4. There is currently no national guidance on how best to manage and plan for Trust to Trust transfers of highly complex cases (in particular those involving patients with both a diagnosed eating disorder such as AN and complex emotional needs). Guidance is therefore required as to the need for:
a) Senior management oversight of the transfer
b) Risk assessments at the time of transfer
c) Clear escalation procedures if concerns are raised during the transfer and
d) Training on any such national 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 Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct risk assessments at the time of complex case transfer
Wider context from the report “4. There is currently no national guidance on how best to manage and plan for Trust to Trust transfers of highly complex cases (in particular those involving patients with both a diagnosed eating disorder such as AN and complex emotional needs). Guidance is therefore required as to the need for:
a) Senior management oversight of the transfer
b) Risk assessments at the time of transfer
c) Clear escalation procedures if concerns are raised during the transfer and
d) Training on any such national 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 Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and manage overlapping needs using a formulation-led approach
Wider context from the report “5. There is currently no national specified treatment pathway for individuals who present with co-existing eating difficulties and complex emotional needs. This, in turn, impacts how services are commissioned, as commissioning arrangements are largely organised around set, diagnosis-specific pathways. To ensure patient safety and national consistency, there is a need for national guidance addressing:
a) How to develop a pathway/protocol for patients with eating disorders and complex emotional needs
b) When bespoke services (such as the creation of Willow Ward at Parklands Hospital in Sunny's case) are required
c) How patients with overlapping needs should be assessed and managed using a formulation-led approach, where single- diagnosis pathways are not appropriate
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Lack of a national treatment pathway for co-existing eating disorders and complex emotional needs
Wider context from the report “3. Secondly, I am concerned that there is a gap at a national level (identified by both SH and AWP) in terms of a pathway for those with a diagnosis of both an eating disorder and complex emotional needs . This lack of a pathway created difficulties when Sunny was transferred from SH (Hampshire) to AWP (Bristol) in order to attend university. It meant that there was an inability to appropriately 'map' her treatment needs to the available mental health services in Bristol. I believe that this needs to be addressed at a national level and not just left for each Trust in England. It is a real concern, given the very high risk of death associated with those with both Anorexia Nervosa and a personality disorder, as was the case here.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to disseminate learning and address identified concerns nationally
Wider context from the report “1. While the two trusts involved in the inquest (Southern Health and Avon & Wiltshire Mental Health Partnership NHS Trust) have undertaken reviews, learned lessons and implemented changes following Sunny’s death, the same has not happened at a national level/England wide Trust level .
2. Firstly, I am concerned that a risk of death may arise in the future if the concerns raised are not addressed more widely and brought to the attention of other Trusts and consideration is not given to the production of national guidance on cross Trust transfer of complex cases, particularly those involving patients with a diagnosis of an eating disorder and complex Post Traumatic Stress Disorder/Emotionally Unstable Personality Disorder/complex emotional needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Lack of senior management oversight of complex case transfers
Wider context from the report “4. There is currently no national guidance on how best to manage and plan for Trust to Trust transfers of highly complex cases (in particular those involving patients with both a diagnosed eating disorder such as AN and complex emotional needs). Guidance is therefore required as to the need for:
a) Senior management oversight of the transfer
b) Risk assessments at the time of transfer
c) Clear escalation procedures if concerns are raised during the transfer and
d) Training on any such national guidance
” Open source report
Concerns raised 2 Lack of national pathway guidance for call handlers on assessing whether someone is breathing and whether CPR is required View source Lack of national pathway guidance for call handlers on assessing how cold the body is 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
Drew John GREAVES-PIMBLETT · 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
Drew John Graves-Pimblett, aged 26 and with a history of epilepsy, was found unresponsive and not breathing at home on 22 March 2025. An ambulance was initially stood down after telephone triage, but police later commenced CPR and Drew was pronounced deceased. The inquest concluded that he died from Sudden Unexpected Death in Epilepsy (SUDEP), related to epilepsy and natural causes. The principal concern was that call handlers lacked sufficient guidance and did not ask probing questions about breathing, body temperature, turning Drew over, or stiffness before deciding that resuscitation would not be effective.
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 Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Lack of national pathway guidance for call handlers on assessing whether someone is breathing and whether CPR is required
Wider context from the report “Though a telephone triage is always challenging and subjective, there appears to be a gap in the national pathways for call handlers . Consideration as to further guidance and assistance to call handlers on probing questioning for fundamental aspects such as breathing and where and how to best show how cold the body is. If someone is not breathing to ask how they know and/or techniques such as head to the chest, where to take a pulse etc. for the call handler to make a more informed decision as to whether someone is breathing and if CPR is required . When a call is made to NWAS, often it is by someone not thinking straight and so specific questions on breathing and general presentation may be of assistance in assessing the call .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Lack of national pathway guidance for call handlers on assessing how cold the body is
Wider context from the report “Though a telephone triage is always challenging and subjective, there appears to be a gap in the national pathways for call handlers . Consideration as to further guidance and assistance to call handlers on probing questioning for fundamental aspects such as breathing and where and how to best show how cold the body is . If someone is not breathing to ask how they know and/or techniques such as head to the chest, where to take a pulse etc. for the call handler to make a more informed decision as to whether someone is breathing and if CPR is required. When a call is made to NWAS, often it is by someone not thinking straight and so specific questions on breathing and general presentation may be of assistance in assessing the call.
” Open source report
Concerns raised 1 Hazardous difficulty manoeuvring at the junction of St Johns Road, Tiffield and the A43 Northamptonshire 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
Jane BENNETT · 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 Bennett was involved in a road traffic collision at the junction of St Johns Road, Tiffield and the A43 on 13 March 2024 and was later confirmed deceased on 15 March 2024. The report raises concern that the junction is very difficult to manoeuvre and that, without changes, further accidents or fatalities are likely.
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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 Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Hazardous difficulty manoeuvring at the junction of St Johns Road, Tiffield and the A43 Northamptonshire
Wider context from the report “The junction of St Johns Road, Tiffield and the A43 Northamptonshire is very difficult to manoeuvre. Witnesses who attended at the inquest gave evidence to the effect that unless some changes are made there are likely to be further accidents/or fatalities. I concur with this view.
” Open source report
Concerns raised 1 Lack of radiographer procedures for escalating care and issuing urgent arrest calls when there are clear signs of imminent danger to life 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
Eleanor Hazel ALDRED-OWEN · 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
Eleanor Hazel ALDRED-OWEN was admitted for elective craniofacial surgery and developed respiratory distress after the procedure. She suffered a cardiac arrest associated with a right-sided tension pneumothorax, and died after life-sustaining measures were withdrawn following catastrophic hypoxic-ischaemic brain injury. The report raised concern that radiographers’ standard operating procedures did not provide for escalation of care or an urgent arrest call when there were clear signs of imminent danger to life.
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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 Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Lack of radiographer procedures for escalating care and issuing urgent arrest calls when there are clear signs of imminent danger to life
Wider context from the report “Evidence was given at the inquest that the standard operating procedure for radiographers did not include provision for radiographers to escalate care and put out an urgent arrest call where there were clear signs of imminent danger to life . It was not known whether this was also the case in other Trusts on a national level.
” Open source report
Concerns raised 3 Search engines readily returning websites selling potentially fatal prescription medications View source Failure of prescription medication supply-chain legitimacy monitoring to prevent ready online supply View source Failure of systems to detect criminal medication supply enterprises and alert relevant authorities 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
Susan Marie Karakoc · 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
Susan Marie Karakoc collapsed at home on 1 December 2023 and died in hospital the following day after suffering a hypoxic brain injury. The report states that she obtained prescription medications from online sources selling medicines off-label, and that toxicological examination identified toxicity associated with the chain of events leading to her death. Concerns included the ready availability of such websites through search engines, inadequate monitoring of online medication supply chains, and ineffective detection of financial services supporting criminal enterprises.
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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 Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Search engines readily returning websites selling potentially fatal prescription medications
Wider context from the report “1. There is evidence of search engines readily returning websites which sell prescription medications , including those that sell highly addictive sleeping tablets and painkillers which can and do cause fatalities . I am concerned how readily search engines return websites such as these ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure of prescription medication supply-chain legitimacy monitoring to prevent ready online supply
Wider context from the report “2. I am concerned that the current system for monitoring the legitimacy of supply chains for medications available in England and Wales via prescription is not preventing the ready supply of such medications online ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure of systems to detect criminal medication supply enterprises and alert relevant authorities
Wider context from the report “3. There is evidence that banks form a legitimate part of the supply chain, and that this is crucial to the functioning of these criminal enterprises. I am concerned that the current system for detecting such criminal enterprises and alerting the relevant authorities is not effective .
” Open source report
Concerns raised 2 Lack of public awareness of life-threatening risks from storing lithium iron battery appliances in domestic properties View source Lack of communication and media coverage about the dangers of storing electronic bikes and scooters in domestic properties 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
Luke Marshall ALBISTON O'DONNELL · 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
Luke Marshall Albiston O'Donnell was an 8-year-old boy who died in hospital following a fire at his home. The fire began when an e-bike lithium battery ignited after coming into contact with combustible materials, and the battery-cell failure allowed the fire to develop rapidly. The report raises concerns that the public may not appreciate the life-threatening risks of storing e-bikes and similar appliances in domestic properties, and that communication about these dangers may be insufficient.
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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 Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Lack of public awareness of life-threatening risks from storing lithium iron battery appliances in domestic properties
Wider context from the report “The general public do not appreciate the life-threatening risks involved with having lithium iron batteries, from electronic bikes in this case, stored in domestic properties. There appears to be a lack of communication/media coverage about the dangers involved with storing appliances such as electronic bikes/scooters in domestic properties. There have already been 3 deaths associated with lithium batteries in the home in Merseyside and we have been informed there a number of similar fatalities across England.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Lack of communication and media coverage about the dangers of storing electronic bikes and scooters in domestic properties
Wider context from the report “The general public do not appreciate the life-threatening risks involved with having lithium iron batteries, from electronic bikes in this case, stored in domestic properties. There appears to be a lack of communication/media coverage about the dangers involved with storing appliances such as electronic bikes/scooters in domestic properties. There have already been 3 deaths associated with lithium batteries in the home in Merseyside and we have been informed there a number of similar fatalities across England.
” Open source report
3 Dec 2024 Paul Martin GOBELL · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Lack of arrangements for welfare checks when the First Night Interview cannot take place View source Failure to obtain Probation input for Open Conditions Suitability Assessments View source Failure to communicate changes in cell sharing risk promptly to prisoners View source Failure to report prisoner disclosures to the Offender Management Unit 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
Paul Martin GOBELL · 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
The supplied text does not describe the circumstances or date of Paul Martin Gobell’s death. It raises concerns about the absence of a welfare check and ACCT after a First Night Interview was missed, communication about cell-sharing risk, and the lack of Probation input into an assessment of his suitability for open conditions.
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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 Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Lack of arrangements for welfare checks when the First Night Interview cannot take place
Wider context from the report “1. Paul Gobell was serving a life sentence for rape. He had served fifteen years in a closed prison, most recently at HMP Prison, Whatton. In August 2021, he was deemed by the Parole Board to be suitable for a move to open conditions and was therefore transferred to HM Prison Hollesley Bay on 20/10/21. He was there for just two and a half weeks. Within a few hours of his return to HM Prison, Whatton on 04/11/21 he was subject to a Control & Restraint incident. His behaviour at this time was reported to be refractory and aggressive. During the incident he received a soft tissue injury which necessitated a trip to the A&E department at the local hospital. As a result, the usual First Night Interview did not take place that evening, nor on the following day. As a result there was no welfare check and no ACCT was opened. There is no national or local policy in place stating what arrangements should be made to carry out a welfare check when, for operational reasons, the First Night Interview cannot take place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain Probation input for Open Conditions Suitability Assessments
Wider context from the report “3. Whilst at HM Prison, Hollesley Bay, Paul Gobell rang the Probation Officer (who had dealt with his Parole Board hearing in August 2021) and told her that he felt he was a poor fit in open conditions, that the environment there was hostile and unpleasant and that he had let slip to another prisoner that he was serving a term of imprisonment for offences of a sexual nature. The Probation Officer concerned did not see fit to report these disclosures to the Offender Management Unit. An Open Conditions Suitability Assessment ('OCSA') was subsequently held at HM Prison, Hollesley Bay on 02/11/24, after Mr. Gobell spoke to an Orderly Officer and asked to be returned to HM Prison, Whatton. Despite the multi-disciplinary nature of the OCSA, no input was obtained or requested from Probation staff at HM Prison, Hollesley Bay or elsewhere. Had the relevant Probation staff been involved this would have better informed the OCSA and steps could have been taken to offer Mr Gobell additional support, designed to encourage him to remain in the open conditions of a 'D' category prison rather than taking the regressive step of being returned to closed conditions. Consideration should be given to imposing a requirement that the input of Probation (both from the Offender Management Unit and outside) is obtained whenever a OCSA is 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 Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate changes in cell sharing risk promptly to prisoners
Wider context from the report “2. Paul Gobell was assessed as being suitable to share a cell in June 2021, having previously been considered high risk. He was not informed off this change until immediately prior to the C&R incident on 04/11/21 and had never had to share a cell before. The Cell Sharing Risk Assessment carried out by Healthcare and Reception staff upon his return to HM Prison, Whatton on 04/11/21 deemed him to be a standard risk. He felt that he should have been designated as high risk. He was concerned for the safety of whoever he might be required to share a cell with, due to the fact that he (Gobell) suffered from paraomnia. Despite protesting to staff, he was told that he would have to share and it was this that sparked the incident leading to the use of control and restraint techniques. Had he been pre-warned of the change to his cell sharing status this incident would not have happened. Consideration should be given to ensuring that any such change of cell sharing risk is communicated promptly to the prisoner concerned.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to report prisoner disclosures to the Offender Management Unit
Wider context from the report “3. Whilst at HM Prison, Hollesley Bay, Paul Gobell rang the Probation Officer (who had dealt with his Parole Board hearing in August 2021) and told her that he felt he was a poor fit in open conditions, that the environment there was hostile and unpleasant and that he had let slip to another prisoner that he was serving a term of imprisonment for offences of a sexual nature. The Probation Officer concerned did not see fit to report these disclosures to the Offender Management Unit. An Open Conditions Suitability Assessment ('OCSA') was subsequently held at HM Prison, Hollesley Bay on 02/11/24, after Mr. Gobell spoke to an Orderly Officer and asked to be returned to HM Prison, Whatton. Despite the multi-disciplinary nature of the OCSA, no input was obtained or requested from Probation staff at HM Prison, Hollesley Bay or elsewhere. Had the relevant Probation staff been involved this would have better informed the OCSA and steps could have been taken to offer Mr Gobell additional support, designed to encourage him to remain in the open conditions of a 'D' category prison rather than taking the regressive step of being returned to closed conditions. Consideration should be given to imposing a requirement that the input of Probation (both from the Offender Management Unit and outside) is obtained whenever a OCSA is undertaken.
” Open source report
Concerns raised 2 Lack of an outside line on the seclusion-room observation handset for direct 999 emergency calls View source Failure to ensure that the ward's immediate access route is known and shared with emergency ambulance services View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Dean John Mark Anthony BRAY · 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
Dean Bray died of acute heart failure on 29 December 2021 while in the seclusion room on Hamtun Ward. The report identified failures to adequately monitor and escalate his high respiratory rate, and concerns about the ability to make emergency calls from the observation room and delays accessing the seclusion area.
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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 Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Lack of an outside line on the seclusion-room observation handset for direct 999 emergency calls
Wider context from the report “Firstly, Staff conducting 121 observations upon a patient within the seclusion room were unable to make a direct 999 emergency call from the observation room as no outside line was available from this handset to respond to a medical emergency. Secondly, I heard evidence from Paramedics of a delay, and difficulty with accessing the patient who was being cared for in seclusion. The most immediate access route to the ward used by secure transport services being unknown by South Central Ambulance Service and not shared with them to assist responding to a medical emergency at Antelope House.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that the ward's immediate access route is known and shared with emergency ambulance services
Wider context from the report “Firstly, Staff conducting 121 observations upon a patient within the seclusion room were unable to make a direct 999 emergency call from the observation room as no outside line was available from this handset to respond to a medical emergency. Secondly, I heard evidence from Paramedics of a delay, and difficulty with accessing the patient who was being cared for in seclusion. The most immediate access route to the ward used by secure transport services being unknown by South Central Ambulance Service and not shared with them to assist responding to a medical emergency at Antelope House.
” Open source report
Concerns raised 1 Delays in sending information about prescriptions to GP surgeries View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Neil Michael YATES · 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
Neil Michael Yates, aged 53, died in a drug-related death; the inquest recorded mixed drug toxicity and bronchopneumonia, with chronic obstructive pulmonary disease and cirrhosis also noted. The substantive concern was delays in information about prescriptions from voluntary and NHS organisations reaching GP surgeries, creating a risk that further medication could be prescribed without knowledge of existing prescriptions.
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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 Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Delays in sending information about prescriptions to GP surgeries
Wider context from the report “The delay of information relating to what has been prescribed to an individual being sent to the GP surgery by voluntary and NHS organisations.
” Open source report
Concerns raised 1 Lack of clinician awareness of the ability to challenge ambulance call categorisation and request clinical review View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Amanda Jane GAINFORD · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Amanda Jane GAINFORD, aged 52, sustained abdominal injuries while detained in a mental health ward and later died at Aintree Hospital on 4 November 2022 from multiorgan failure due to splenic laceration and liver cirrhosis. The inquest identified missed opportunities to provide intravenous fluids and call an ambulance earlier while she had prolonged low blood pressure. It also raised concern that clinicians were not sufficiently aware of the ability to challenge ambulance call categorisation and request a clinical review from the ambulance service.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Lack of clinician awareness of the ability to challenge ambulance call categorisation and request clinical review
Wider context from the report “During the inquest the court heard evidence from the North West Ambulance Service (NWAS) witness who confirmed that call handlers for the service are not medically trained but receive basic medical training. The system used nationally to categorise calls is reliant upon questions asked and information which is input by the call handler to achieve a categorisation of a call. In this case, there was no evidence the call categorisation was incorrect, however, an ambulance was called on 3 occasions due to Amanda's condition, on the last occasion that call was made by a Doctor on the scene providing care for Amanda, who as of the opinion that he was unable to keep the patient stable due to low blood pressure over a prolonged period. The NWAS witness gave evidence to the court that had the Doctor disagreed with the category 2 classification of the call or sought to escalate his clinical concerns regarding a patient, that he had the ability to challenge that and to request a review by a clinician available to NWAS. The Doctor was unaware that he had the ability to challenge the call handler categorisation and to seek a review by a clinician at NWAS , at which point the nature and seriousness of Amanda's condition could have been further reviewed and clearly understood. At a further course attended subsequently by the Doctor he advised that of 50 Doctors in attendance, only 1 was aware of the ability to escalate concerns regarding a patient and the categorisation of a 999 call to the Ambulance service and subsequent response time . It appears that this is an important fact unknown by many clinicians which would enable a clinician to clinician review of a critical patient and the use and dispatch of ambulance resources to prevent the loss of life in critical cases which are not automatically categorised at the highest level of response.
” Open source report
15 Oct 2024 Paul Anthony CHASE · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 2 Lack of mental health, alcoholism and addiction support, treatment and therapy for veterans across service stages View source Insufficient resources causing delays in veterans' access to support and treatment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Paul Anthony CHASE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paul Anthony Chase, also known as Paul Anthony Malone, was found deceased hanging in Woolton Woods, Liverpool, on 13 March 2024; the post-mortem examination found the cause of death to be hanging. He had a history of post-traumatic stress disorder and cocaine use, and the inquest concluded that he died by suicide. The report raised concerns about limited mental health, alcoholism and addiction support for veterans, including waits of up to 18 months for some services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Lack of mental health, alcoholism and addiction support, treatment and therapy for veterans across service stages
Wider context from the report “The lack of mental health/alcoholism/addiction support, treatment and therapy provided to veterans whilst they are:
1. Serving within the armed forces.
2. Undergoing intensive combat training whilstserving within the armed forces.
3. When they are released from the armed forces.
The availability of resources appears to be extremely limited with some ex-veterans having to wait 18 months before a place is available.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Insufficient resources causing delays in veterans' access to support and treatment
Wider context from the report “The lack of mental health/alcoholism/addiction support, treatment and therapy provided to veterans whilst they are:
1. Serving within the armed forces.
2. Undergoing intensive combat training whilstserving within the armed forces.
3. When they are released from the armed forces.
The availability of resources appears to be extremely limited with some ex-veterans having to wait 18 months before a place is available .
” Open source report
Concerns raised 5 Inadequate positioning and visibility of No Entry signage for wrong-way slip-road entry View source Frequent wrong-way driving down the slip road into oncoming traffic View source Slip-road geometry allowing wrong-way vehicles to enter and build up considerable speed View source Failure to maintain adequate visibility of road-surface No Entry markings at the slip-road junction View source Failure of commonly used satnav applications to provide unambiguous verbal directions at the junction 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
Amal Mohamed AHMED · 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
Amal Mohamed Ahmed died at the scene after entering the A5 southbound off slip road in the wrong direction and colliding head-on with another vehicle. The other vehicle’s driver later died in hospital, and a passenger suffered life-threatening injuries. The principal concern was that inadequate, poorly positioned and poorly visible signage and the unlit, wide junction allowed drivers to enter the slip road incorrectly; other drivers were observed making the same manoeuvre.
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 Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Inadequate positioning and visibility of No Entry signage for wrong-way slip-road entry
Wider context from the report “The exit point of the A5 "off" slip road at the Little Brickhill junction is wide. The signage indicating No Entry appears to be inadequate as there are two No Entry signs which are widely spaced at the junction. One is positioned to appear to forbid entry to the road over the bridge leading over the A5 and does not obviously relate to the slip road. The second is positioned such that it obliquely faces the road over the bridge and would not be visible to a driver turning right onto the slip road until they had completed the manoeuvre placing them at risk. There is a No Right Turn sign as the junction is approached. There is also No Entry in large white letters at the mouth of the slip road junction, however, this may be (1) obscured by vehicles leaving the slip road and (2) the junction is unlit and was said by a witness as being "pitch black". After the collision attention police officers saw three further vehicles perform exactly the same manoeuvre as Ms Ahmed and attempt to travel down the slip road in the wrong direction. Local residents have contacted police and claimed that it is a very common occurrence for drivers to mistakenly travel down the slip road in the wrong direction. The slip road is long and allows for the build up of considerable speed in turn facilitating what the police describe as a high energy impact. Following the collision, large temporary No Entry signs were positioned at the slip road junction. They were quickly removed apparently because the original signs were deemed to comply with necessary regulations. That seems wholly irrelevant to me because drivers are clearly commonly not seeing the signs because of the large numbers who mistakenly drive the wrong way onto the slip road. In my opinion, consideration should be given to alternative arrangements to prevent vehicles entering and travelling along the slip road in the wrong direction.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Frequent wrong-way driving down the slip road into oncoming traffic
Wider context from the report “I have made observations regarding the slip road at this junction in my initial pre-Inquest Report To Prevent Future Deaths dated the 21st December 2023.
National Highways undertook a number of immediate remedial measures to try to prevent drivers turning and travelling the wrong way down this slip road, including narrowing the "mouth" of the slip road to one lane, placement of very large temporary "No Entry" signs and placement of signs indicating "Do Not Use Satnav" at the site. CCTV monitoring of driver behaviour was commenced. Police activity and monitoring by National Highways showed that despite these measures, drivers were still turning early and attempting to drive the wrong way down the slip road . Further enquiries by the police and information volunteered by members of the public who made the same incorrect manoeuvre led to the finding that while the visual map display on commonly used satnav applications at this junction displayed the correct information, the verbal commands gave information likely to confuse and direct drivers down the wrong slip road into the path of oncoming traffic . This was observed to happen frequently.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Slip-road geometry allowing wrong-way vehicles to enter and build up considerable speed
Wider context from the report “The exit point of the A5 "off" slip road at the Little Brickhill junction is wide. The signage indicating No Entry appears to be inadequate as there are two No Entry signs which are widely spaced at the junction. One is positioned to appear to forbid entry to the road over the bridge leading over the A5 and does not obviously relate to the slip road. The second is positioned such that it obliquely faces the road over the bridge and would not be visible to a driver turning right onto the slip road until they had completed the manoeuvre placing them at risk. There is a No Right Turn sign as the junction is approached. There is also No Entry in large white letters at the mouth of the slip road junction, however, this may be (1) obscured by vehicles leaving the slip road and (2) the junction is unlit and was said by a witness as being "pitch black". After the collision attention police officers saw three further vehicles perform exactly the same manoeuvre as Ms Ahmed and attempt to travel down the slip road in the wrong direction. Local residents have contacted police and claimed that it is a very common occurrence for drivers to mistakenly travel down the slip road in the wrong direction. The slip road is long and allows for the build up of considerable speed in turn facilitating what the police describe as a high energy impact. Following the collision, large temporary No Entry signs were positioned at the slip road junction. They were quickly removed apparently because the original signs were deemed to comply with necessary regulations. That seems wholly irrelevant to me because drivers are clearly commonly not seeing the signs because of the large numbers who mistakenly drive the wrong way onto the slip road. In my opinion, consideration should be given to alternative arrangements to prevent vehicles entering and travelling along the slip road in the wrong direction.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain adequate visibility of road-surface No Entry markings at the slip-road junction
Wider context from the report “The exit point of the A5 "off" slip road at the Little Brickhill junction is wide. The signage indicating No Entry appears to be inadequate as there are two No Entry signs which are widely spaced at the junction. One is positioned to appear to forbid entry to the road over the bridge leading over the A5 and does not obviously relate to the slip road. The second is positioned such that it obliquely faces the road over the bridge and would not be visible to a driver turning right onto the slip road until they had completed the manoeuvre placing them at risk. There is a No Right Turn sign as the junction is approached. There is also No Entry in large white letters at the mouth of the slip road junction, however, this may be (1) obscured by vehicles leaving the slip road and (2) the junction is unlit and was said by a witness as being "pitch black". After the collision attention police officers saw three further vehicles perform exactly the same manoeuvre as Ms Ahmed and attempt to travel down the slip road in the wrong direction. Local residents have contacted police and claimed that it is a very common occurrence for drivers to mistakenly travel down the slip road in the wrong direction. The slip road is long and allows for the build up of considerable speed in turn facilitating what the police describe as a high energy impact. Following the collision, large temporary No Entry signs were positioned at the slip road junction. They were quickly removed apparently because the original signs were deemed to comply with necessary regulations. That seems wholly irrelevant to me because drivers are clearly commonly not seeing the signs because of the large numbers who mistakenly drive the wrong way onto the slip road. In my opinion, consideration should be given to alternative arrangements to prevent vehicles entering and travelling along the slip road in the wrong direction.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure of commonly used satnav applications to provide unambiguous verbal directions at the junction
Wider context from the report “I have made observations regarding the slip road at this junction in my initial pre-Inquest Report To Prevent Future Deaths dated the 21st December 2023.
National Highways undertook a number of immediate remedial measures to try to prevent drivers turning and travelling the wrong way down this slip road, including narrowing the "mouth" of the slip road to one lane, placement of very large temporary "No Entry" signs and placement of signs indicating "Do Not Use Satnav" at the site. CCTV monitoring of driver behaviour was commenced. Police activity and monitoring by National Highways showed that despite these measures, drivers were still turning early and attempting to drive the wrong way down the slip road. Further enquiries by the police and information volunteered by members of the public who made the same incorrect manoeuvre led to the finding that while the visual map display on commonly used satnav applications at this junction displayed the correct information, the verbal commands gave information likely to confuse and direct drivers down the wrong slip road into the path of oncoming traffic . This was observed to happen frequently.
” Open source report
Concerns raised 2 Failure of commonly used satnav applications to provide safe verbal directions at the junction View source Frequent wrong-way driving on the slip road 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
Tracey Julie HAYBITTLE · 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
Tracey Julie Haybittle died at the John Radcliffe Hospital after a head-on collision when another driver entered the wrong slip road at the Little Brickhill junction. The report raised concerns that verbal commands from commonly used satnav applications could confuse and direct drivers down the wrong slip road into oncoming traffic, and that this occurred frequently despite remedial measures.
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 Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure of commonly used satnav applications to provide safe verbal directions at the junction
Wider context from the report “I have made observations regarding the slip road at this junction in my initial pre-Inquest Report To Prevent Future Deaths dated the 21st December 2023 in respect of the linked case of Amal Mohamed Ahmood.
National Highways undertook a number of immediate remedial measures to try to prevent drivers turning and travelling the wrong way down this slip road, including narrowing the "mouth" of the slip road to one lane, placement of very large temporary "No Entry" signs and placement of signs indicating "Do Not Use Satnav" at the site. CCTV monitoring of driver behaviour was commenced. Police activity and monitoring by National Highways showed that despite these measures, drivers were still turning early and attempting to drive the wrong way down the slip road. Further enquiries by the police and information volunteered by members of the public who made the same incorrect manoeuvre led to the finding that while the visual map display on commonly used satnav applications at this junction displayed the correct information, the verbal commands gave information likely to confuse and direct drivers down the wrong slip road into the path of oncoming traffic . This was observed to happen frequently.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Frequent wrong-way driving on the slip road
Wider context from the report “I have made observations regarding the slip road at this junction in my initial pre-Inquest Report To Prevent Future Deaths dated the 21st December 2023 in respect of the linked case of Amal Mohamed Ahmood.
National Highways undertook a number of immediate remedial measures to try to prevent drivers turning and travelling the wrong way down this slip road, including narrowing the "mouth" of the slip road to one lane, placement of very large temporary "No Entry" signs and placement of signs indicating "Do Not Use Satnav" at the site. CCTV monitoring of driver behaviour was commenced. Police activity and monitoring by National Highways showed that despite these measures, drivers were still turning early and attempting to drive the wrong way down the slip road . Further enquiries by the police and information volunteered by members of the public who made the same incorrect manoeuvre led to the finding that while the visual map display on commonly used satnav applications at this junction displayed the correct information, the verbal commands gave information likely to confuse and direct drivers down the wrong slip road into the path of oncoming traffic. This was observed to happen frequently .
” Open source report
Concerns raised 1 Failure to share and discuss investigation findings and recommendations with relevant prison and healthcare staff 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
Craig Steadman · 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
Craig Steadman was in custody at HMP Winchester and had diabetes, a mental health history, and previous self-harming incidents. He was found suspended by a ligature in his cell after a further self-harm incident, and CPR was unsuccessful. The principal concern was that findings and recommendations from investigations into his death were not shared with staff directly involved in his care, limiting the dissemination and implementation of learning.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to share and discuss investigation findings and recommendations with relevant prison and healthcare staff
Wider context from the report “There were several investigations into Craig Steadman’s death including a post incident review by HMP Winchester, the PPO,and the prison healthcare provider.
Various recommendations flowed from the above.
However upon questioning of various members of staff called to give evidence at the Inquest it became clear that several of them were not aware of the findings of the investigations nor the recommendations . The reports had not been shared with staff directly involved with Craig during his recent time in custody .
It is not possible for learning to be fully disseminated and acted upon if there is no process for sharing the findings of those organisations tasked with investigating deaths in custody and discussing these with the relevant Prison/Healthcare staff .
” Open source report
Concerns raised 2 Failure to consistently inform agreed next-of-kin contacts of appointments View source Lack of a system for notifying chosen contacts of short-notice appointment changes 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
Owen Donald GARDNER · 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
Owen Donald GARDNER, aged 29, died following a road traffic collision; the medical cause of death was recorded as multiple injuries. The report raises concern that agreed next-of-kin contacts were not consistently informed about appointments or short-notice changes, contributing to missed appointments for a person with limited short-term memory and cognitive deficit, and that no system was in place to facilitate this.
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 Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to consistently inform agreed next-of-kin contacts of appointments
Wider context from the report “In evidence it was heard that Owen had a limited short-term memory and a cognitive deficit, due to the previous Traumatic Brain Injuries that he had suffered.
As a result of Owen’s limited short-term memory and cognitive deficit, it was agreed that his next of kin would be informed of all of the appointments Owen had with the NSFT clinician’s providing his care.
Evidence at inquest heard that Owen’s next of kin had been informed of such meetings on some occasions, but that it did not occur on every occasion.
In addition, evidence was heard that when meetings were changed a short notice (due to unforeseen circumstances, staff sickness or leave absence), Owen himself would be informed, but not his agreed next of kin contact.
This led to Owen missing a number of appointments as he had forgotten the changes made, whereas his next of kin would have been able to remind him, and prompt him to attend.
It was acknowledged by the court, that in Owen’s case there was no evidence that his attendance at one of his missed appointments would have changed the tragic outcome.
However, I am concerned that in the future, an individual with a short-term memory and a cognitive deficit will miss an appointment which could prevent their death, if their next of kin (or chosen point of contact) are not also told of short notice changes to the timings of that appointment.
Evidence was heard that there is no system in place to facilitate this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for notifying chosen contacts of short-notice appointment changes
Wider context from the report “In evidence it was heard that Owen had a limited short-term memory and a cognitive deficit, due to the previous Traumatic Brain Injuries that he had suffered.
As a result of Owen’s limited short-term memory and cognitive deficit, it was agreed that his next of kin would be informed of all of the appointments Owen had with the NSFT clinician’s providing his care.
Evidence at inquest heard that Owen’s next of kin had been informed of such meetings on some occasions, but that it did not occur on every occasion.
In addition, evidence was heard that when meetings were changed a short notice (due to unforeseen circumstances, staff sickness or leave absence), Owen himself would be informed, but not his agreed next of kin contact.
This led to Owen missing a number of appointments as he had forgotten the changes made, whereas his next of kin would have been able to remind him, and prompt him to attend.
It was acknowledged by the court, that in Owen’s case there was no evidence that his attendance at one of his missed appointments would have changed the tragic outcome.
However, I am concerned that in the future, an individual with a short-term memory and a cognitive deficit will miss an appointment which could prevent their death, if their next of kin (or chosen point of contact) are not also told of short notice changes to the timings of that appointment.
Evidence was heard that there is no system in place to facilitate this .
” Open source report
Concerns raised 7 Insufficient specialist medical capacity for timely and proactive care of older hospital patients View source Inadequate ambulance staff training in recognising and dealing with patients who have fallen View source Failure of ambulance staff to recognise falls risk and initiate further action View source Failure to identify and apply learning from falls-related incidents View source Failure to complete falls risk assessments in accordance with JRCALC guidelines View source Lack of clear guidelines for holistic management of older hospital patients View source Hospital falls causing fatal injuries View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Gerald Roy Cruse · 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
Gerald Cruse fell from a bed while being assisted to use the toilet in an ambulance cohort area after admission following a fall at home. He sustained multiple rib fractures, a haemopneumothorax and surgical emphysema, later developed pneumonia, and died in hospital. Concerns included inadequate falls-risk assessment and recognition by ambulance staff, a lack of identified learning after investigation, and wider concerns about the organisation of care for older patients requiring both surgical and geriatric medical input.
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 Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Insufficient specialist medical capacity for timely and proactive care of older hospital patients
Wider context from the report “(1) That over 75% of patients receiving hospital care are 65 and over. There is a conflict and tension between where within the hospital those patients should be receiving their care. A proportion of these patients require admission to a surgical ward due to the elements of their care which require surgical oversight and management, for example, analgesia through an epidural, insertion of a chest drain. However, this group of patients have multiple co-morbidities and complexities due to their age, which would be better managed by a medical team specialising in care of the elderly. Whilst medical teams can review patients, their limited resources mean it may not be as quickly as it needs to be, and they cannot be proactive in following up on the care of these patients. This results in an increasing risk that these patients will not receive the care they need in a timely manner. There is an increasing need for more doctors specialising in the care of older persons and this is a national issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Inadequate ambulance staff training in recognising and dealing with patients who have fallen
Wider context from the report “(6) An investigation took place but the staff did not identify any learning and did not undertake the case study to help them identify such patients in the future. Bristol Ambulance Emergency Medical Services still run some cohort areas alongside South Western Ambulance NHS Foundation Trust, and continue to convey patients to hospital. The evidence given on behalf of this organisation did not provide reassurance that this is a matter which the ambulance service have adequately addressed. There is a real concern that ambulance staff throughout the organisation may not be adequately trained in recognising and dealing with patients who have had a fall or falls.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance staff to recognise falls risk and initiate further action
Wider context from the report “(5) The other two ambulance staff did not seem to understand that Mr Cruse was a falls risk , they did not consider that he was at a greater risk of falls and did not consider that any further action should have been considered or taken .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and apply learning from falls-related incidents
Wider context from the report “(6) An investigation took place but the staff did not identify any learning and did not undertake the case study to help them identify such patients in the future . Bristol Ambulance Emergency Medical Services still run some cohort areas alongside South Western Ambulance NHS Foundation Trust, and continue to convey patients to hospital. The evidence given on behalf of this organisation did not provide reassurance that this is a matter which the ambulance service have adequately addressed. There is a real concern that ambulance staff throughout the organisation may not be adequately trained in recognising and dealing with patients who have had a fall or falls.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to complete falls risk assessments in accordance with JRCALC guidelines
Wider context from the report “(4) The paramedic working within the cohort area did not complete a falls risk assessment in accordance with the JRCALC guidelines following the admission of a patient who had just had a fall at home.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidelines for holistic management of older hospital patients
Wider context from the report “(2) There are currently no clear guidelines as to how these patients should best be managed and there remains a serious risk that the care they receive is not holistic .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Hospital falls causing fatal injuries
Wider context from the report “(3) Patients falling in hospitals and sustaining injuries which lead to their death remains a matter of grave concern.
” Open source report
Concerns raised 4 Lack of comprehensive medical guidance for pilots making Pilot Medical Declarations View source Lack of guidance for medical professionals on Pilot Medical Declaration standards View source Revalidation of certain aircraft ratings without independent assessment of ability or fitness to fly View source Lack of a system to coordinate licence revocation and licence surrender activities 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
Peter John WALKER · 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
Peter Walker died after the microlight aircraft he was flying alone crashed in a field adjacent to the runway at Beccles Aerodrome on 24 March 2022. The concerns included shortcomings in the Civil Aviation Authority’s guidance and systems for medical self-declarations, licence revalidation, and managing licence revocation or surrender for older pilots and certain microlight licence holders.
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 Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Lack of comprehensive medical guidance for pilots making Pilot Medical Declarations
Wider context from the report “However, unlike the DVLA the CAA provides no comprehensive guidance for the individual pilot making the self-declaration . As such the CAA provides no list of identifiable conditions that would either preclude the pilot flying, or any conditions which suggest the pilot should seeks further medical opinion regarding their fitness to fly .
It was identified that the CAA provided no guidance to any medical professionals to alert them to the medical standards required for an individual making a Pilot Medical Declaration, should that individual approach them for a medical opinion regarding their fitness to fly.
It was identified that the DVLA has an efficient centrally controlled system to manage medically related driving licence decisions and to coordinate licence revocation and licence surrender activities. The CAA has no such system to coordinate their licence revocation and licence surrender activities.
It was identified, that any pilot of the type of aircraft being flown by Peter, who qualified on that type prior to 2008, can revalidate their licence to fly that type of aircraft by providing a self-declaration of evidence of experience of flying that aircraft. As the Pilot Medication Declaration system, and the licence revalidation procedure for this type of aircraft both rely on self-declarations only, it was identified that a pilot over 70 who flies this type of aircraft, can be revalidated to fly it without any independent third-party assessment of their actual ability or fitness to fly.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for medical professionals on Pilot Medical Declaration standards
Wider context from the report “However, unlike the DVLA the CAA provides no comprehensive guidance for the individual pilot making the self-declaration. As such the CAA provides no list of identifiable conditions that would either preclude the pilot flying, or any conditions which suggest the pilot should seeks further medical opinion regarding their fitness to fly.
It was identified that the CAA provided no guidance to any medical professionals to alert them to the medical standards required for an individual making a Pilot Medical Declaration , should that individual approach them for a medical opinion regarding their fitness to fly.
It was identified that the DVLA has an efficient centrally controlled system to manage medically related driving licence decisions and to coordinate licence revocation and licence surrender activities. The CAA has no such system to coordinate their licence revocation and licence surrender activities.
It was identified, that any pilot of the type of aircraft being flown by Peter, who qualified on that type prior to 2008, can revalidate their licence to fly that type of aircraft by providing a self-declaration of evidence of experience of flying that aircraft. As the Pilot Medication Declaration system, and the licence revalidation procedure for this type of aircraft both rely on self-declarations only, it was identified that a pilot over 70 who flies this type of aircraft, can be revalidated to fly it without any independent third-party assessment of their actual ability or fitness to fly.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Revalidation of certain aircraft ratings without independent assessment of ability or fitness to fly
Wider context from the report “However, unlike the DVLA the CAA provides no comprehensive guidance for the individual pilot making the self-declaration. As such the CAA provides no list of identifiable conditions that would either preclude the pilot flying, or any conditions which suggest the pilot should seeks further medical opinion regarding their fitness to fly.
It was identified that the CAA provided no guidance to any medical professionals to alert them to the medical standards required for an individual making a Pilot Medical Declaration, should that individual approach them for a medical opinion regarding their fitness to fly.
It was identified that the DVLA has an efficient centrally controlled system to manage medically related driving licence decisions and to coordinate licence revocation and licence surrender activities. The CAA has no such system to coordinate their licence revocation and licence surrender activities.
It was identified, that any pilot of the type of aircraft being flown by Peter, who qualified on that type prior to 2008, can revalidate their licence to fly that type of aircraft by providing a self-declaration of evidence of experience of flying that aircraft . As the Pilot Medication Declaration system, and the licence revalidation procedure for this type of aircraft both rely on self-declarations only , it was identified that a pilot over 70 who flies this type of aircraft, can be revalidated to fly it without any independent third-party assessment of their actual ability or fitness to fly .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Lack of a system to coordinate licence revocation and licence surrender activities
Wider context from the report “However, unlike the DVLA the CAA provides no comprehensive guidance for the individual pilot making the self-declaration. As such the CAA provides no list of identifiable conditions that would either preclude the pilot flying, or any conditions which suggest the pilot should seeks further medical opinion regarding their fitness to fly.
It was identified that the CAA provided no guidance to any medical professionals to alert them to the medical standards required for an individual making a Pilot Medical Declaration, should that individual approach them for a medical opinion regarding their fitness to fly.
It was identified that the DVLA has an efficient centrally controlled system to manage medically related driving licence decisions and to coordinate licence revocation and licence surrender activities. The CAA has no such system to coordinate their licence revocation and licence surrender activities .
It was identified, that any pilot of the type of aircraft being flown by Peter, who qualified on that type prior to 2008, can revalidate their licence to fly that type of aircraft by providing a self-declaration of evidence of experience of flying that aircraft. As the Pilot Medication Declaration system, and the licence revalidation procedure for this type of aircraft both rely on self-declarations only, it was identified that a pilot over 70 who flies this type of aircraft, can be revalidated to fly it without any independent third-party assessment of their actual ability or fitness to fly.
” Open source report
Concerns raised 3 Lack of a requirement to assess and manage scalding risk in HMOs accommodating vulnerable persons View source Lack of a requirement for thermostatic control valves on hot water taps in supported accommodation View source Lack of regulatory oversight and inspection of HMOs accommodating vulnerable persons 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
Christopher Evans · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher Evans, who was vulnerable and had physical health problems, was found unresponsive and almost completely submerged in a bath of very hot water on 28 September 2020 and was pronounced dead at the scene. The report identified concerns that his supported accommodation was not subject to CQC or HSE oversight and that the regulatory framework did not require assessment or management of scalding risks or provision of engineering controls for vulnerable residents.
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 Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Lack of a requirement to assess and manage scalding risk in HMOs accommodating vulnerable persons
Wider context from the report “(1) Mr. Evans resided in supported accommodation which was appropriately licensed as an HMO. The provision and maintenance of services, including electricity, gas and water was the responsibility of Supported Independence Limited. However, the HMO licence did not require there be thermostatic control valves fitted to the hot water taps in the Deceased's flat.
(2) Since the Deceased resided in his own accommodation and was not provided with a regulated activity, the accommodation was not regulated nor subject to inspection by the CQC.
(3) Similarly the HSE had no authority to inspect premises under the Health and Safety at Work Act 1974 as the Deceased resided in his own home.
(4) If the Deceased, who was vulnerable, had resided in health and social care premises then there would have been a requirement to assess the risk of scalding and burning in the context of his vulnerability.
(5) Engineering controls could then have been provided to minimise the risk of scalding particularly where there is whole body immersion.
(6) In accommodating vulnerable persons in such an HMO there appears to be a deficiency in the regulatory framework in that there is no requirement to assess and manage the risk of scalding and no overview by any regulatory body.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Lack of a requirement for thermostatic control valves on hot water taps in supported accommodation
Wider context from the report “(1) Mr. Evans resided in supported accommodation which was appropriately licensed as an HMO. The provision and maintenance of services, including electricity, gas and water was the responsibility of Supported Independence Limited. However, the HMO licence did not require there be thermostatic control valves fitted to the hot water taps in the Deceased's flat .
(2) Since the Deceased resided in his own accommodation and was not provided with a regulated activity, the accommodation was not regulated nor subject to inspection by the CQC.
(3) Similarly the HSE had no authority to inspect premises under the Health and Safety at Work Act 1974 as the Deceased resided in his own home.
(4) If the Deceased, who was vulnerable, had resided in health and social care premises then there would have been a requirement to assess the risk of scalding and burning in the context of his vulnerability.
(5) Engineering controls could then have been provided to minimise the risk of scalding particularly where there is whole body immersion.
(6) In accommodating vulnerable persons in such an HMO there appears to be a deficiency in the regulatory framework in that there is no requirement to assess and manage the risk of scalding and no overview by any regulatory body.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Lack of regulatory oversight and inspection of HMOs accommodating vulnerable persons
Wider context from the report “(1) Mr. Evans resided in supported accommodation which was appropriately licensed as an HMO. The provision and maintenance of services, including electricity, gas and water was the responsibility of Supported Independence Limited. However, the HMO licence did not require there be thermostatic control valves fitted to the hot water taps in the Deceased's flat.
(2) Since the Deceased resided in his own accommodation and was not provided with a regulated activity, the accommodation was not regulated nor subject to inspection by the CQC .
(3) Similarly the HSE had no authority to inspect premises under the Health and Safety at Work Act 1974 as the Deceased resided in his own home.
(4) If the Deceased, who was vulnerable, had resided in health and social care premises then there would have been a requirement to assess the risk of scalding and burning in the context of his vulnerability.
(5) Engineering controls could then have been provided to minimise the risk of scalding particularly where there is whole body immersion.
(6) In accommodating vulnerable persons in such an HMO there appears to be a deficiency in the regulatory framework in that there is no requirement to assess and manage the risk of scalding and no overview by any regulatory body .
” Open source report
Concerns raised 2 Failure to ask about family history of sudden cardiac death during reception health screening View source Failure to record and clearly flag family history of sudden cardiac death in SystmOne 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
Joseph Andrew Price · 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
Joseph Andrew Price was found dead in his cell at HMP Durham on 20 September 2020, after being remanded there ten days earlier. The pathologist concluded that the medical cause of death was Sudden Cardiac Death, following evidence of a paternal family history of premature cardiac-related deaths. The principal concern was that this family history had not been recorded or elicited during healthcare assessments, making it unavailable to inform possible genetic screening; symptoms before death were also potentially confusable with drug withdrawal and mental or emotional distress.
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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 Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to ask about family history of sudden cardiac death during reception health screening
Wider context from the report “The best, in some cases the only, way to predict a pre-disposition to a death of this nature is by reference to family medical history of such, or similar, occurrences. Once this is known, the person can then be referred for genetic screening. Sadly, in Andrew`s case no one in healthcare, some of whom had been familiar with him for years from previous terms of imprisonment, had any knowledge of the family history, as it did not feature on system one, and Andrew had never volunteered it. Equally, he had never been asked about it. This is not a criticism, simply a statement of fact made starkly relevant by the circumstances, unusual though they are.
The head of healthcare at HMP Durham gave evidence, when asked directly by me, that provision for a question in the reception health screen template about any family history of sudden cardiac death could help to prevent deaths of this kind recurring at the prison . She, with the health care provider for HMP Durham (Spectrum Community Health), has helpfully and very pro-actively put this into immediate effect locally (at HMP Durham and those other prisons covered by the health care provider). Specifically, the second health screen template (see attached - at pages 7 and 8) now shows that a question with regards family history (FH) of a ‘FH: Cardiac Disorder (incl. Sudden Cardiac Death)’ has been added to the second reception screen. The updating of the first reception health screen template is currently in hand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to record and clearly flag family history of sudden cardiac death in SystmOne
Wider context from the report “Additionally, the health care provider proposed the introduction of a read code specifically for ‘FH: Sudden Cardiac Death’ in the SystmOne template. This read code does not currently exist in SystmOne and so locally, the health care provider has now added it as a prompt in the read code for ‘FH: Cardiac Disorder (XM1JV)’ and add to this (‘incl. Sudden Cardiac Death’). By adding ‘FH: Sudden Cardiac Death’ as a read code in its own right, it will make it easier to search for and flag on the SystmOne records of prisoners so staff can clearly see and be aware of this previous family history .
” Open source report
Concerns raised 1 Failure to supervise syringe medication 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
Beryl ELLISON · 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
Beryl Ellison was receiving end-of-life care at Alexandra Care Home and was found deceased there on 28 June 2022. The inquest concluded that her death resulted from underlying poor health in combination with taking an excessive quantity of prescribed medication. Concerns included unsupervised access to syringe medication, prior family reports about medication being left in her room, and the absence of an explanation for the excessive oxycodone concentration found after her 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 Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to supervise syringe medication
Wider context from the report “Mrs Ellison was resident at Alexandra Care Home and was found deceased on 28th June 2022 by staff. Her family expressed concern that she had been left with syringe medication unsupervised by staff and raised concerns about this with the care home both historically and four days prior to her death. A post mortem examination revealed Mrs Ellison to have an excessive concentration of oxycodone in her system which was likely to exceed any acquired tolerance level. The evidence heard at inquest revealed no explanation as to why Mrs Ellison was found to have taken the excessive quantity of oxycodone which contributed to her death. Furthermore, the systems at the care home were stated categorically to be the same as those that were in place prior to Mrs Ellison's death .
” Open source report
Concerns raised 3 Failure to update nursing care plan risk assessments in response to changes in clinical presentation and falls View source Failure to assign overall responsibility for monitoring adherence to hydration requirements View source Poor completion of nursing care plan documentation 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
Anthony David Blower · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Anthony David Blower died at home on 25 October 2020 after sustaining multiple falls, bilateral subdural haematoma and further bleeding following hospital admission and surgery. The concerns identified included nursing care-plan risk assessments not being updated, poor documentation, and inadequate oversight of hydration, with Mr Blower becoming seriously dehydrated during his admission.
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 Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to update nursing care plan risk assessments in response to changes in clinical presentation and falls
Wider context from the report “1) Evidence at inquest revealed that none of the nursing care plan risk assessments, which had been completed on Mr Blower’s arrival on the ward, had been updated during his stay . I heard evidence that there are changes to his clinical presentation that were recorded in the nursing notes and that these should have been reflected in updated risk assessments . The multi factorial falls risk assessment had not been fully updated after an in-patient fall by Mr Blower .
The evidence I heard from the nursing staff was that they are potentially missing opportunities for nursing interventions when risk assessments are not updated and that they do not always have the time to review the nursing notes.
I note that the hospital is carrying out audits of documentation completion and updating some systems. However, some 2 years after the death of Mr Blower, the ward manager stated in evidence that her reviews of care plans showed a huge variety in the level of completion and that records with documentation remained poor. The hospital witnesses noted that staff were under significant time pressure and completing documentation is not seen as a priority.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to assign overall responsibility for monitoring adherence to hydration requirements
Wider context from the report “2) Mr Blower was found to be dehydrated and he required IV fluids during his admission. The hospital nutrition policy (section entitled hydration) states that it is the responsibility of the registered nurse and medical practitioner to ensure patients receive adequate fluids and that a minimum of 7 drinks should be provided daily.
In evidence I was informed that the nurses monitor fluid intake by keeping an eye on water levels in patients’ jugs (for those not deemed to require fluid intake charts). There is no-one on a ward with overall responsibility for ensuring that the trust policy on hydration is adhered to . Representations from the hospital state that other members of staff also keep an eye on nutrition. This was not sufficient to prevent Mr Blower from becoming seriously dehydrated .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Poor completion of nursing care plan documentation
Wider context from the report “1) Evidence at inquest revealed that none of the nursing care plan risk assessments, which had been completed on Mr Blower’s arrival on the ward, had been updated during his stay. I heard evidence that there are changes to his clinical presentation that were recorded in the nursing notes and that these should have been reflected in updated risk assessments. The multi factorial falls risk assessment had not been fully updated after an in-patient fall by Mr Blower.
The evidence I heard from the nursing staff was that they are potentially missing opportunities for nursing interventions when risk assessments are not updated and that they do not always have the time to review the nursing notes.
I note that the hospital is carrying out audits of documentation completion and updating some systems. However, some 2 years after the death of Mr Blower, the ward manager stated in evidence that her reviews of care plans showed a huge variety in the level of completion and that records with documentation remained poor . The hospital witnesses noted that staff were under significant time pressure and completing documentation is not seen as a priority .
” Open source report
Concerns raised 2 Failure to understand the implementation, significance and effect of Section 5(2) doctors holding power View source Failure to properly complete Section 5(2) Mental Health Act paperwork 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
Mollie Rose Stansfield · 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
Mollie Rose Stansfield, aged 22, died on 10 July 2019 after falling at Princes Quay, Hull, following her discharge from a place of safety under section 136 of the Mental Health Act 1983. The report identified failures at Hull Royal Infirmary to understand and correctly implement section 5(2) of the Mental Health Act 1983, with the relevant paperwork being invalid while Mollie was apparently subject to that section and subsequently absconded.
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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 Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to understand the implementation, significance and effect of Section 5(2) doctors holding power
Wider context from the report “There was a failure at Hull Royal Infirmary to understand the process of implementing Section 5(2) of the Mental Health act 1983 [MHA] (Doctors Holding Power) as well as general uncertainty about its significance and effect . Mollie absconded from the ward whilst apparently under this section. The paperwork for the implementation of this section of the MHA 1983 was in fact not properly completed and hence invalid. Whilst the Hull & East Yorkshire NHS Trust has taken steps to educate doctors about this power, these were only local measures and I believe that all doctors working in England and Wales should be aware of section 5(2) and nurses of their equivalent power pursuant to section 5(4) of the MHA 1983 and that appropriate awareness and training should be given.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to properly complete Section 5(2) Mental Health Act paperwork
Wider context from the report “There was a failure at Hull Royal Infirmary to understand the process of implementing Section 5(2) of the Mental Health act 1983 [MHA] (Doctors Holding Power) as well as general uncertainty about its significance and effect. Mollie absconded from the ward whilst apparently under this section. The paperwork for the implementation of this section of the MHA 1983 was in fact not properly completed and hence invalid . Whilst the Hull & East Yorkshire NHS Trust has taken steps to educate doctors about this power, these were only local measures and I believe that all doctors working in England and Wales should be aware of section 5(2) and nurses of their equivalent power pursuant to section 5(4) of the MHA 1983 and that appropriate awareness and training should be given.
” Open source report
Concerns raised 2 Failure to include medication security instructions in the digital application used by carers View source Failure to keep medication in a locked box 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
Tracy Marie BROWN · 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
Tracy Marie BROWN died at home on 5 January 2022 after taking an excessive quantity of some of her prescribed medication. Medication was required to be kept in a locked box because of an identified risk, but a week’s supply was regularly left unsecured and the carers’ digital application did not state that it needed to be stored securely.
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 Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to include medication security instructions in the digital application used by carers
Wider context from the report “I heard evidence that medication for Ms Brown was required to be kept in a locked box due to a risk of her not taking the correct amount or taking too much medication. This was since Apex Care became involved in her care in March 2021.
Despite this identified risk staff left regularly a nomad box containing a week's worth of medication unsecured in her kitchen cupboard.
On the digital application used to inform carers of what medication to administer, which was used by the carers daily, there was no reference to keeping the medication in the secure box.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to keep medication in a locked box
Wider context from the report “I heard evidence that medication for Ms Brown was required to be kept in a locked box due to a risk of her not taking the correct amount or taking too much medication . This was since Apex Care became involved in her care in March 2021.
Despite this identified risk staff left regularly a nomad box containing a week's worth of medication unsecured in her kitchen cupboard .
On the digital application used to inform carers of what medication to administer, which was used by the carers daily, there was no reference to keeping the medication in the secure box.
” Open source report
21 Oct 2022 Daniel John O’Sullivan · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 7 Delays in alerting police when psychiatric patients fail to return from leave View source Poor contemporaneous documentation of unescorted leave View source Failure of Serious Incident Investigations to investigate missing records and interview relevant witnesses View source Failure to formulate Care and Treatment plans identifying core treatment needs View source Failure to update suicide self-harm risk assessments View source Vulnerability of psychiatric patients on voluntary leave to self-harm and predation View source Failure of Serious Incident Investigations to investigate care and treatment plan deficiencies and make recommendations View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Daniel John O’Sullivan · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Daniel John O’Sullivan was found deceased on 27 March 2019 while a voluntary psychiatric patient at St Charles Hospital, after leaving the hospital unescorted and failing to return. The principal concerns were failures to update his self-harm risk assessment, formulate a care and treatment plan, document unescorted leave, and promptly notify police when he did not return. The report also raised concerns that the hospital’s serious incident investigation did not identify or investigate these issues adequately.
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 Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Delays in alerting police when psychiatric patients fail to return from leave
Wider context from the report “2) My second concern is the poor contemporaneous documentation of the grant of unescorted leave from the hospital and the time taken to alert the police when Daniel failed to return on 26/3/19 by 21:00 pm. A ward nurse eventually contacted the police after midnight.
i) I am concerned that an earlier call to the police may have prevented the death, because Daniel was recorded on General Security Zone (GSZ) cameras at 22:21 leaving Vauxhall bridge, and returning, on foot at 23:48. An earlier call might have enabled police to intervene before he was able to commence the actions which ended his life.
ii) The ward manager claimed in evidence that he had instructed others to call the police when Daniel failed to return at 21:00. However, this was not documented anywhere in the medical records and a leave book with handwritten entries went missing after the death. The missing leave book was not investigated by the SII.
iii) A nurse who called the police, sometime before 00:30 according to the medical records, at 01:10 according to police records, was not interviewed by the SII.
I found these investigative deficits troubling because the learning of lessons in patient care depends, in part, on an early SII by the hospital concerned so that risks to patient safety can be identified to enable recommendations and improvements long before an inquest conclusion.
The delay in reporting the failure to return to the Ward was a factor that contributed to the dangerous situation already created by rescinding s.2.
I am nonetheless concerned that, in general, psychiatric patients being tested on voluntary leave are a vulnerable group and as such failures to return should be reported with expedition not only because they may be a danger to themselves, but also due to a risk of being preyed upon by others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Poor contemporaneous documentation of unescorted leave
Wider context from the report “2) My second concern is the poor contemporaneous documentation of the grant of unescorted leave from the hospital and the time taken to alert the police when Daniel failed to return on 26/3/19 by 21:00 pm. A ward nurse eventually contacted the police after midnight.
i) I am concerned that an earlier call to the police may have prevented the death, because Daniel was recorded on General Security Zone (GSZ) cameras at 22:21 leaving Vauxhall bridge, and returning, on foot at 23:48. An earlier call might have enabled police to intervene before he was able to commence the actions which ended his life.
ii) The ward manager claimed in evidence that he had instructed others to call the police when Daniel failed to return at 21:00. However, this was not documented anywhere in the medical records and a leave book with handwritten entries went missing after the death. The missing leave book was not investigated by the SII.
iii) A nurse who called the police, sometime before 00:30 according to the medical records, at 01:10 according to police records, was not interviewed by the SII.
I found these investigative deficits troubling because the learning of lessons in patient care depends, in part, on an early SII by the hospital concerned so that risks to patient safety can be identified to enable recommendations and improvements long before an inquest conclusion.
The delay in reporting the failure to return to the Ward was a factor that contributed to the dangerous situation already created by rescinding s.2.
I am nonetheless concerned that, in general, psychiatric patients being tested on voluntary leave are a vulnerable group and as such failures to return should be reported with expedition not only because they may be a danger to themselves, but also due to a risk of being preyed upon by others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure of Serious Incident Investigations to investigate missing records and interview relevant witnesses
Wider context from the report “2) My second concern is the poor contemporaneous documentation of the grant of unescorted leave from the hospital and the time taken to alert the police when Daniel failed to return on 26/3/19 by 21:00 pm. A ward nurse eventually contacted the police after midnight.
i) I am concerned that an earlier call to the police may have prevented the death, because Daniel was recorded on General Security Zone (GSZ) cameras at 22:21 leaving Vauxhall bridge, and returning, on foot at 23:48. An earlier call might have enabled police to intervene before he was able to commence the actions which ended his life.
ii) The ward manager claimed in evidence that he had instructed others to call the police when Daniel failed to return at 21:00. However, this was not documented anywhere in the medical records and a leave book with handwritten entries went missing after the death. The missing leave book was not investigated by the SII.
iii) A nurse who called the police, sometime before 00:30 according to the medical records, at 01:10 according to police records, was not interviewed by the SII.
I found these investigative deficits troubling because the learning of lessons in patient care depends, in part, on an early SII by the hospital concerned so that risks to patient safety can be identified to enable recommendations and improvements long before an inquest conclusion.
The delay in reporting the failure to return to the Ward was a factor that contributed to the dangerous situation already created by rescinding s.2.
I am nonetheless concerned that, in general, psychiatric patients being tested on voluntary leave are a vulnerable group and as such failures to return should be reported with expedition not only because they may be a danger to themselves, but also due to a risk of being preyed upon by others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to formulate Care and Treatment plans identifying core treatment needs
Wider context from the report “1) On completion of the inquest, I found the decision to rescind detention under s.2 on 25/3/19 was undermined in two essential respects:
a) A failure to update a suicide self-harm risk assessment.
b) A failure to formulate a Care and Treatment plan identifying core treatment needs.
A Serious Incident Investigation (SII), commissioned by CNWL, completed on 9/9/2019, investigated the Risk Assessment and made recommendations which I heard from a CNWL witness had subsequently been implemented and I am satisfied that his risk to life has been satisfactorily reduced.
However, I remain concerned that the Care and Treatment plan aspect was not identified by the SII and as such no recommendations were identified and followed up.
The psychiatrist who rescinded s.2, on 25/3/2019, was unable to participate in the inquest through illness.
As a result, I instructed an independent expert psychiatrist who gave evidence that there had been no treatment plan addressing Daniel’s core treatment needs.
The core treatment needs were that Daniel required antipsychotic medication to control his delusional beliefs and psychological intervention to address his substance misuse which exacerbated his delusional beliefs.
The expert also identified from statements and medical records that Daniel lacked insight into his mental health conditions and thereby lacked capacity. The treatment Daniel required was twofold. Assertive treatment of the delusional disorder with antipsychotics, whilst detained under s.2, to achieve stability, coupled with psychological therapy to address the illicit drug use.
I heard evidence that antipsychotics could not commence until the results of liver function tests were available, but this did not persuade the expert, that recession of s.2 was correct.
The psychiatrist who rescinded s.2 on 25/3/19 was interviewed by the SII but the care and treatment plan aspect was not explored by that investigation.
My concern is that failures in the formulation of a Care and Treatment Plan made a significant contribution to the death and this failing was not exposed until the inquest when it could have been identified much earlier by the SII in September 2019.
The fact that a Care and Treatment plan was not formulated gives me concern that the mistake could be repeated in future and my concern is compounded by the SII failing to investigate and make recommendations arising from this issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to update suicide self-harm risk assessments
Wider context from the report “1) On completion of the inquest, I found the decision to rescind detention under s.2 on 25/3/19 was undermined in two essential respects:
a) A failure to update a suicide self-harm risk assessment.
b) A failure to formulate a Care and Treatment plan identifying core treatment needs.
A Serious Incident Investigation (SII), commissioned by CNWL, completed on 9/9/2019, investigated the Risk Assessment and made recommendations which I heard from a CNWL witness had subsequently been implemented and I am satisfied that his risk to life has been satisfactorily reduced.
However, I remain concerned that the Care and Treatment plan aspect was not identified by the SII and as such no recommendations were identified and followed up.
The psychiatrist who rescinded s.2, on 25/3/2019, was unable to participate in the inquest through illness.
As a result, I instructed an independent expert psychiatrist who gave evidence that there had been no treatment plan addressing Daniel’s core treatment needs.
The core treatment needs were that Daniel required antipsychotic medication to control his delusional beliefs and psychological intervention to address his substance misuse which exacerbated his delusional beliefs.
The expert also identified from statements and medical records that Daniel lacked insight into his mental health conditions and thereby lacked capacity. The treatment Daniel required was twofold. Assertive treatment of the delusional disorder with antipsychotics, whilst detained under s.2, to achieve stability, coupled with psychological therapy to address the illicit drug use.
I heard evidence that antipsychotics could not commence until the results of liver function tests were available, but this did not persuade the expert, that recession of s.2 was correct.
The psychiatrist who rescinded s.2 on 25/3/19 was interviewed by the SII but the care and treatment plan aspect was not explored by that investigation.
My concern is that failures in the formulation of a Care and Treatment Plan made a significant contribution to the death and this failing was not exposed until the inquest when it could have been identified much earlier by the SII in September 2019.
The fact that a Care and Treatment plan was not formulated gives me concern that the mistake could be repeated in future and my concern is compounded by the SII failing to investigate and make recommendations arising from this issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Vulnerability of psychiatric patients on voluntary leave to self-harm and predation
Wider context from the report “2) My second concern is the poor contemporaneous documentation of the grant of unescorted leave from the hospital and the time taken to alert the police when Daniel failed to return on 26/3/19 by 21:00 pm. A ward nurse eventually contacted the police after midnight.
i) I am concerned that an earlier call to the police may have prevented the death, because Daniel was recorded on General Security Zone (GSZ) cameras at 22:21 leaving Vauxhall bridge, and returning, on foot at 23:48. An earlier call might have enabled police to intervene before he was able to commence the actions which ended his life.
ii) The ward manager claimed in evidence that he had instructed others to call the police when Daniel failed to return at 21:00. However, this was not documented anywhere in the medical records and a leave book with handwritten entries went missing after the death. The missing leave book was not investigated by the SII.
iii) A nurse who called the police, sometime before 00:30 according to the medical records, at 01:10 according to police records, was not interviewed by the SII.
I found these investigative deficits troubling because the learning of lessons in patient care depends, in part, on an early SII by the hospital concerned so that risks to patient safety can be identified to enable recommendations and improvements long before an inquest conclusion.
The delay in reporting the failure to return to the Ward was a factor that contributed to the dangerous situation already created by rescinding s.2.
I am nonetheless concerned that, in general, psychiatric patients being tested on voluntary leave are a vulnerable group and as such failures to return should be reported with expedition not only because they may be a danger to themselves, but also due to a risk of being preyed upon by others .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure of Serious Incident Investigations to investigate care and treatment plan deficiencies and make recommendations
Wider context from the report “1) On completion of the inquest, I found the decision to rescind detention under s.2 on 25/3/19 was undermined in two essential respects:
a) A failure to update a suicide self-harm risk assessment.
b) A failure to formulate a Care and Treatment plan identifying core treatment needs.
A Serious Incident Investigation (SII), commissioned by CNWL, completed on 9/9/2019, investigated the Risk Assessment and made recommendations which I heard from a CNWL witness had subsequently been implemented and I am satisfied that his risk to life has been satisfactorily reduced.
However, I remain concerned that the Care and Treatment plan aspect was not identified by the SII and as such no recommendations were identified and followed up.
The psychiatrist who rescinded s.2, on 25/3/2019, was unable to participate in the inquest through illness.
As a result, I instructed an independent expert psychiatrist who gave evidence that there had been no treatment plan addressing Daniel’s core treatment needs.
The core treatment needs were that Daniel required antipsychotic medication to control his delusional beliefs and psychological intervention to address his substance misuse which exacerbated his delusional beliefs.
The expert also identified from statements and medical records that Daniel lacked insight into his mental health conditions and thereby lacked capacity. The treatment Daniel required was twofold. Assertive treatment of the delusional disorder with antipsychotics, whilst detained under s.2, to achieve stability, coupled with psychological therapy to address the illicit drug use.
I heard evidence that antipsychotics could not commence until the results of liver function tests were available, but this did not persuade the expert, that recession of s.2 was correct.
The psychiatrist who rescinded s.2 on 25/3/19 was interviewed by the SII but the care and treatment plan aspect was not explored by that investigation.
My concern is that failures in the formulation of a Care and Treatment Plan made a significant contribution to the death and this failing was not exposed until the inquest when it could have been identified much earlier by the SII in September 2019.
The fact that a Care and Treatment plan was not formulated gives me concern that the mistake could be repeated in future and my concern is compounded by the SII failing to investigate and make recommendations arising from this issue .
” Open source report
Concerns raised 2 Neglect affecting vulnerable children View source Failure to adequately test evidence and reconsider charging criteria in suspected child neglect cases View source
Responses linked to these concerns
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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
Dainton Harley Hill Cressell GITTOS · 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
Dainton Harley Hill, an 11-year-old vulnerable child with cerebral palsy who could not speak, bear his own weight, or call for help, was left unsupervised in a bath on 22 January 2021 and was later found unresponsive. The inquest concluded that parental neglect in failing to supervise him contributed directly to his death, which was consistent with drowning. Concerns were raised about the lack of supervision, failure to use a non-slip bath mattress, prior social services records concerning neglect and emotional harm, and the decision not to bring charges.
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 Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Neglect affecting vulnerable children
Wider context from the report “I refer to all the evidence heard at the Inquest particularly, that of DC ████████ and the Police’s own expert Dr. ████████, (recited above) and do not accept why any charges have not been brought against either or both parents focusing on s1(1) Children and Young Persons Act 1933
The police are asked to review their file again in view of the many concessions made by CPS and the findings as to cause of death now made in the Coroner’s Court (admittedly on a different standard of proof but they are still findings after hearing evidence).
Neglect runs right through this case and irrespective of the parent’s allegations against each other in the Coroner’s Court the belief is that the evidence needs to be tested and if agreed charging criteria reconsidered as there are 3 other siblings .
A vulnerable child aged 11 is dead.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately test evidence and reconsider charging criteria in suspected child neglect cases
Wider context from the report “I refer to all the evidence heard at the Inquest particularly, that of DC ████████ and the Police’s own expert Dr. ████████, (recited above) and do not accept why any charges have not been brought against either or both parents focusing on s1(1) Children and Young Persons Act 1933
The police are asked to review their file again in view of the many concessions made by CPS and the findings as to cause of death now made in the Coroner’s Court (admittedly on a different standard of proof but they are still findings after hearing evidence).
Neglect runs right through this case and irrespective of the parent’s allegations against each other in the Coroner’s Court the belief is that the evidence needs to be tested and if agreed charging criteria reconsidered as there are 3 other siblings.
A vulnerable child aged 11 is dead.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations