Concerns raised 2 Lack of mandatory inspection and approval checks on ligature alarm placement in newly built mental health units View source Lack of mandatory requirements for fitting ligature alarms to doors in newly built mental health units View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Sergio DUNKLEY · 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
Sergio DUNKLEY was admitted voluntarily to a mental health ward on 24 July 2020 after threats to end his life. He was last seen alive shortly after midnight on 18 August 2020 and was found to have taken his own life before 1.30am. The report raised concerns about the lack of mandatory requirements for ligature alarms and for checking their placement in newly built mental health units, as well as failures to record observation changes and suicide-risk assessments 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 Lack of mandatory inspection and approval checks on ligature alarm placement in newly built mental health units
Wider context from the report “(3) That inspection and approval of newly built mental health units contains no mandatory requirement for the checking as to the placement of ligature alarms .
” Open source report × Source evidence
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 mandatory requirements for fitting ligature alarms to doors in newly built mental health units
Wider context from the report “(1) That there is no statutory requirement nor any current regulations which specifically require the doors within newly build mental health units to be fitted with ligature alarms .
(2) That whilst Health Building Note 03-01 as published by the Department of Health gives guidance that “ All fixtures and fittings should be ant ligature” the requirement to do so is not stated to be mandatory .
” Open source report
Concerns raised 2 Failure to ensure widespread understanding of the risks of fetal growth restriction View source Delays in providing urgently required fetal growth scans 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
Oliver Christopher Lindsay · 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
Oliver Christopher Lindsay was identified as having fetal growth restriction before suffering an unexpected placental abruption at home on 6 September 2020. He was born with ambulance support, received advanced paediatric life support, and was transferred to hospital, where he was found to have a severe hypoxic brain injury and died on 12 September 2020. The principal concerns were delays in obtaining a growth scan because of scanning capacity issues and limited understanding of the risks associated with fetal growth restriction.
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 ensure widespread understanding of the risks of fetal growth restriction
Wider context from the report “2. The inquest heard evidence from a number of obstetricians about the very significant risks fetal growth restriction presented to the health of a baby. There was clear evidence that the risks of fetal growth restriction were not widely understood outside experienced obstetric professionals and that greater understanding and clarity of the risks was important in helping all those involved. This was particularly true in relation to parents faced with a sudden change at a difficult time. It was suggested during the inquest that as part of the Saving Babies bundle a FAQ sheet should be developed for parents which set out what fetal growth restriction is ; the risks it presented to a baby at various stages of a pregnancy and the national guidance to reduce risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Delays in providing urgently required fetal growth scans
Wider context from the report “1. At his mother’s midwife check-up, it was identified that Oliver may have fetal growth restriction and that a scan was urgently required. A referral was made to the acute trust. However scanning capacity issues meant that there was a delay in an appointment being offered. Oliver’s parents were very concerned and felt they had no choice but to pay to have a private scan which did confirm fetal growth restriction and resulted in his mother attending the acute trust to be seen. The inquest heard evidence that there were capacity issues in relation to growth scans nationally particularly after a bank holiday or a weekend.
” Open source report
14 Jan 2022 Alfie Stone · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 6 Failure to accept recommendations to carry and administer buccal midazolam when necessary View source Failure to ask parents whether the child had vomited View source Lack of paramedic training in the use of buccal midazolam View source Lack of evidence of paramedic training following an independent Serious Incident Report and agreed recommendations View source Failure to attempt alternative oxygenation View source Failure to attempt suction View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Alfie Stone · 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
Alfie Stone, aged 12, died after prolonged seizures, status epilepticus, hypoxia and multiple organ failure following admission to hospital. Concerns included paramedics’ lack of training in buccal midazolam, inadequate oxygenation, no suction attempt, and insufficient evidence of training following an earlier Serious Incident Report.
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 accept recommendations to carry and administer buccal midazolam when necessary
Wider context from the report “(5) East Midlands Ambulance Service were not accepting the recommendations 3 within the report to carry and administer Buccal Midazolam when necessary .
” Open source report × Source evidence
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 parents whether the child had vomited
Wider context from the report “(3) No suction attempted and the question was not asked of the parents as to whether the child had vomited .
” Open source report × Source evidence
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 paramedic training in the use of buccal midazolam
Wider context from the report “(1) Apparent lack of training of paramedics in the use of Buccal Midazolam
” Open source report × Source evidence
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 evidence of paramedic training following an independent Serious Incident Report and agreed recommendations
Wider context from the report “(4) No evidence of training to the paramedics who attended and gave evidence following an independent Serious Incident Report and its agreed recommendations
” Open source report × Source evidence
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 attempt alternative oxygenation
Wider context from the report “(2) No other form of oxygenation attempted such as bagging or the child being taken earlier to the ambulance to secure and deliver oxygen
” Open source report × Source evidence
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 attempt suction
Wider context from the report “(3) No suction attempted and the question was not asked of the parents as to whether the child had vomited.
” Open source report
Concerns raised 3 Failure to record resident aggression incidents in care plans View source Failure of staff to be aware of care plan contents View source Failure to raise safeguarding alerts with the local authority 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
Dorothy Seekings · 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
Dorothy Seekings, a resident of Clifton Court Nursing Home, was found dead in her room on 8 August 2019 after another resident entered the room; a post-mortem examination showed blunt force injuries, which were probably caused by that resident. Concerns included care plans not recording the other resident’s aggressive incidents towards staff, failure to raise a safeguarding alert, and staff appearing unaware of the care plan contents.
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 record resident aggression incidents in care plans
Wider context from the report “(1) the care plans for ████████ did not record incidents where ████████ had acted aggressively to staff members including an occasion when a staff member was kicked in the mouth by ████████.
(2) the failure to raise a safeguarding alert with the local authority regarding the above incident.
(3) The staff did not appear to be aware of the contents of the care plan for ████████ or other resident
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to be aware of care plan contents
Wider context from the report “(1) the care plans for ████████ did not record incidents where ████████ had acted aggressively to staff members including an occasion when a staff member was kicked in the mouth by ████████.
(2) the failure to raise a safeguarding alert with the local authority regarding the above incident.
(3) The staff did not appear to be aware of the contents of the care plan for ████████ or other resident
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to raise safeguarding alerts with the local authority
Wider context from the report “(1) the care plans for ████████ did not record incidents where ████████ had acted aggressively to staff members including an occasion when a staff member was kicked in the mouth by ████████.
(2) the failure to raise a safeguarding alert with the local authority regarding the above incident .
(3) The staff did not appear to be aware of the contents of the care plan for ████████ or other resident
” Open source report
Concerns raised 4 Failure to report falls-related matters to regulatory bodies View source Delayed staff supervision and discussion of falls prevention View source Failure to commence a timely investigation of falls-related matters View source Failure to apply falls risk assessment and prevention procedures 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
Pauline BRUMFITT · 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
Pauline BRUMFITT died on 15 April 2020 after a fall at a care home led to hospital admission and diagnosis of an intracranial bleed. The concerns were that falls risk assessments, prevention measures and referrals were not implemented after her previous falls, and that the incident was not promptly reported or investigated.
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 report falls-related matters to regulatory bodies
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The policies and procedures in existence at the care home pertaining to falls risk assessment and prevention were not applied to Pauline Brumfitt (as stated above) as they should have been.
(2) Pauline fell on 3 occasions and the opportunities to assess Pauline’s risks and take appropriate action to prevent further falls were not taken as they should have been.
(3) The matter was (given in evidence) not reported to the regulatory bodies and again as given in evidence an investigation had not been commenced at the time of the inquest and staff supervision/discussion re falls prevention had only been commenced in Feb/March 2021, appropriate timely action could have helped (and could still help) to prevent future deaths in similar circumstances where dependent elderly residents are at risk of falling and suffering serious injury/death as a consequence.
” Open source report × Source evidence
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 Delayed staff supervision and discussion of falls prevention
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The policies and procedures in existence at the care home pertaining to falls risk assessment and prevention were not applied to Pauline Brumfitt (as stated above) as they should have been.
(2) Pauline fell on 3 occasions and the opportunities to assess Pauline’s risks and take appropriate action to prevent further falls were not taken as they should have been.
(3) The matter was (given in evidence) not reported to the regulatory bodies and again as given in evidence an investigation had not been commenced at the time of the inquest and staff supervision/discussion re falls prevention had only been commenced in Feb/March 2021 , appropriate timely action could have helped (and could still help) to prevent future deaths in similar circumstances where dependent elderly residents are at risk of falling and suffering serious injury/death as a consequence.
” Open source report × Source evidence
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 commence a timely investigation of falls-related matters
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The policies and procedures in existence at the care home pertaining to falls risk assessment and prevention were not applied to Pauline Brumfitt (as stated above) as they should have been.
(2) Pauline fell on 3 occasions and the opportunities to assess Pauline’s risks and take appropriate action to prevent further falls were not taken as they should have been.
(3) The matter was (given in evidence) not reported to the regulatory bodies and again as given in evidence an investigation had not been commenced at the time of the inquest and staff supervision/discussion re falls prevention had only been commenced in Feb/March 2021, appropriate timely action could have helped (and could still help) to prevent future deaths in similar circumstances where dependent elderly residents are at risk of falling and suffering serious injury/death as a consequence.
” Open source report × Source evidence
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 apply falls risk assessment and prevention procedures
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The policies and procedures in existence at the care home pertaining to falls risk assessment and prevention were not applied to Pauline Brumfitt (as stated above) as they should have been.
(2) Pauline fell on 3 occasions and the opportunities to assess Pauline’s risks and take appropriate action to prevent further falls were not taken as they should have been .
(3) The matter was (given in evidence) not reported to the regulatory bodies and again as given in evidence an investigation had not been commenced at the time of the inquest and staff supervision/discussion re falls prevention had only been commenced in Feb/March 2021, appropriate timely action could have helped (and could still help) to prevent future deaths in similar circumstances where dependent elderly residents are at risk of falling and suffering serious injury/death as a consequence.
” Open source report
20 Jun 2019 Pte Geoff Gray · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Lack of specific guidance on appropriate post-mortem examination in firearms deaths View source Cursory post-mortem investigations following assumptions of suicide View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Pte Geoff Gray · 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
On 17 September 2001, 17-year-old Private Geoff Gray was found shot in the grounds of the Officers’ Mess at Princess Royal Barracks, Deepcut, with two fatal head wounds and a SA80 rifle beside him. The report raises concerns that the death was initially assumed to be suicide and investigated through a routine rather than forensic post-mortem, with photographs, imaging, wound documentation and clothing retention not undertaken, creating a risk that homicides could go undetected.
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 specific guidance on appropriate post-mortem examination in firearms deaths
Wider context from the report “2. Both ████████ and ████████, the forensic pathologist who conducted the post-mortem told me that that there is no specific guidance to either pathologists, and as I understand it to coroners, that urges them to give particular consideration to the nature of the post-mortem examination in cases of death by firearms, even when that death is of a child .
” Open source report × Source evidence
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 Cursory post-mortem investigations following assumptions of suicide
Wider context from the report “3. It is of concern that where assumptions of suicide lead to cursory post-mortem investigations this creates a risk that homicides will go undetected.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include guidance advising coroners to consider the need or scope of post-mortem examinations in deaths involving potentially self-inflicted stab or gunshot injuries.
Verbatim wording from the response “I have included the following text in the forthcoming Guidance on second post-mortems (and post-mortems more generally), which will be published this Autumn:” Source location 2019-0216-Response-by-Chief-Coroner
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish new guidance on second post-mortems and post-mortems more generally, including encouragement to consider CT scans and photographic or video evidence capture.
Verbatim wording from the response “I have included the following text in the forthcoming Guidance on second post-mortems (and post-mortems more generally), which will be published this Autumn:” Source location 2019-0216-Response-by-Chief-Coroner
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Chief Coroner cannot direct coroners’ independent judicial decisions or prescribe post-mortem examinations through guidance.
Verbatim wording from the response “I am very grateful for you bringing these important issues to my attention. First, it is important for me to make clear that as Chief Coroner I cannot direct coroners on their independent judicial decisions in individual cases, whether in Guidance or elsewhere. Ultimately coroners must make their own decisions, including on whether (and in what form) to order a post-mortem examination. Much depends on the circumstances of each case.” Source location 2019-0216-Response-by-Chief-Coroner
Open published response
8 May 2019 Bernard Pius O’Flynn · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Lack of practising expert input into formulation of medical emergency policies View source Potential medical emergencies outside Code Red and Code Blue requiring hospital transfer within less than an hour 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
Bernard Pius O’Flynn · 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
Bernard Pius O’Flynn was imprisoned at HMP Thameside and developed back and abdominal pain before being diagnosed with an acute abdomen. His transfer to hospital was delayed for three days; he was later diagnosed with metastatic adenocarcinoma and died in hospital on 26 August 2018. The report identified concerns about urgent hospital transfers from prison, including the absence of expert emergency-medicine input into policies for emergencies outside Code Red and Code Blue situations.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Lack of practising expert input into formulation of medical emergency policies
Wider context from the report “The failures identified in the clinical review and PPO reports were, in my view, deeply troubling. That said I am encouraged by the cooperation and efforts made by Oxleas and SERCO to formulate a policy to deal with medical emergencies falling outside the Code Red and Code Blue scenarios.
However I remain concerned that a practising expert in Emergency Medicine has not yet had input into the formulation of the policies promulgated by the joint meeting between SERCO and Oxleas .
In particular my concern is that there may be medical emergencies which do not fall within Code Red or Code Blue but may, nonetheless, require immediate transfer to hospital within less than an hour. It is possible that an expert in emergency medicine would be able to easily identify whether or not there are residual cases within this category.
I am therefore of the view that I am under a duty to report this residual concern to Oxleas NHS Foundation Trust in order to take appropriate action, if so advised by an expert Consultant in Emergency Medicine, to reduce the risk of fatalities in future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Potential medical emergencies outside Code Red and Code Blue requiring hospital transfer within less than an hour
Wider context from the report “The failures identified in the clinical review and PPO reports were, in my view, deeply troubling. That said I am encouraged by the cooperation and efforts made by Oxleas and SERCO to formulate a policy to deal with medical emergencies falling outside the Code Red and Code Blue scenarios.
However I remain concerned that a practising expert in Emergency Medicine has not yet had input into the formulation of the policies promulgated by the joint meeting between SERCO and Oxleas.
In particular my concern is that there may be medical emergencies which do not fall within Code Red or Code Blue but may, nonetheless, require immediate transfer to hospital within less than an hour . It is possible that an expert in emergency medicine would be able to easily identify whether or not there are residual cases within this category.
I am therefore of the view that I am under a duty to report this residual concern to Oxleas NHS Foundation Trust in order to take appropriate action, if so advised by an expert Consultant in Emergency Medicine, to reduce the risk of fatalities in future.
” Open source report
4 Apr 2019 Julia Luxmore Peto · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Lack of louvres preventing pedestrian see-through at two-stage pedestrian crossings View source Lack of road markings warning pedestrians of traffic direction at two-stage pedestrian crossings 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
Julia Luxmore Peto · 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
On 16 September 2018, Julia Luxmore Peto was struck by a bus while crossing Deptford Broadway and suffered a catastrophic head injury; she died in hospital the following day. The principal concern was that pedestrians might be distracted or confused by green pedestrian signals visible across the other carriageway at two-stage crossings, with wider concern about similar crossings lacking louvres and road markings to indicate traffic direction.
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 louvres preventing pedestrian see-through at two-stage pedestrian crossings
Wider context from the report “TfL informed me, at the inquest, that they are putting in place “Look Left” and “Look Right” markings on the road to inform pedestrians on the direction of approaching traffic (A copy of the TfL report to me is appended for ease of reference. This contains a useful plan and photographs). From the evidence I heard I am satisfied that these particular changes would not have a wider impact on traffic flow but would improve the safety of pedestrians.
I was pleased to hear that TfL had taken proactive practical measures to reduce the risk at this particular junction but I remain concerned that there are likely be other “two stage” pedestrian crossings throughout England and Wales which also do not currently have louvres to prevent pedestrian ‘see-through’ and road markings to warn pedestrians of traffic direction.
I am therefore of the view that I am under a duty to report this wider concern to the Department of Transport to take appropriate action to reduce the risk of fatalities and serious injuries at two stage crossings throughout England and Wales.
” Open source report × Source evidence
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 road markings warning pedestrians of traffic direction at two-stage pedestrian crossings
Wider context from the report “TfL informed me, at the inquest, that they are putting in place “Look Left” and “Look Right” markings on the road to inform pedestrians on the direction of approaching traffic (A copy of the TfL report to me is appended for ease of reference. This contains a useful plan and photographs). From the evidence I heard I am satisfied that these particular changes would not have a wider impact on traffic flow but would improve the safety of pedestrians.
I was pleased to hear that TfL had taken proactive practical measures to reduce the risk at this particular junction but I remain concerned that there are likely be other “two stage” pedestrian crossings throughout England and Wales which also do not currently have louvres to prevent pedestrian ‘see-through’ and road markings to warn pedestrians of traffic direction .
I am therefore of the view that I am under a duty to report this wider concern to the Department of Transport to take appropriate action to reduce the risk of fatalities and serious injuries at two stage crossings throughout England and Wales.
” Open source report
14 Dec 2018 BARNABY LUKE AYLWARD · Prevention of Future Deaths report West Yorkshire (West)
View report summary
Concerns raised 8 Failure to share relevant risk information between agencies View source Failure to conduct regular multi-agency preventative review and reassessment of fire risks View source Failure to carry out regular property inspections and provide assistance View source Failure to record significant clutter and associated risk in clinical notes View source Lack of collective or assigned responsibility for reducing home fire risk View source Limited efforts to extend practical and financial support through family members View source Failure of care plan documentation to record behavioural fire risks and planned review View source Failure to facilitate private professional discussion during risk management and MHA assessment View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
BARNABY LUKE AYLWARD · 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
Barnaby Luke Aylward died in the early hours of 4 September 2017 after being overcome by smoke from an accidental house fire caused more likely than not by a lit cigarette. The report identified concerns about known fire risks associated with his heavy smoking, clutter and serious mental illness, including insufficient multi-agency risk assessment, information sharing, property inspection, care planning and preventative support.
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 relevant risk information between agencies
Wider context from the report “(1) Mr Aylward was a social housing tenant. He exhibited certain behaviours that were in part linked to his serious mental illness. Those presented risk of death in a fire at home including heavy smoking and allowing clutter and waste to accumulate there. Those behaviours and thus the risks were known to certain individuals, including his family, and agencies but they did not except in time of crisis or emergency:
a) review those potential risks with a multi agency preventative approach and re assess those risks regularly over time;
b) take any collective responsibility nor for any one person or agency to take responsibility to reduce or eliminate risk by action eg clearing clutter and fire risk; and education about risk and reluctance to compel Mr Aylward to improve his environment regularly if needed;
c) did not feel empowered to make property inspections regularly or at all and advise Mr Aylward and other agencies, or have sufficient resources at the right level to inspect and assist;
d) may have been hampered by issues of confidentiality in communications between agencies .
If all agencies had shared the particulars of his behaviours the burden of risk might be shared and understood and potential to reduce or eliminate the risk attempted, reviewed and managed.
” Open source report × Source evidence
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 regular multi-agency preventative review and reassessment of fire risks
Wider context from the report “(1) Mr Aylward was a social housing tenant. He exhibited certain behaviours that were in part linked to his serious mental illness. Those presented risk of death in a fire at home including heavy smoking and allowing clutter and waste to accumulate there. Those behaviours and thus the risks were known to certain individuals, including his family, and agencies but they did not except in time of crisis or emergency:
a) review those potential risks with a multi agency preventative approach and re assess those risks regularly over time ;
b) take any collective responsibility nor for any one person or agency to take responsibility to reduce or eliminate risk by action eg clearing clutter and fire risk; and education about risk and reluctance to compel Mr Aylward to improve his environment regularly if needed;
c) did not feel empowered to make property inspections regularly or at all and advise Mr Aylward and other agencies, or have sufficient resources at the right level to inspect and assist;
d) may have been hampered by issues of confidentiality in communications between agencies.
If all agencies had shared the particulars of his behaviours the burden of risk might be shared and understood and potential to reduce or eliminate the risk attempted, reviewed and managed.
” Open source report × Source evidence
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 carry out regular property inspections and provide assistance
Wider context from the report “(1) Mr Aylward was a social housing tenant. He exhibited certain behaviours that were in part linked to his serious mental illness. Those presented risk of death in a fire at home including heavy smoking and allowing clutter and waste to accumulate there. Those behaviours and thus the risks were known to certain individuals, including his family, and agencies but they did not except in time of crisis or emergency:
a) review those potential risks with a multi agency preventative approach and re assess those risks regularly over time;
b) take any collective responsibility nor for any one person or agency to take responsibility to reduce or eliminate risk by action eg clearing clutter and fire risk; and education about risk and reluctance to compel Mr Aylward to improve his environment regularly if needed;
c) did not feel empowered to make property inspections regularly or at all and advise Mr Aylward and other agencies, or have sufficient resources at the right level to inspect and assist ;
d) may have been hampered by issues of confidentiality in communications between agencies.
If all agencies had shared the particulars of his behaviours the burden of risk might be shared and understood and potential to reduce or eliminate the risk attempted, reviewed and managed.
” Open source report × Source evidence
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 significant clutter and associated risk in clinical notes
Wider context from the report “(3) The presence of clutter and thus risk was not always evidenced in other clinical notes as a symptom of Mr Aylward's illness of significance as were other presentations of his illness.
” Open source report × Source evidence
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 collective or assigned responsibility for reducing home fire risk
Wider context from the report “(1) Mr Aylward was a social housing tenant. He exhibited certain behaviours that were in part linked to his serious mental illness. Those presented risk of death in a fire at home including heavy smoking and allowing clutter and waste to accumulate there. Those behaviours and thus the risks were known to certain individuals, including his family, and agencies but they did not except in time of crisis or emergency:
a) review those potential risks with a multi agency preventative approach and re assess those risks regularly over time;
b) take any collective responsibility nor for any one person or agency to take responsibility to reduce or eliminate risk by action eg clearing clutter and fire risk; and education about risk and reluctance to compel Mr Aylward to improve his environment regularly if needed ;
c) did not feel empowered to make property inspections regularly or at all and advise Mr Aylward and other agencies, or have sufficient resources at the right level to inspect and assist;
d) may have been hampered by issues of confidentiality in communications between agencies.
If all agencies had shared the particulars of his behaviours the burden of risk might be shared and understood and potential to reduce or eliminate the risk attempted, reviewed and managed.
” Open source report × Source evidence
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 Limited efforts to extend practical and financial support through family members
Wider context from the report “(4) There was some but not much evidence of seeking to extend support to Mr Aylward through his family members including practical and financial help.
” Open source report × Source evidence
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 care plan documentation to record behavioural fire risks and planned review
Wider context from the report “(2) The mental health care delivered to Mr Aylward was within a Care Planning Approach. The Care Plan documentation did not identify his above behaviours in writing and thus potential risks, nor indicate review and solutions including with housing provision
” Open source report × Source evidence
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 facilitate private professional discussion during risk management and MHA assessment
Wider context from the report “(5) The appropriateness for a risk management meeting and also MHA assessment in part to be held away from the patient to enable frank discussions to take place between mental health professionals rather than in front of the patient perhaps more robust views may not have been enabled .
” Open source report
Concerns raised 4 Failure of Addaction to communicate and provide feedback to GPs View source Failure to consider consent for disclosure to GPs at Recovery Plan reviews View source Lack of consideration of underlying mental health issues in patients with alcohol or drug problems View source Failure of mental health services to accept responsibility for providing professional care View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Benjamin Colin Williamson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Benjamin Colin Williamson had a long history of alcohol-related issues and was receiving treatment, with regular GP contact. He died on 4 April 2018, and the inquest recorded a conclusion of suicide, with asphyxia by hanging and alcohol intoxication. Concerns included fragmented mental health services for people with both mental health and alcohol problems, and inadequate liaison and feedback between Addaction and the GP.
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 Addaction to communicate and provide feedback to GPs
Wider context from the report “CMHT Commissioners
At inquest, I heard from ████████, a partner at Mullion and Constantine Group Practice and the Locality Lead for Commissioning. Mr Williamson was his patient. ███ told me that Mr Williamson had been referred twice to CMHT. On both occasions, ████████ described this as having a significant impact upon his patient who was left feeling he was not ill enough to be worthy of support. ████████ expressed his view that the system is not set up to serve the population. He said it was his experience that patients like Benjamin are bounced between the various mental health services seemingly with ████████ one willing or able to accept responsibility for providing professional care, and he felt it had failed to meet the needs of his patient.
████████ identified that the problem was particularly acute for patients who have a mental health issue plus an alcohol (or drug) problem. He felt that while referring Benjamin to Addaction had addressed his alcohol-related concerns, there had been a total lack of consideration of any underlying mental health issue. This is not the first occasion on which observations of this nature have been made before me although in ████████ I have rarely had a more articulate or well-placed witness.
Addaction
████████ told me that after referring Benjamin to Addaction he had no communications or feedback from the service . I heard from ████████ in this regard. It was accepted that there should have been more liaison with the GP and that, in particular, a letter from the doctor in January 2018 was not answered and should have been.
Upon further exploration, it emerged that Benjamin had not given full consent for disclosure to his GP. I was told that his Recovery Plan had been reviewed on 25/5/17, 16/8/17, 27/10/17 and 12/2/18. I was advised that the issue of consent should have been considered at these reviews but that did not appear to have happened. Both Benjamin’s mother and ████████ were of the view that if this matter had been dealt with fully, consent for disclosure to the GP would have been provided. ████████ felt that the lack of feedback compromised his ability to provide care to his patient.
” Open source report × Source evidence
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 consider consent for disclosure to GPs at Recovery Plan reviews
Wider context from the report “CMHT Commissioners
At inquest, I heard from ████████, a partner at Mullion and Constantine Group Practice and the Locality Lead for Commissioning. Mr Williamson was his patient. ███ told me that Mr Williamson had been referred twice to CMHT. On both occasions, ████████ described this as having a significant impact upon his patient who was left feeling he was not ill enough to be worthy of support. ████████ expressed his view that the system is not set up to serve the population. He said it was his experience that patients like Benjamin are bounced between the various mental health services seemingly with ████████ one willing or able to accept responsibility for providing professional care, and he felt it had failed to meet the needs of his patient.
████████ identified that the problem was particularly acute for patients who have a mental health issue plus an alcohol (or drug) problem. He felt that while referring Benjamin to Addaction had addressed his alcohol-related concerns, there had been a total lack of consideration of any underlying mental health issue. This is not the first occasion on which observations of this nature have been made before me although in ████████ I have rarely had a more articulate or well-placed witness.
Addaction
████████ told me that after referring Benjamin to Addaction he had no communications or feedback from the service. I heard from ████████ in this regard. It was accepted that there should have been more liaison with the GP and that, in particular, a letter from the doctor in January 2018 was not answered and should have been.
Upon further exploration, it emerged that Benjamin had not given full consent for disclosure to his GP. I was told that his Recovery Plan had been reviewed on 25/5/17, 16/8/17, 27/10/17 and 12/2/18. I was advised that the issue of consent should have been considered at these reviews but that did not appear to have happened . Both Benjamin’s mother and ████████ were of the view that if this matter had been dealt with fully, consent for disclosure to the GP would have been provided. ████████ felt that the lack of feedback compromised his ability to provide care to his patient.
” Open source report × Source evidence
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 consideration of underlying mental health issues in patients with alcohol or drug problems
Wider context from the report “CMHT Commissioners
At inquest, I heard from ████████, a partner at Mullion and Constantine Group Practice and the Locality Lead for Commissioning. Mr Williamson was his patient. ███ told me that Mr Williamson had been referred twice to CMHT. On both occasions, ████████ described this as having a significant impact upon his patient who was left feeling he was not ill enough to be worthy of support. ████████ expressed his view that the system is not set up to serve the population. He said it was his experience that patients like Benjamin are bounced between the various mental health services seemingly with ████████ one willing or able to accept responsibility for providing professional care, and he felt it had failed to meet the needs of his patient.
████████ identified that the problem was particularly acute for patients who have a mental health issue plus an alcohol (or drug) problem. He felt that while referring Benjamin to Addaction had addressed his alcohol-related concerns, there had been a total lack of consideration of any underlying mental health issue . This is not the first occasion on which observations of this nature have been made before me although in ████████ I have rarely had a more articulate or well-placed witness.
Addaction
████████ told me that after referring Benjamin to Addaction he had no communications or feedback from the service. I heard from ████████ in this regard. It was accepted that there should have been more liaison with the GP and that, in particular, a letter from the doctor in January 2018 was not answered and should have been.
Upon further exploration, it emerged that Benjamin had not given full consent for disclosure to his GP. I was told that his Recovery Plan had been reviewed on 25/5/17, 16/8/17, 27/10/17 and 12/2/18. I was advised that the issue of consent should have been considered at these reviews but that did not appear to have happened. Both Benjamin’s mother and ████████ were of the view that if this matter had been dealt with fully, consent for disclosure to the GP would have been provided. ████████ felt that the lack of feedback compromised his ability to provide care to his patient.
” Open source report × Source evidence
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 mental health services to accept responsibility for providing professional care
Wider context from the report “CMHT Commissioners
At inquest, I heard from ████████, a partner at Mullion and Constantine Group Practice and the Locality Lead for Commissioning. Mr Williamson was his patient. ███ told me that Mr Williamson had been referred twice to CMHT. On both occasions, ████████ described this as having a significant impact upon his patient who was left feeling he was not ill enough to be worthy of support. ████████ expressed his view that the system is not set up to serve the population. He said it was his experience that patients like Benjamin are bounced between the various mental health services seemingly with ████████ one willing or able to accept responsibility for providing professional care , and he felt it had failed to meet the needs of his patient.
████████ identified that the problem was particularly acute for patients who have a mental health issue plus an alcohol (or drug) problem. He felt that while referring Benjamin to Addaction had addressed his alcohol-related concerns, there had been a total lack of consideration of any underlying mental health issue. This is not the first occasion on which observations of this nature have been made before me although in ████████ I have rarely had a more articulate or well-placed witness.
Addaction
████████ told me that after referring Benjamin to Addaction he had no communications or feedback from the service. I heard from ████████ in this regard. It was accepted that there should have been more liaison with the GP and that, in particular, a letter from the doctor in January 2018 was not answered and should have been.
Upon further exploration, it emerged that Benjamin had not given full consent for disclosure to his GP. I was told that his Recovery Plan had been reviewed on 25/5/17, 16/8/17, 27/10/17 and 12/2/18. I was advised that the issue of consent should have been considered at these reviews but that did not appear to have happened. Both Benjamin’s mother and ████████ were of the view that if this matter had been dealt with fully, consent for disclosure to the GP would have been provided. ████████ felt that the lack of feedback compromised his ability to provide care to his patient.
” Open source report
5 Oct 2018 ROBIN ANDREW JAMES MCEWAN · Prevention of Future Deaths report North Yorkshire
View report summary
Concerns raised 3 Lack of guidance on accessible self-help therapies and online training for lay supporters of people experiencing suicidal crisis View source Insufficient exploration of family support to provide mental health scaffolding during delays in professional help View source Failure to share potentially key welfare and safety information between private therapy services and primary care 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
ROBIN ANDREW JAMES MCEWAN · 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
On 26 January 2018, Robin Andrew James McEwan was found hanging in the basement of his home after returning from drinks with workmates. He was taken to Harrogate Hospital, where he was considered brain stem dead and died on 2 February 2018 after life support was withdrawn. The concerns included a lack of direct communication between his private therapy service and GP, limited guidance and support during delays in accessing specialist mental health services, and further possible exploration of family support.
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 guidance on accessible self-help therapies and online training for lay supporters of people experiencing suicidal crisis
Wider context from the report “Within the contexts of
a) Primary Care and
b) acknowledgement that referral access to specialist mental health services is considerably delayed and
c) recourse to private therapy was sought in the meantime pending any referral and
d) there are resources that can be shared in the ‘waiting’ period then:
(1) there was a disconnect in communication between that private therapy service and the GP. They were not sharing directly potentially key information that may have influenced concerns and decisions as to Mr McEwan’s welfare and safety;
(2) there was evidence of regard to specific mental health approach and self help by the GP but it was stated that there were other approaches and in particular that a significant number of Health Trusts and CCGs reportedly subscribe to one known as “Zero Suicide Alliance”;
(3) that there was no other guidance specifically to particular self help therapies that might be free of charge (or covered by the CCG if not), nor to online training package(s) for lay people supporting others experiencing suicidal crisis ;
(4) there might have been more exploration of potential support by and working with the patient’s family to the intent that mental health ‘scaffolding’ was in place when no other professional help might be immediately 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 exploration of family support to provide mental health scaffolding during delays in professional help
Wider context from the report “Within the contexts of
a) Primary Care and
b) acknowledgement that referral access to specialist mental health services is considerably delayed and
c) recourse to private therapy was sought in the meantime pending any referral and
d) there are resources that can be shared in the ‘waiting’ period then:
(1) there was a disconnect in communication between that private therapy service and the GP. They were not sharing directly potentially key information that may have influenced concerns and decisions as to Mr McEwan’s welfare and safety;
(2) there was evidence of regard to specific mental health approach and self help by the GP but it was stated that there were other approaches and in particular that a significant number of Health Trusts and CCGs reportedly subscribe to one known as “Zero Suicide Alliance”;
(3) that there was no other guidance specifically to particular self help therapies that might be free of charge (or covered by the CCG if not), nor to online training package(s) for lay people supporting others experiencing suicidal crisis;
(4) there might have been more exploration of potential support by and working with the patient’s family to the intent that mental health ‘scaffolding’ was in place when no other professional help might be immediately 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 Failure to share potentially key welfare and safety information between private therapy services and primary care
Wider context from the report “Within the contexts of
a) Primary Care and
b) acknowledgement that referral access to specialist mental health services is considerably delayed and
c) recourse to private therapy was sought in the meantime pending any referral and
d) there are resources that can be shared in the ‘waiting’ period then:
(1) there was a disconnect in communication between that private therapy service and the GP. They were not sharing directly potentially key information that may have influenced concerns and decisions as to Mr McEwan’s welfare and safety ;
(2) there was evidence of regard to specific mental health approach and self help by the GP but it was stated that there were other approaches and in particular that a significant number of Health Trusts and CCGs reportedly subscribe to one known as “Zero Suicide Alliance”;
(3) that there was no other guidance specifically to particular self help therapies that might be free of charge (or covered by the CCG if not), nor to online training package(s) for lay people supporting others experiencing suicidal crisis;
(4) there might have been more exploration of potential support by and working with the patient’s family to the intent that mental health ‘scaffolding’ was in place when no other professional help might be immediately available
” Open source report
7 Aug 2018 Mr. Steven John Welch · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 4 Lack of employed interventional radiologists to provide tertiary support View source Lack of software enabling electronic transfer of radiology for external review and consultation View source Failure to provide rapid A&E review for head injury patients with reducing or fluctuating Glasgow Coma Scores View source Delays in transferring patients to hospitals or specialist centres providing neurosurgical diagnosis and treatment View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr. Steven John Welch · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr. Steven John Welch was found at home on 26 December 2017 after a reported fall and head injury, and was later diagnosed with a subarachnoid haemorrhage, hydrocephalus and an aneurysm. His condition deteriorated during delays in assessment, neurosurgical admission and transfer of radiology images for specialist review; he was transferred to Southmead Hospital but died from a pulmonary embolism, with deep vein thrombosis and subarachnoid haemorrhage also recorded in the medical cause of death. The principal concerns included delayed emergency assessment and neurosurgical treatment, lack of interventionist radiology cover, and inadequate facilities for transferring radiological images to hospitals outside Wales.
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 employed interventional radiologists to provide tertiary support
Wider context from the report “At inquest, the errors in assessing the urgency of the need for medical assistance and the delay in providing that assistance were considered unlikely to have contributed to Steven Welch’s death. However, it was acknowledged that such errors could cause or contribute to the death of others where a subarachnoid haemorrhage had been sustained and for this reason, the Cwm Taf University Health Board is invited through this Regulation 28 to consider the following:
i) Provision of rapid A&E review of a patient with a reported head injury and reducing or fluctuating Glasgow Coma Score even at times of public holidays;
ii) Rapid transfer to a hospital or specialist centre providing neurosurgical diagnosis and treatment when such facilities are unavailable within the admitting hospital;
iii) Failure by the Cardiff and Vale University Local Health Board to have any interventionist radiologists in employment at the time thereby failing to provide tertiary support to the RGH and necessitating its patients to be sent out of area to England for treatment with inevitable delay;
iv) Failure by the Cwm Taf Health Board and Vale University Local Health Board to have computer software in place to enable electronic transfer of radiology to hospitals and specialist centres out of Wales for review and consultation.
” Open source report × Source evidence
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 software enabling electronic transfer of radiology for external review and consultation
Wider context from the report “At inquest, the errors in assessing the urgency of the need for medical assistance and the delay in providing that assistance were considered unlikely to have contributed to Steven Welch’s death. However, it was acknowledged that such errors could cause or contribute to the death of others where a subarachnoid haemorrhage had been sustained and for this reason, the Cwm Taf University Health Board is invited through this Regulation 28 to consider the following:
i) Provision of rapid A&E review of a patient with a reported head injury and reducing or fluctuating Glasgow Coma Score even at times of public holidays;
ii) Rapid transfer to a hospital or specialist centre providing neurosurgical diagnosis and treatment when such facilities are unavailable within the admitting hospital;
iii) Failure by the Cardiff and Vale University Local Health Board to have any interventionist radiologists in employment at the time thereby failing to provide tertiary support to the RGH and necessitating its patients to be sent out of area to England for treatment with inevitable delay;
iv) Failure by the Cwm Taf Health Board and Vale University Local Health Board to have computer software in place to enable electronic transfer of radiology to hospitals and specialist centres out of Wales for review and consultation .
” Open source report × Source evidence
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 provide rapid A&E review for head injury patients with reducing or fluctuating Glasgow Coma Scores
Wider context from the report “At inquest, the errors in assessing the urgency of the need for medical assistance and the delay in providing that assistance were considered unlikely to have contributed to Steven Welch’s death. However, it was acknowledged that such errors could cause or contribute to the death of others where a subarachnoid haemorrhage had been sustained and for this reason, the Cwm Taf University Health Board is invited through this Regulation 28 to consider the following:
i) Provision of rapid A&E review of a patient with a reported head injury and reducing or fluctuating Glasgow Coma Score even at times of public holidays ;
ii) Rapid transfer to a hospital or specialist centre providing neurosurgical diagnosis and treatment when such facilities are unavailable within the admitting hospital;
iii) Failure by the Cardiff and Vale University Local Health Board to have any interventionist radiologists in employment at the time thereby failing to provide tertiary support to the RGH and necessitating its patients to be sent out of area to England for treatment with inevitable delay;
iv) Failure by the Cwm Taf Health Board and Vale University Local Health Board to have computer software in place to enable electronic transfer of radiology to hospitals and specialist centres out of Wales for review and consultation.
” Open source report × Source evidence
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 transferring patients to hospitals or specialist centres providing neurosurgical diagnosis and treatment
Wider context from the report “At inquest, the errors in assessing the urgency of the need for medical assistance and the delay in providing that assistance were considered unlikely to have contributed to Steven Welch’s death. However, it was acknowledged that such errors could cause or contribute to the death of others where a subarachnoid haemorrhage had been sustained and for this reason, the Cwm Taf University Health Board is invited through this Regulation 28 to consider the following:
i) Provision of rapid A&E review of a patient with a reported head injury and reducing or fluctuating Glasgow Coma Score even at times of public holidays;
ii) Rapid transfer to a hospital or specialist centre providing neurosurgical diagnosis and treatment when such facilities are unavailable within the admitting hospital ;
iii) Failure by the Cardiff and Vale University Local Health Board to have any interventionist radiologists in employment at the time thereby failing to provide tertiary support to the RGH and necessitating its patients to be sent out of area to England for treatment with inevitable delay;
iv) Failure by the Cwm Taf Health Board and Vale University Local Health Board to have computer software in place to enable electronic transfer of radiology to hospitals and specialist centres out of Wales for review and consultation.
” Open source report
Concerns raised 7 Failure of the HTT to obtain a written discharge plan from the hospital View source Failure to liaise with the HTT before discharge View source Failure to formulate a written discharge plan identifying the responsible community HTT View source Failure of the HTT to establish the patient's consent to contact a support person View source Failure to identify a responsible HTT for the discharge address View source Failure to inform the relevant HTT of consent to contact support persons View source Failure to contact consented friends and relatives regarding community support 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
Anne Morris · 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
Anne Morris died by suicide after hanging herself while alone in a friend’s house on 26 June 2017. The principal concerns were that the Priory Hospital did not contact consented friends or relatives, did not establish a written discharge and follow-up plan, and did not liaise adequately with the relevant Oxleas Home Treatment Team before discharge. Concerns were also raised that the Oxleas team did not obtain a discharge plan or know that Anne had agreed to contact with a friend regarding community support and suicide risk.
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 the HTT to obtain a written discharge plan from the hospital
Wider context from the report “(4) The Oxleas HTT do not appear to have proactively contacted the Priory Hospital for a written discharge plan prior to, or at the time, of the home visit on the 25/6/17. Had the HTT made contact with the Priory Hospital it would still have been possible to formulate a plan (including the availability of collateral assistance from Messrs ████████).
” Open source report × Source evidence
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 liaise with the HTT before discharge
Wider context from the report “(3) The Priory Hospital did not identify a responsible HTT for the discharge address in Eltham and there was no liaison with an HTT prior to discharge .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to formulate a written discharge plan identifying the responsible community HTT
Wider context from the report “(2) The Priory Hospital did not formulate a written plan, before discharge from hospital, identifying the HTT who would be responsible for onward care in the community and, in particular making the relevant HTT aware that Anne was agreeable to health care professionals speaking to Peter Forester and Bernard Bakes regarding support with her mental health issues.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure of the HTT to establish the patient's consent to contact a support person
Wider context from the report “(5) The Oxleas HTT do not appear to have been aware of Anne’s willingness for mental health professionals to contact her friend ████████ regarding community support with her suicide risk . Had Oxleas HTT proactively made contact with the Priory Hospital they could have been made aware of this arrangement.
” Open source report × Source evidence
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 a responsible HTT for the discharge address
Wider context from the report “(3) The Priory Hospital did not identify a responsible HTT for the discharge address in Eltham and there was no liaison with an HTT prior to discharge.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the relevant HTT of consent to contact support persons
Wider context from the report “(2) The Priory Hospital did not formulate a written plan, before discharge from hospital, identifying the HTT who would be responsible for onward care in the community and, in particular making the relevant HTT aware that Anne was agreeable to health care professionals speaking to Peter Forester and Bernard Bakes regarding support with her mental health issues .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to contact consented friends and relatives regarding community support
Wider context from the report “(1) I am concerned that the staff at the Priory Hospital did not make contact with friends and relatives after Anne had consented to them being contacted .
” Open source report
Concerns raised 2 Failure to accurately triage emergency calls View source Insufficient resources for timely emergency response 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
Reginald Dixon · 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
Reginald Dixon, a 70-year-old man, suffered an unwitnessed fall downstairs on 26 June 2017, sustaining multiple injuries including a severe head injury. He was taken to hospital after a 57-minute delay from the original emergency call and died the same day. Concerns included the incorrect triage of a later call and insufficient ambulance resources contributing to delays in response times.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately triage emergency calls
Wider context from the report “1. Firstly, evidence emerged during the inquest that the second call received by the WMAS operator at 1921 hours had been incorrectly triaged as Level 3 . The evidence of vomiting and drowsiness should have resulted in a Level 2 categorisation and therefore faster response time.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Insufficient resources for timely emergency response
Wider context from the report “2. Evidence also emerged during the inquest that there were insufficient resources available and average response times of 29 minutes . This delay posed a risk to patients .
” Open source report
Concerns raised 4 Failure to incorporate relevant information into discharge assessment View source Failure to communicate relapse warning signs to family View source Failure to make formal post-discharge referral or contact with community mental health services and general practitioner View source Lack of post-discharge community aftercare 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
Melvin James and Anne-Marie James · 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
Melvin James experienced psychotic symptoms, was admitted to hospital, and was discharged without planned psychiatric follow-up. On 8 March 2017, he fatally stabbed his sister, Anne-Marie James, injured his mother, and sustained fatal stab wounds himself. The principal concerns were missed communication about his continuing delusions, inadequate information-sharing with family, and the absence of formal referral or aftercare following discharge.
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 incorporate relevant information into discharge assessment
Wider context from the report “1. Evidence emerged during the inquest that by the time of his discharge on Friday 10th February 2017 and as far as the Hospital were concerned, they recorded he showed no evidence of mental illness . However, the Clinician who dealt with the discharge confirmed that he wasn’t aware of the conversation he had with his brother on the way to Wolverhampton where Mr James was still talking about his delusions including creatures transforming. Significantly, during the inquest he accepted, had he known this he would have formed the view that he was still unwell .
” Open source report × Source evidence
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 relapse warning signs to family
Wider context from the report “2. He also accepted that there was a missed opportunity in communication and information sharing and it was regrettable they didn’t speak to the family and explain what symptoms to look out for in case of relapse .
” Open source report × Source evidence
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 make formal post-discharge referral or contact with community mental health services and general practitioner
Wider context from the report “3. Evidence also emerged during the inquest that after discharge, there was no formal referral or contact made with Mental Health services or his General Practitioner based in the Wolverhampton area . There was no evidence of any aftercare being delivered after discharge back into the community.
” Open source report × Source evidence
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 post-discharge community aftercare
Wider context from the report “3. Evidence also emerged during the inquest that after discharge, there was no formal referral or contact made with Mental Health services or his General Practitioner based in the Wolverhampton area. There was no evidence of any aftercare being delivered after discharge back into the community .
” Open source report
Concerns raised 2 Failure by radiologists to assess scans for findings requiring further investigation View source Failure to note fractures on X-rays during admission 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
Dorothy Webb · 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
Dorothy Webb’s health declined amid falls, suspected neurological events, hyponatraemia and subsequently identified small cell carcinoma of the right lung with liver metastases. She died shortly after aspirating vomited blood and gastric contents following episodes of coffee-ground vomiting. The report identified a missed opportunity to assess a CT scan showing a mass and a failure to note a fracture on an earlier x-ray.
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 by radiologists to assess scans for findings requiring further investigation
Wider context from the report “1. Evidence emerged during the inquest that there was a missed opportunity and failure by the Radiologist to assess the scan which would have resulted in further investigation of the “mass” that was identified . Although this may not, on the balance of probability prevented the outcome, it may well have resulted in further medical investigation and treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Failure to note fractures on X-rays during admission
Wider context from the report “2. There was also a failure to note a fracture from the x-ray during the admission in February 2017 and consequently the patient and family were unaware of its existence until the re-admission in April 2017.
” Open source report
Concerns raised 2 Lack of fencing or other appropriate measures to mitigate lake swimming risks View source Lack of adequate warning notices about the risks of swimming in the lake 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
Spencer Lloyd Hurst · 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
On the evening of 20 June 2017, 15-year-old Spencer Lloyd Hurst went into a lake with friends, got into trouble while swimming, and went below the surface. His body was recovered by emergency services shortly afterwards and he was pronounced deceased. Concerns included the absence of adequate warnings, fencing, or other measures to mitigate the risks of swimming, despite a similar death at the same location in 2007.
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 fencing or other appropriate measures to mitigate lake swimming risks
Wider context from the report “1. Evidence emerged during the investigation and pre-inquest hearing review that another young male had died in very similar circumstances at the same location on the 11 June 2007.
2. Despite this being the second death, evidence emerged that there have been no adequate notices displayed to warn of the risks of swimming in the lake and no evidence of any fencing or appropriate measures taken to mitigate the risks .
” Open source report × Source evidence
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 adequate warning notices about the risks of swimming in the lake
Wider context from the report “1. Evidence emerged during the investigation and pre-inquest hearing review that another young male had died in very similar circumstances at the same location on the 11 June 2007.
2. Despite this being the second death, evidence emerged that there have been no adequate notices displayed to warn of the risks of swimming in the lake and no evidence of any fencing or appropriate measures taken to mitigate the risks.
” Open source report
Concerns raised 2 Inadequate staff training to recognise emergency situations View source Reliance on presumptions when assessing unresponsive patients in serious situations 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
Maureen Ann Colclough · 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
Maureen Ann Colclough was found unresponsive at home on 16 December 2016 and was later confirmed deceased by paramedics. The report states that she was likely in a comatose state and that earlier medical intervention could have saved her. The principal concerns were inadequate staff training to recognise an emergency and reliance on presumptions when finding an unresponsive patient in a serious situation.
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 staff training to recognise emergency situations
Wider context from the report “1. Inadequate training of staff to recognise emergency situation .
” Open source report × Source evidence
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 Reliance on presumptions when assessing unresponsive patients in serious situations
Wider context from the report “2. Relying on presumptions when finding an unresponsive patient in a serious situation .
” Open source report
26 Jul 2017 KENNETH JOHN SWIFT · Prevention of Future Deaths report York City
View report summary
Concerns raised 1 Unavailability of falls sensors for patients assessed at risk of falls 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
KENNETH JOHN SWIFT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kenneth John Swift was admitted to York Hospital with community acquired pneumonia and, while assessed as being at risk of falls, fell unaccompanied on 21 April 2017 and fractured his neck of femur. He died in hospital on 28 April 2017. The principal concern was that no falls sensor was immediately available despite his assessed risk and attempts to mobilise without supervision, raising concerns about the potential for similar fall-related harm to other patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Chief Coroner; that does not assign responsibility.
PFD Monitor interpretation Unavailability of falls sensors for patients assessed at risk of falls
Wider context from the report “(1) Although assessed as being at risk of falls and despite being positioned in a bay that was close to the Nurses’ Station in the Ward for better observation, Mr Swift was also recommended to have a falls sensor as he was observed by occupational therapist and physiotherapist trying to mobilise without supervision despite advice not to do so.
(2) It was said in evidence that:
No falls sensor was immediately available- Mr Swift was put on a ‘waiting list’ of 34 existing patients needing such equipment.
The cost of a chair sensor was said to be £60; of a bed sensor £90. The Hospital was said to be in a tendering process to acquire such equipment.
In the relevant Ward (AMU/AMB) 95% of the usual 30 patients (when full) at any one time would have been assessed at risk of falls.
Four sensors have been acquired since Mr Swift’s death for use at the present time in that Ward.
(3) Such a mechanism may have made staff aware that Mr Swift, an elderly man known to be capable of confusion and already suffering from infection that could be aggravated by immobility if injured, was mobilising unsupervised.
(4) That in this Ward at least there is the potential for future deaths resulting from, or the aggravation of, conditions by the consequences of falls in other patients.
” Open source report
Concerns raised 2 Failure to take previous abnormal ECG results into account during paramedic handover View source Failure to record and endorse the reviewing doctor’s name on ECGs 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
Mrs Sarah Poole · 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 Sarah Poole was admitted to hospital with sudden headache and back pain, but an abnormal ECG was incorrectly considered normal and she was discharged home. She was readmitted the following day, diagnosed with an aortic dissection and underwent emergency surgery, but developed complications and died on 5 November 2016. The principal concern was a failure to record and endorse the reviewing doctor’s name and to consider previous abnormal ECG results during handover.
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 take previous abnormal ECG results into account during paramedic handover
Wider context from the report “1. Evidence emerged during the inquest that there were failures to record and endorse the name of the Doctor reviewing the ECG and a failure to take into account previous abnormal ECG results during the handover from the paramedic staff .
” Open source report × Source evidence
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 endorse the reviewing doctor’s name on ECGs
Wider context from the report “1. Evidence emerged during the inquest that there were failures to record and endorse the name of the Doctor reviewing the ECG and a failure to take into account previous abnormal ECG results during the handover from the paramedic staff.
” Open source report
Concerns raised 3 Failure to conduct scheduled neuro observations View source Failure to accurately calculate NEWS scores and trigger required medical review View source Failure to continue NEWS observations 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
Clive Davies · 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
Clive Davies, who was generally in poor health and had a history of falls, fell down the stairs at home on 22 August 2016 and sustained serious head and neck injuries. He died in hospital on 30 August 2016; concerns included failures in routine NEWS and neurological observations, including an incorrectly calculated NEWS score and missed observations.
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 conduct scheduled neuro observations
Wider context from the report “(1) The evidence revealed that there were generalised failures in relation to routine observations conducted upon Mr Davies – both NEWS observations and “neuro” observations . On the 29th August neuro observations were performed at 0600 hours but were then supposed to be conducted every 4 hours but were not at 10AM 2PM 6PM and 10PM . The final neuro observation was conducted at 11PM and no explanation could be found as to why this had not happened. The last NEWS score was conducted at 1745 on the 29th August but not thereafter. Upon review it appeared that that NEWS score which was undertaken was incorrectly calculated meaning that he was not subject to a medical review when clearly he should have been. It was accepted at the inquest that this was a failure for which no explanation was forthcoming.
” Open source report × Source evidence
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 accurately calculate NEWS scores and trigger required medical review
Wider context from the report “(1) The evidence revealed that there were generalised failures in relation to routine observations conducted upon Mr Davies – both NEWS observations and “neuro” observations. On the 29th August neuro observations were performed at 0600 hours but were then supposed to be conducted every 4 hours but were not at 10AM 2PM 6PM and 10PM. The final neuro observation was conducted at 11PM and no explanation could be found as to why this had not happened. The last NEWS score was conducted at 1745 on the 29th August but not thereafter. Upon review it appeared that that NEWS score which was undertaken was incorrectly calculated meaning that he was not subject to a medical review when clearly he should have been . It was accepted at the inquest that this was a failure for which no explanation was forthcoming.
” Open source report × Source evidence
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 continue NEWS observations
Wider context from the report “(1) The evidence revealed that there were generalised failures in relation to routine observations conducted upon Mr Davies – both NEWS observations and “neuro” observations. On the 29th August neuro observations were performed at 0600 hours but were then supposed to be conducted every 4 hours but were not at 10AM 2PM 6PM and 10PM. The final neuro observation was conducted at 11PM and no explanation could be found as to why this had not happened. The last NEWS score was conducted at 1745 on the 29th August but not thereafter . Upon review it appeared that that NEWS score which was undertaken was incorrectly calculated meaning that he was not subject to a medical review when clearly he should have been. It was accepted at the inquest that this was a failure for which no explanation was forthcoming.
” Open source report
Concerns raised 6 Failure to comprehensively assess and record falls risk and implement a clear care plan View source Failure to ensure trained staff carry out neuro observations in line with policy View source Failure of qualified nurse oversight to identify omitted neuro observations View source Failure to complete all components of neuro observations at the required frequency View source Insufficient ward staffing to manage care demands View source Failure to provide indicated continuous 1:1 supervision for a high falls-risk patient View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Maurice ISAACS · 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
Maurice ISAACS, who had dementia and other chronic health conditions, was admitted to hospital after deteriorating and suffered multiple falls. He fell from his bed on 12 June 2016, sustained a head injury and died two days later. Concerns included shortcomings in falls-risk assessment, care planning and supervision, as well as failures in carrying out and overseeing neurological observations after the final fall.
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 comprehensively assess and record falls risk and implement a clear care plan
Wider context from the report “(1) The investigation into his death revealed shortcomings in the way in which his risk of falls were assessed and recorded . For example, no clear care plan was introduced until after the fourth fall . Although there were some occasions when he was given 1:1 care that was not consistent and despite the increasing number of falls, he was never given true 1:1 supervision / observation. Despite the medical notes showing that this should have been in place at the time of his final fall, the reality on the ward was that he was being observed by a nurse on a 1:4 basis. Despite the ward being staffed to "agreed staffing levels" the evidence showed that on the ground, on occasions, this was simply not enough staff to manage the demands of the ward.
His condition was so variable and unpredictable, and against a background of so many falls, 1:1 care was indicated. The evidence showed that whilst there was a review of his situation after each fall, a more 'holistic' approach, recognising the dangers posed by his unpredictable behaviour, and the causes of that , might have prevented so many 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 ensure trained staff carry out neuro observations in line with policy
Wider context from the report “(2) After the final fall, shortcomings were identified in the way that the standard "Neuro Observations" were carried out. They were not carried out in line with Trust Policy . They were conducted by a Health Care Assistant, who had not been trained and who failed to conduct one part of the test for a period of six hours. The omission was not spotted by the qualified nurse whose duty it was to oversee the work of the Healthcare Assistant.
” Open source report × Source evidence
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 qualified nurse oversight to identify omitted neuro observations
Wider context from the report “(2) After the final fall, shortcomings were identified in the way that the standard "Neuro Observations" were carried out. They were not carried out in line with Trust Policy. They were conducted by a Health Care Assistant, who had not been trained and who failed to conduct one part of the test for a period of six hours. The omission was not spotted by the qualified nurse whose duty it was to oversee the work of the Healthcare Assistant .
” Open source report × Source evidence
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 all components of neuro observations at the required frequency
Wider context from the report “(2) After the final fall, shortcomings were identified in the way that the standard "Neuro Observations" were carried out. They were not carried out in line with Trust Policy. They were conducted by a Health Care Assistant, who had not been trained and who failed to conduct one part of the test for a period of six hours . The omission was not spotted by the qualified nurse whose duty it was to oversee the work of the Healthcare Assistant.
” Open source report × Source evidence
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 ward staffing to manage care demands
Wider context from the report “(1) The investigation into his death revealed shortcomings in the way in which his risk of falls were assessed and recorded. For example, no clear care plan was introduced until after the fourth fall. Although there were some occasions when he was given 1:1 care that was not consistent and despite the increasing number of falls, he was never given true 1:1 supervision / observation. Despite the medical notes showing that this should have been in place at the time of his final fall, the reality on the ward was that he was being observed by a nurse on a 1:4 basis. Despite the ward being staffed to "agreed staffing levels" the evidence showed that on the ground, on occasions, this was simply not enough staff to manage the demands of the ward .
His condition was so variable and unpredictable, and against a background of so many falls, 1:1 care was indicated. The evidence showed that whilst there was a review of his situation after each fall, a more 'holistic' approach, recognising the dangers posed by his unpredictable behaviour, and the causes of that, might have prevented so many 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 provide indicated continuous 1:1 supervision for a high falls-risk patient
Wider context from the report “(1) The investigation into his death revealed shortcomings in the way in which his risk of falls were assessed and recorded. For example, no clear care plan was introduced until after the fourth fall. Although there were some occasions when he was given 1:1 care that was not consistent and despite the increasing number of falls, he was never given true 1:1 supervision / observation . Despite the medical notes showing that this should have been in place at the time of his final fall, the reality on the ward was that he was being observed by a nurse on a 1:4 basis . Despite the ward being staffed to "agreed staffing levels" the evidence showed that on the ground, on occasions, this was simply not enough staff to manage the demands of the ward.
His condition was so variable and unpredictable, and against a background of so many falls, 1:1 care was indicated . The evidence showed that whilst there was a review of his situation after each fall, a more 'holistic' approach, recognising the dangers posed by his unpredictable behaviour, and the causes of that, might have prevented so many falls.
” Open source report
Concerns raised 2 Lack of a legal requirement for riders of this class of vehicle to wear seatbelts View source Lack of a legal requirement for riders of this class of vehicle to wear protective helmets 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
Colin George Wellings · 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
Colin George Wellings was riding a domestically constructed three-wheeled motorised trike when he lost control entering a mini island, was thrown from it and died at the scene from serious head and other injuries. The concerns were that this class of vehicle was exempt from seatbelt and helmet requirements and that legislation should be considered to bring such vehicles in line with other mainstream mechanically propelled vehicles.
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 legal requirement for riders of this class of vehicle to wear seatbelts
Wider context from the report “(1) The machine that the deceased was riding was a domestically manufactured machine with a 3.5 litre engine registered in 1973 and as such was exempt from the requirement for the driver/rider to wear either a seatbelt or a protective helmet .
(2) Given the inherent risk that this vehicle, and others like it, pose, not only to their riders, but to other road users, consideration should be given to legislation to ensure that this class of vehicle is brought in line with other mainstream mechanically propelled vehicles by amendment to the Road Traffic Act and the Construction and Use Regulations.
” Open source report × Source evidence
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 legal requirement for riders of this class of vehicle to wear protective helmets
Wider context from the report “(1) The machine that the deceased was riding was a domestically manufactured machine with a 3.5 litre engine registered in 1973 and as such was exempt from the requirement for the driver/rider to wear either a seatbelt or a protective helmet .
(2) Given the inherent risk that this vehicle, and others like it, pose, not only to their riders, but to other road users, consideration should be given to legislation to ensure that this class of vehicle is brought in line with other mainstream mechanically propelled vehicles by amendment to the Road Traffic Act and the Construction and Use Regulations.
” 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