21 Nov 2013 Jack William PARTINGTON · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 8 Lack of national standardised guidance on the management of ventilation in neonates View source Failure to routinely check medical records for new neonatal admissions View source Failure to routinely use disposable exhaled carbon dioxide detectors on the NNU View source Failure to ensure effective oversight and monitoring of the ventilatory pressure dial following intubation View source Lack of national standardised guidance on the management and administration of paralysing agents to neonates needing intubation View source Failure to make treatment decisions collaboratively and using all available information View source Lack of individualised neonatal nursing care plans View source Failure to provide 1:1 neonatal nurse/cotside handover at shift change 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.
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AI-generated summary
Jack William PARTINGTON · 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
Jack Partington was born by planned caesarean section on 25 November 2011 and developed breathing difficulties requiring neonatal ventilation. After developing a pneumothorax, he was treated with intubation and ventilation but deteriorated and died on 26 November 2011. Concerns included gaps in neonatal handover and care planning, treatment decisions made without multidisciplinary consultation, lack of routine use of exhaled carbon dioxide detectors, absence of national guidance on paralysing agents and neonatal ventilation, and inadequate monitoring of ventilatory pressure after intubation.
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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of national standardised guidance on the management of ventilation in neonates
Wider context from the report “4) There are no national standardised policies, protocols or guidance on the management and administration of paralysing agents to neonates in need of intubation and/or the management of ventilation in neonates .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely check medical records for new neonatal admissions
Wider context from the report “1) That there was no 1:1 neonatal nurse/cotside ‘handover’ at shift change, no individualised neonatal nursing care plan in use and no routine checks of medical records for new neonatal admissions .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely use disposable exhaled carbon dioxide detectors on the NNU
Wider context from the report “3) That disposable exhaled carbon dioxide detectors (ET CO2) were not routinely used on the NNU (as an adjunct) and that they are not currently/routinely used in many NNUs throughout the country.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure effective oversight and monitoring of the ventilatory pressure dial following intubation
Wider context from the report “5) No single individual within the neonatal (resuscitation) team was allocated to oversee and monitor the ventilatory pressure dial following intubation. The dial in question was situated on the side of the incubator/cot, out of the direct line of sight of the clinician controlling the airway/ventilatory process.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of national standardised guidance on the management and administration of paralysing agents to neonates needing intubation
Wider context from the report “4) There are no national standardised policies, protocols or guidance on the management and administration of paralysing agents to neonates in need of intubation and/or the management of ventilation in neonates.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make treatment decisions collaboratively and using all available information
Wider context from the report “2) Nursing staff, rather than the multi-disciplinary team plus parents, took treatment/change of treatment decisions in isolation and without consulting all available information (such as medical records etc.)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of individualised neonatal nursing care plans
Wider context from the report “1) That there was no 1:1 neonatal nurse/cotside ‘handover’ at shift change, no individualised neonatal nursing care plan in use and no routine checks of medical records for new neonatal admissions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide 1:1 neonatal nurse/cotside handover at shift change
Wider context from the report “1) That there was no 1:1 neonatal nurse/cotside ‘handover’ at shift change , no individualised neonatal nursing care plan in use and no routine checks of medical records for new neonatal admissions.
” Open source report
7 Aug 2013 Jean Miller · Prevention of Future Deaths report Manchester (West)
View report summary
Concerns raised 5 Failure to involve tissue viability specialists when needed View source Poor communication by district nursing teams with GPs View source Poor record keeping by district nursing teams View source Lack of baseline assessments by district nursing teams View source Lack of basic equipment for district nursing teams View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jean Miller · 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
Jean Miller was admitted for incisional hernia repair, discharged home under district nursing care, and later readmitted with a purulent wound discharge before dying in hospital on 24 January 2013. The report identified concerns about the district nursing team’s lack of baseline wound assessments, failure to involve tissue viability specialists, absence of thermometers, poor record keeping, and poor communication with 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve tissue viability specialists when needed
Wider context from the report “1. The quality of care offered by the district nursing team arising from poor practices being in place in particular a lack of baseline assessments and poor understanding of the need to involve tissue viability specialists in such cases as Mrs Miller’s
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor communication by district nursing teams with GPs
Wider context from the report “4. Poor communication by the District Nursing Team with the GP
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor record keeping by district nursing teams
Wider context from the report “3. Poor record keeping by the District Nursing Team
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of baseline assessments by district nursing teams
Wider context from the report “1. The quality of care offered by the district nursing team arising from poor practices being in place in particular a lack of baseline assessments and poor understanding of the need to involve tissue viability specialists in such cases as Mrs Miller’s
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of basic equipment for district nursing teams
Wider context from the report “2. The lack of basic equipment issued to the District Nursing Team in particular thermometers
” Open source report
30 Jan 2013 Gareth Mark Slater · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 13 Delays in completing and sending the discharge summary View source Failure to reassess ability to live independently View source Failure to involve family in discharge planning View source Lack of a discharge care plan View source Failure to carry out discharge planning View source Uninhabitable and inadequately maintained accommodation View source Lack of guidance on frequency of community contact View source Lack of a structured and considered care plan View source Failure to hold a Section 17 discharge planning meeting View source Failure to use extended leave to assess tenancy management View source Lack of planning for activities to structure daily living View source Lack of follow-up appointments at discharge View source Insufficient time for considered Community Treatment Order renewal View source See 10 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
Gareth Mark Slater · 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
Gareth Mark Slater, who had a history of bipolar affective disorder and had been discharged from hospital into his own accommodation, was found in the River Medlock on 31 March 2013 after apparently falling from Bardsley Bridge. The Inquest concluded that he died from drowning and multiple injuries, with bipolar affective disorder recorded as a contributing condition, and found no evidence of an intention to end his life. Concerns included inadequate discharge planning, lack of a care plan and follow-up arrangements, insufficient assessment of his ability to live independently, and poor preparation of his accommodation.
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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in completing and sending the discharge summary
Wider context from the report “8. The discharge summary was not dictated and sent to his new outpatient Consultant until the 18th February over three months from his discharge from hospital . There were no follow up appointments in place for Gareth at the time of 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reassess ability to live independently
Wider context from the report “3. There was no further assessment since 2011 of Gareth’s ability to live independently (as opposed to in supported accommodation which had failed).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve family in discharge planning
Wider context from the report “4. There was no attempt to involve Gareth’s family in the discharge of Gareth .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a discharge care plan
Wider context from the report “1. The discharge planning in relation to Mr Slater was overshadowed by the impasse in clinical opinion and the length of time it took to resolve this. No doubt because of the difficulties to resolve Gareth’s situation there was a failure to actually carry out the important task of discharge planning. No care plan was in place for Gareth, merely a recognition of the conditions of his Community Treatment Order .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out discharge planning
Wider context from the report “1. The discharge planning in relation to Mr Slater was overshadowed by the impasse in clinical opinion and the length of time it took to resolve this. No doubt because of the difficulties to resolve Gareth’s situation there was a failure to actually carry out the important task of discharge planning . No care plan was in place for Gareth, merely a recognition of the conditions of his Community Treatment Order.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Uninhabitable and inadequately maintained accommodation
Wider context from the report “6. On his discharge the flat was unfurnished, without carpets and he was not able to reside there . The condition of the flat at the time of Gareth’s death remained sparsely furnished with a large water leak in the kitchen .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on frequency of community contact
Wider context from the report “10. The lack of a structured and considered Care Plan meant that the only person having any contact with Gareth in the Community was his Care Co-Ordinator who had only been involved with Gareth since the 8th October 2012. There was no guidance to his Care Co-Ordinator as to how often should be seen .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a structured and considered care plan
Wider context from the report “10. The lack of a structured and considered Care Plan meant that the only person having any contact with Gareth in the Community was his Care Co-Ordinator who had only been involved with Gareth since the 8th October 2012. There was no guidance to his Care Co-Ordinator as to how often should be seen.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to hold a Section 17 discharge planning meeting
Wider context from the report “2. There was no Section 17 discharge planning meeting .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use extended leave to assess tenancy management
Wider context from the report “5. There was no use of extended periods of leave for Gareth to assess his ability to manage his tenancy .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of planning for activities to structure daily living
Wider context from the report “7. There was no planning as to requirements Gareth may need or could be considered to help structure his day i.e. activities, etc.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of follow-up appointments at discharge
Wider context from the report “8. The discharge summary was not dictated and sent to his new outpatient Consultant until the 18th February over three months from his discharge from hospital. There were no follow up appointments in place for Gareth at the time of 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 Pennine Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient time for considered Community Treatment Order renewal
Wider context from the report “9. The renewal of his Community Treatment Order was rushed , a piece of work which would normally take weeks to carry out was given to an Approved Mental Health Practitioner on the Friday afternoon before Gareth’s appointment at 10am on the Monday morning, meaning that she had just over an hour to consider the suitability of the CTO being renewed .
” 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