Concerns raised 4 Lack of national guidance for A&E clinicians on when to administer possible antidotes for toxic substances View source Failure to use Serious Incident Reviews and internal investigations to learn lessons from suicide cases View source Lack of national guidance and timely information for mental health practitioners about sodium nitrate/nitrite risks View source Failure to disseminate information about sodium nitrate/nitrite risks beyond immediately involved colleagues 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
JAMES MICHAEL NOWSHADI · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Michael Nowshadi died after ingesting a substance he had obtained online to end his life, suffering cardiac arrest and being pronounced dead on 1 April 2020. Concerns included insufficient national guidance and information-sharing about the risks of sodium nitrate/nitrite, missed opportunities for learning from the Serious Incident Review, and a lack of guidance for emergency clinicians on the use of methylene blue in cases involving cardiac arrest.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for A&E clinicians on when to administer possible antidotes for toxic substances
Wider context from the report “3. The inquest heard evidence from a senior Accident & Emergency doctor about the information available from the National Poisons Information Service to emergency departments who encounter patients who have ingested ████████. This included information about the potential availability of an antidote, ‘methylene blue’. However, there is apparently no national guidance about the appropriate use of the antidote in cases involving cardiac arrest and whether attempts should be made to administer it in such cases . I am concerned that there is a risk of future fatalities if A&E clinicians do not have access to comprehensive and up-to-date information about toxic substances and their possible antidotes to know when – and when not – to administer 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to use Serious Incident Reviews and internal investigations to learn lessons from suicide cases
Wider context from the report “2. The family raised concerns about the risks of ████████ in suicides as part of the Serious Incident Review undertaken by the Trust but this section was omitted from the final report at the direction of the SIR review panel. This meant that there was a missed opportunity for the Trust to reflect on lessons that may properly be learned from James’ death, an omission which they now appear to be taking steps to remedy. However, I am concerned that there is a risk of future fatalities at a national level if Mental Health Trusts are not using Serious Incident Reviews and other internal investigations to learn lessons from suicide cases, including about the risks presented by sodium nitrate/nitrite .
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance and timely information for mental health practitioners about sodium nitrate/nitrite risks
Wider context from the report “1. There does not appear to be any national guidance available to psychiatrists and mental health practitioners dealing with possible ████████ cases . Those involved in James’ care made insufficient effort to research or evaluate the potential risks and consequences of James obtaining and using the ████████ to end his life and any information that was obtained from brief internet searches was not disseminated to colleagues beyond those immediately involved in James’ care only. I am concerned that there is a risk of future fatalities if mental health practitioners do not have ready access to timely and up-to-date information about the risks associated with sodium nitrate/nitrite .
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to disseminate information about sodium nitrate/nitrite risks beyond immediately involved colleagues
Wider context from the report “1. There does not appear to be any national guidance available to psychiatrists and mental health practitioners dealing with possible ████████ cases. Those involved in James’ care made insufficient effort to research or evaluate the potential risks and consequences of James obtaining and using the ████████ to end his life and any information that was obtained from brief internet searches was not disseminated to colleagues beyond those immediately involved in James’ care only . I am concerned that there is a risk of future fatalities if mental health practitioners do not have ready access to timely and up-to-date information about the risks associated with sodium nitrate/nitrite.
” Open source report
7 May 2021 Stacey Camille Alexander-Harriss · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Lack of public awareness of the need to seek urgent medical attention after a dog or cat bite when generally unwell with an underlying illness View source Lack of medical-profession awareness of Capnocytophagia canimorsus and associated high-risk medical conditions 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
Stacey Camille Alexander-Harriss · 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
Stacey Camille Alexander-Harriss was bitten by a dog on 15 June 2020, became unwell two days later, and was taken to hospital with suspected sepsis. She suffered a cardiac arrest in the early hours of 18 June 2020 and could not be resuscitated; a later blood culture identified Capnocytophagia canimorsus. The concerns included a knowledge gap among attending doctors about this organism and the risks associated with dog or cat bites, as well as a possible need for greater public awareness.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Lack of public awareness of the need to seek urgent medical attention after a dog or cat bite when generally unwell with an underlying illness
Wider context from the report “The evidence during the course of the Inquest gave rise to a concern as to a knowledge gap in relation to the organism Capnocytophagia canimorsus. The attending doctors were not familiar with this form of bacteria living within the mouths of dogs and cats and how easy it is to infect people with this organism. A severe traumatic injury is not required for infection to develop. This organism can cause an overwhelming infection in susceptible individuals. The Inquest heard that conditions such as type II diabetes and hepatic steatosis render the individual to a higher risk of serious infection. The inquest heard that raising awareness of this organism and the underlying high risk medical conditions within the medical profession, may prevent future deaths.
The Inquest also heard that there may be a need for greater public awareness in relation to the need to seek urgent medical attention if a person suffers from a relevant underlying illness and becomes generally unwell following a dog or cat bite .
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Lack of medical-profession awareness of Capnocytophagia canimorsus and associated high-risk medical conditions
Wider context from the report “The evidence during the course of the Inquest gave rise to a concern as to a knowledge gap in relation to the organism Capnocytophagia canimorsus . The attending doctors were not familiar with this form of bacteria living within the mouths of dogs and cats and how easy it is to infect people with this organism . A severe traumatic injury is not required for infection to develop. This organism can cause an overwhelming infection in susceptible individuals. The Inquest heard that conditions such as type II diabetes and hepatic steatosis render the individual to a higher risk of serious infection. The inquest heard that raising awareness of this organism and the underlying high risk medical conditions within the medical profession , may prevent future deaths.
The Inquest also heard that there may be a need for greater public awareness in relation to the need to seek urgent medical attention if a person suffers from a relevant underlying illness and becomes generally unwell following a dog or cat bite.
” Open source report
31 Mar 2021 Nicholas Hugh Winterton · Prevention of Future Deaths report City of London
View report summary
Concerns raised 3 Failure to ensure nationally consistent formulation of Mycobacterium Chimaera risk levels View source Failure to keep national Mycobacterium Chimaera risk guidance and web information updated View source Failure to capture the true incidence of Mycobacterium Chimaera infection View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Nicholas Hugh Winterton · 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
Nicholas Hugh Winterton developed Mycobacterium chimaera infection after aortic valve replacement surgery involving a heater-cooler unit in May 2016. The infection led to endocarditis, sepsis and multi-organ failure, and he died on 29 September 2018. The principal concerns were that the nationally reported infection risk was based on outdated and incomplete data, and that equipment use was not recorded and cleaning was performed less frequently than recommended by the manufacturer.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure nationally consistent formulation of Mycobacterium Chimaera risk levels
Wider context from the report “1. It is apparent that it is important that the nationally recognised level of the risk of developing Mycobacterium Chimaera from exposure to a heater cooler unit is accurate, in that it accurately reflects the most current statistical data, and is based on the best gathering of statistical data as to the true incidence of such infection as can practically be achieved. This is because the nationally recognised level of risk is the proper basis upon which –
(i) The informed consent of a patient for a relevant surgery is obtained, and
(ii) Post-operatively, the patient and the clinician(s) caring for him (including his General Practitioner) will base their “threshold for suspicion” for Mycobacterium Chimaera if the patient develops an infection which cannot quickly be identified and treated.
2. Public Health England, together with the National Institute for Cardiovascular Outcomes Research, the Society for Cardiothoracic Surgery, and the College of Clinical Perfusion Scientists, are the national bodies which are able to co-ordinate collation of relevant statistical evidence and then formulate and disseminate accurate information about the level of risk. It is inappropriate for individual hospitals, cardiac centres, or Trusts to formulate risk level on the basis of their own data as this would result, nationally, in the dissemination of inconsistent information.
3. Public Health England’s “Clinical guidance for secondary care” and “Information for general practice” are based on January 2017 data. Further, on its website, under the heading “Who could be at risk of Mycobacterium chimaera infection”, Public Health England currently states,
“People most at risk are those who’ve had heart valve surgery since January 2013. About 1 person in every 5,000 who has this type of surgery will develop the infection.”
This assessment is also based on data collated to January 2017.
4. The evidence at the inquest showed that the figure of “1 person in every 5,000” is inaccurate, in that :
(i) It is based on data from 2017 and not updated data, and
(ii) It is based on data which reflects only those patients who are reported to Public Health England as having died of Mycobacterium Chimaera infection, whereas the true incidence of the infection is very likely to be higher; the likelihood is that there is a potentially significant number of deaths from undiagnosed Mycobacterium Chimaera, given the patient cohort’s usual level of co-morbidities and clinicians’ low threshold of suspicion for this infection.
5. A more accurate assessment of the risk, and more accurate guidance, would therefore result from –
(i) An immediate review by Public Health England of all data held to date with a re-calculation of the incidence of Mycobacterium Chimaera infection and consequential risk being reflected in updated guidance and web-site information, and
(ii) Consideration being given by all the bodies to whom this Report is sent of whether there is a better investigative basis which could be used for obtaining relevant data and statistics as to the true incidence of Mycobacterium Chimaera infection, whether by means of a research study or otherwise.
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to keep national Mycobacterium Chimaera risk guidance and web information updated
Wider context from the report “1. It is apparent that it is important that the nationally recognised level of the risk of developing Mycobacterium Chimaera from exposure to a heater cooler unit is accurate, in that it accurately reflects the most current statistical data, and is based on the best gathering of statistical data as to the true incidence of such infection as can practically be achieved. This is because the nationally recognised level of risk is the proper basis upon which –
(i) The informed consent of a patient for a relevant surgery is obtained, and
(ii) Post-operatively, the patient and the clinician(s) caring for him (including his General Practitioner) will base their “threshold for suspicion” for Mycobacterium Chimaera if the patient develops an infection which cannot quickly be identified and treated.
2. Public Health England, together with the National Institute for Cardiovascular Outcomes Research, the Society for Cardiothoracic Surgery, and the College of Clinical Perfusion Scientists, are the national bodies which are able to co-ordinate collation of relevant statistical evidence and then formulate and disseminate accurate information about the level of risk. It is inappropriate for individual hospitals, cardiac centres, or Trusts to formulate risk level on the basis of their own data as this would result, nationally, in the dissemination of inconsistent information.
3. Public Health England’s “Clinical guidance for secondary care” and “Information for general practice” are based on January 2017 data. Further, on its website, under the heading “Who could be at risk of Mycobacterium chimaera infection”, Public Health England currently states,
“People most at risk are those who’ve had heart valve surgery since January 2013. About 1 person in every 5,000 who has this type of surgery will develop the infection.”
This assessment is also based on data collated to January 2017.
4. The evidence at the inquest showed that the figure of “1 person in every 5,000” is inaccurate, in that :
(i) It is based on data from 2017 and not updated data , and
(ii) It is based on data which reflects only those patients who are reported to Public Health England as having died of Mycobacterium Chimaera infection, whereas the true incidence of the infection is very likely to be higher; the likelihood is that there is a potentially significant number of deaths from undiagnosed Mycobacterium Chimaera, given the patient cohort’s usual level of co-morbidities and clinicians’ low threshold of suspicion for this infection.
5. A more accurate assessment of the risk, and more accurate guidance, would therefore result from –
(i) An immediate review by Public Health England of all data held to date with a re-calculation of the incidence of Mycobacterium Chimaera infection and consequential risk being reflected in updated guidance and web-site information, and
(ii) Consideration being given by all the bodies to whom this Report is sent of whether there is a better investigative basis which could be used for obtaining relevant data and statistics as to the true incidence of Mycobacterium Chimaera infection, whether by means of a research study or otherwise.
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to capture the true incidence of Mycobacterium Chimaera infection
Wider context from the report “1. It is apparent that it is important that the nationally recognised level of the risk of developing Mycobacterium Chimaera from exposure to a heater cooler unit is accurate, in that it accurately reflects the most current statistical data, and is based on the best gathering of statistical data as to the true incidence of such infection as can practically be achieved. This is because the nationally recognised level of risk is the proper basis upon which –
(i) The informed consent of a patient for a relevant surgery is obtained, and
(ii) Post-operatively, the patient and the clinician(s) caring for him (including his General Practitioner) will base their “threshold for suspicion” for Mycobacterium Chimaera if the patient develops an infection which cannot quickly be identified and treated.
2. Public Health England, together with the National Institute for Cardiovascular Outcomes Research, the Society for Cardiothoracic Surgery, and the College of Clinical Perfusion Scientists, are the national bodies which are able to co-ordinate collation of relevant statistical evidence and then formulate and disseminate accurate information about the level of risk. It is inappropriate for individual hospitals, cardiac centres, or Trusts to formulate risk level on the basis of their own data as this would result, nationally, in the dissemination of inconsistent information.
3. Public Health England’s “Clinical guidance for secondary care” and “Information for general practice” are based on January 2017 data. Further, on its website, under the heading “Who could be at risk of Mycobacterium chimaera infection”, Public Health England currently states,
“People most at risk are those who’ve had heart valve surgery since January 2013. About 1 person in every 5,000 who has this type of surgery will develop the infection.”
This assessment is also based on data collated to January 2017.
4. The evidence at the inquest showed that the figure of “1 person in every 5,000” is inaccurate, in that :
(i) It is based on data from 2017 and not updated data, and
(ii) It is based on data which reflects only those patients who are reported to Public Health England as having died of Mycobacterium Chimaera infection, whereas the true incidence of the infection is very likely to be higher ; the likelihood is that there is a potentially significant number of deaths from undiagnosed Mycobacterium Chimaera , given the patient cohort’s usual level of co-morbidities and clinicians’ low threshold of suspicion for this infection.
5. A more accurate assessment of the risk, and more accurate guidance, would therefore result from –
(i) An immediate review by Public Health England of all data held to date with a re-calculation of the incidence of Mycobacterium Chimaera infection and consequential risk being reflected in updated guidance and web-site information, and
(ii) Consideration being given by all the bodies to whom this Report is sent of whether there is a better investigative basis which could be used for obtaining relevant data and statistics as to the true incidence of Mycobacterium Chimaera infection, whether by means of a research study or otherwise.
” 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 Complete and submit an updated M. chimaera infection risk assessment for publication.
Verbatim wording from the response “updated risk assessment was undertaken by PHE in November 2019 and submitted to an international medical conference with a view to publication of an article in a medical journal. An extract from the conference abstract book is attached at Exhibit PHE1¹. The advent of the COVID-19 pandemic resulted in the cancellation of the conference and delayed completion of the publication.” Source location 2021-0204-Response-from-Public-Health-England-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Further update the risk estimates and publish them by September 2021.
Verbatim wording from the response “9) PHE will further update the risk estimates and ensure that these are published by September 2021. The respondent bodies will thereafter cascade these updated risk estimates to healthcare professionals involved in informing and consenting patients or investigating and diagnosing these infections, namely consultant microbiologists and cardiothoracic surgeons. This will be achieved through our respective clinical networks.” Source location 2021-0204-Response-from-Public-Health-England-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Cascade updated risk estimates through clinical networks to professionals informing or consenting patients and investigating or diagnosing infections.
Verbatim wording from the response “9) PHE will further update the risk estimates and ensure that these are published by September 2021. The respondent bodies will thereafter cascade these updated risk estimates to healthcare professionals involved in informing and consenting patients or investigating and diagnosing these infections, namely consultant microbiologists and cardiothoracic surgeons. This will be achieved through our respective clinical networks.” Source location 2021-0204-Response-from-Public-Health-England-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Forward requests to NHS England to agree responsibility and a timetable for updating healthcare guidance and NHS website information.
Verbatim wording from the response “12) Given the transfer of responsibility for management for the incident, we will forward this request for the further updating of guidance and to the need to update the NHS website to NHS England to agree responsibilities and a timetable for updating.” Source location 2021-0204-Response-from-Public-Health-England-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain surveillance capturing all potential M. chimaera cases and publish information on newly diagnosed cases and associated deaths.
Verbatim wording from the response “4) In responding to the potential threat posed by transmission of M. chimaera from contaminated heater cooler units (“HCUs”) used in open-heart surgery, PHE established a surveillance system to capture data on all cases (not just cases resulting in death) potentially arising as a result of open-heart surgery performed in the UK. PHE continues to collate and publish information on newly diagnosed cases and associated deaths. This can be found on:” Source location 2021-0204-Response-from-Public-Health-England-Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is responsible for updating guidance and the NHS website, so the requests will be forwarded to it.
Verbatim wording from the response “10) In relation to the updating of the guidance for healthcare providers, we would like to make the Coroner aware that NHS England assumed responsibility for management of the M. chimaera incident in October 2016. PHE and SCTS worked with NHS England to support the patient notification exercise launched in February 2017, including the development of guidance for healthcare providers.” Source location 2021-0204-Response-from-Public-Health-England-Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The risk estimate was not inaccurate because it measured infection risk using data on all reported cases, not only deaths.
Verbatim wording from the response “3) With regard to the concern in paragraph (1)(ii) above, we would like to clarify to the Coroner that these risk calculations were not based solely on risk of death but in fact based on risk of infection associated with this type of surgery, namely heart-valve surgery performed on bypass. As such, data collection was not restricted to patients reported to PHE as having died of Mycobacterium chimaera (M. chimaera) infection.” Source location 2021-0204-Response-from-Public-Health-England-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing surveillance provides a reasonable basis for ongoing risk monitoring, so a revised or alternative investigative method is unnecessary.
Verbatim wording from the response “7) With reference to paragraph (2)(ii) above and given that the current methodology includes surveillance data not just restricted to deaths, the respondent bodies believe the established mechanism provides a reasonable means for ongoing monitoring of risk and that a revised or alternative investigative basis is not required.” Source location 2021-0204-Response-from-Public-Health-England-Redacted
Open published response
9 Dec 2020 Leslie Harris · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Failure to provide clear and consistent guidance on movement of patients to wards where other patients are in isolation from Covid View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Leslie Harris · 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
Leslie Harris was admitted to Stepping Hill Hospital after an accidental fall, underwent surgery for a fractured hip, and later died after testing positive for Covid-19. The principal concern was that interpretation of Public Health England guidance led to his movement to a ward where patients were isolating from Covid-19, potentially exposing vulnerable inpatients to infection; the trust subsequently changed its policy.
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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear and consistent guidance on movement of patients to wards where other patients are in isolation from Covid
Wider context from the report “The inquest heard that he was moved to a ward where other patients were in isolation from Covid due to the interpretation of Public Health England guidance about management in these circumstances. As a result of reflection and concerns about interpreting the guidance in this way the trust have changed their policy and such movement no longer takes place. However, the guidance from PHE has not been amended and it was unknown how other trusts were choosing to interpret the guidance and as such putting potentially vulnerable patients at risk of developing Covid 19 whilst an in-patient .
” 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 Update and clarify infection-control guidance on isolating or cohorting exposed inpatients and using COVID-19 risk pathways.
Verbatim wording from the response “National Infection, Prevention and Control guidance is issued jointly by the four nations. PHE publishes this guidance. Guidance at the time contained information on infection control precautions, including cohorting of patients. This guidance was updated after the sad passing of Mr Harris. Updated versions of the guidance, with most recent updates on 20th August 2020 and 21st January 2021, provide advice on reducing the risk of COVID-19 transmission through use of high, medium and low risk COVID-19 risk pathways determined by risk assessment of individuals based on information including test status.” Source location 2020-0280-Response-from-Public-Health-England-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Further review the guidance to tighten wording and prevent misinterpretation of the advice.
Verbatim wording from the response “PHE will be further reviewing this guidance to ensure that wording is tightened to prevent any misinterpretation of the advice.” Source location 2020-0280-Response-from-Public-Health-England-Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Published guidance already contained clear segregation advice and had been updated to address COVID-19 transmission risks.
Verbatim wording from the response “This report states that Mr Harris died of COVID-19 pneumonia acquired whilst an inpatient at Stepping Hill Hospital, contributed to by the complications of an accidental fall. It outlines that the inquest heard that he was moved to a ward where other patients were in isolation from COVID-19 due to the interpretation of Public Health England guidance about management in these circumstances. As a result of reflection and concerns about interpreting the guidance in this way, the trust has changed their policy and such movement no longer takes place. It also states that the Public Health England guidance has not been amended and it was unknown how other trusts were choosing to interpret the guidance as such putting potentially vulnerable patients at risk of developing COVID-19 whilst an in-patient.” Source location 2020-0280-Response-from-Public-Health-England-Redacted
Open published response
1 Dec 2020 Anthony Slack · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Failure to maintain staff clarity about PPE requirements View source Limited documentation of care home staff observations View source Failure to share and implement changes to PPE guidance View source Lack of risk assessment for admission of new residents View source Failure to undertake observations of sufficient quality View source Insufficient ambulance availability for timely transport to an acute setting View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what this recipient says about the concern when it does not describe a specific action. 3
Position
Documentation, observations, vulnerability assessment, COVID-19 transmission, and ambulance delay were outside the respondent’s remit, control, and responsibility.
Outside remitThe respondent said that this matter was outside its role or authority. View source
Position
Established incident-response governance and communication cascades were used to disseminate PPE guidance updates to relevant health and social care partners.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Other named organisations, including the care home, regulators, NHS England, and the local partnership, were responsible for commenting on remaining concerns.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source See 2 more positions
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AI-generated summary
Anthony Slack · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Anthony Slack, who had underlying health issues including asbestos-related pulmonary fibrosis, suffered an unwitnessed fall at a care home and waited over four hours for an ambulance. He later deteriorated, was transferred to hospital, and died on 13 April 2020. Concerns included limited care-home documentation and observations, unclear Covid-19 admission risk assessment and PPE arrangements, and ambulance delays linked to pandemic-related capacity pressures.
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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain staff clarity about PPE requirements
Wider context from the report “4. Staff were unclear as to the PPE requirements as a result of changes to the guidance that were occurring on a regular basis and it was unclear how changes were being shared with staff and implemented.
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Limited documentation of care home staff observations
Wider context from the report “1. The documentation available at the inquest from the home was limited in detail . As a result, it was difficult to understand what observations had been undertaken by care home staff were monitoring him.
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to share and implement changes to PPE guidance
Wider context from the report “4. Staff were unclear as to the PPE requirements as a result of changes to the guidance that were occurring on a regular basis and it was unclear how changes were being shared with staff and implemented .
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Lack of risk assessment for admission of new residents
Wider context from the report “3. The inquest heard that after the home went into lockdown Covid 19 was found in residents within the home. At the inquest the home were unclear if staff had brought it into the home or if the admission of residents from the community who were not tested for Covid 19 before admission were the cause of the entering the home. There was no risk assessment in place relating to admission of new residents.
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake observations of sufficient quality
Wider context from the report “2. The evidence given at the inquest was that the observations were of limited quality notwithstanding the diagnosis of Covid 19 and his vulnerability.
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Insufficient ambulance availability for timely transport to an acute setting
Wider context from the report “5. The inquest heard that the ambulance was delayed due to shortages of available ambulances . The inquest was told this was driven by a number of factors. This included staff absences due to the need to self-isolate awaiting testing and the increased cleaning needs in relation to ambulances required by Covid 19. The inquest was told that at some points in the day and in some acute trusts, ambulance crews were being supported by on-site cleaning crews. This meant quicker turnaround times and increased capacity. This was not consistent and not on a 24/7 basis. As a result, ambulances were struggling to reach vulnerable and unwell members of the public and transport them to an acute setting .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate national PPE and other guidance changes through incident-response governance, regional email cascades and onward local-authority distribution to care homes.
Verbatim wording from the response “Communication of changes to all national guidance, including the use of PPE, was (and continues to be) delivered under the established PHE incident response governance structures, which were activated in March at the outset of the pandemic. Regarding PPE guidance during March and April, partners in Health and Social care across the North West of England received written communication in a timely and proportionate manner via the PHE NW Incident Control Centre (ICC) email cascade on all updates and changes to guidance. This included all NW Directors of Public Health, Directors of Adult Social Care, with an onward cascade via Local Authority routes to Care Homes for which they had responsibility.” Source location 2020-0264-Response-from-Public-Health-England-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate PPE guidance changes directly to local infection prevention and control teams and the North West Association of Directors of Adult Social Care.
Verbatim wording from the response “In addition, PHE NW's ICC communicated directly with local Infection Prevention and Control Teams and North West Association of Directors of Social care (ADASS) to minimise the risk that guidance was missed.” Source location 2020-0264-Response-from-Public-Health-England-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with adult social care stakeholders to develop guidance meeting sector needs, including PPE donning and doffing tutorials and an illustrated PPE guide.
Verbatim wording from the response “Guidance on the use of PPE has continued to develop in line with increasing scientific knowledge. PHE has worked with stakeholders in the adult social care sector to ensure that developing guidance meets the needs of the sector. As an example, PHE has developed video tutorials on the donning and doffing of PPE, and an illustrated guide to PPE for community and social care settings.” Source location 2020-0264-Response-from-Public-Health-England-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support development of adult social care guidance on admissions, hospital discharges, infection prevention and control, PPE and visiting.
Verbatim wording from the response “PHE has supported DHSC and NHS England in the development of a number of guidance documents to support the adult social care sector in responding to the pandemic, including guidance on admission and care of residents, discharge of residents from hospital, infection prevention and control, personal protective equipment and visiting.” Source location 2020-0264-Response-from-Public-Health-England-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Documentation, observations, vulnerability assessment, COVID-19 transmission, and ambulance delay were outside the respondent’s remit, control, and responsibility.
Verbatim wording from the response “It is not appropriate that this response provides detail regarding points in the Regulation 28 Report on the limited details in documentation available at the inquest from the home, the quality of observations and assessment of vulnerability of Mr Slack, the route of transmission of COVID-19 into the home and the delay of the ambulance, as these are outside the remit, control and responsibility of PHE.” Source location 2020-0264-Response-from-Public-Health-England-Redacted
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Established incident-response governance and communication cascades were used to disseminate PPE guidance updates to relevant health and social care partners.
Verbatim wording from the response “Communication of changes to all national guidance, including the use of PPE, was (and continues to be) delivered under the established PHE incident response governance structures, which were activated in March at the outset of the pandemic. Regarding PPE guidance during March and April, partners in Health and Social care across the North West of England received written communication in a timely and proportionate manner via the PHE NW Incident Control Centre (ICC) email cascade on all updates and changes to guidance. This included all NW Directors of Public Health, Directors of Adult Social Care, with an onward cascade via Local Authority routes to Care Homes for which they had responsibility.” Source location 2020-0264-Response-from-Public-Health-England-Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Other named organisations, including the care home, regulators, NHS England, and the local partnership, were responsible for commenting on remaining concerns.
Verbatim wording from the response “PHE understands that the Regulation 28 Report has been sent to the Care Quality Commission, The Vicarage Residential Care Home, NHS England, Greater Manchester Health and social care partnership who will be able to comment on the remaining concerns. Additionally, PHE has shared this report with the DHSC who will provide further comment.” Source location 2020-0264-Response-from-Public-Health-England-Redacted
Open published response
21 Oct 2020 Roger Wood · Prevention of Future Deaths report East London
View report summary
Concerns raised 1 Reliance on GP assessment and referral within the AAA treatment pathway 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
Roger Wood · 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
Roger Wood had been monitored for an abdominal aortic aneurysm, which measured 5.5 cm in June 2017. The scan result was sent to his GP but was not acted upon, and he was not referred for specialist treatment. He later died from a fatal rupture of the aneurysm on 12 February 2019. The principal concern was that the treatment pathway relied on a GP referral link that could fail, allowing vital diagnostic information not to be acted upon.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Reliance on GP assessment and referral within the AAA treatment pathway
Wider context from the report “In 2017, the policy in place was for AAA ultrasound scan results to be sent to the patient’s GP for assessment. The GP was to decide whether to refer the patient for treatment.
In Mr Wood’s case, the GP either overlooked the results or considered them and determined that the size of the AAA did not require follow-up treatment. In either scenario, vital diagnostic information was not acted upon with a fatal result.
In the light of the sad facts of Mr Wood’s death, Barking, Havering and Redbridge University NHS Trust have now changed Trust policy. Now when a patient is identified to have a AAA equal or greater than 5.5cm results include auto mailed to make a vascular referral are not simply sent to a GP electronically, they are also emailed. This change undoubtedly improves matters, but does not entirely eliminate the risk of these tragic circumstances being repeated by directly triggering a referral.
My concern is that the current treatment pathway contains a possibly redundant link, the role of the GP. A link, which as demonstrated in Mr Wood’s case, is capable of failure.
” Open source report
14 Aug 2020 Brenda Elmer · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 4 Failure to communicate outbreak information to relevant patients outside the local area View source Failure of hospital trusts to send Listeria isolates View source Failure of private laboratories to share Listeria isolates with PHE View source Failure of private laboratories to retain Listeria isolates View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Brenda Elmer · 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
Brenda Elmer acquired a Listeria infection after consuming a contaminated sandwich while attending St Richard’s Hospital and died on 17 July 2019 after becoming seriously ill. Concerns included inadequate communication with patients who had left the area during the outbreak, which delayed recognition and appropriate treatment, and the absence of requirements for laboratories and hospital trusts to retain or share Listeria isolates, hindering the identification of connected outbreaks.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate outbreak information to relevant patients outside the local area
Wider context from the report “3. Whilst it was accepted that details of the possible outbreak were shared locally with other medical professionals (and therefore there was a local knowledge of the Listeria outbreak) there did not appear to be any attempt by NHS England or PHE (by way of a Public Health message) to communicate with those patients who were treated within the Trust but who were now out of the area in different parts of the Country .
4. It was unfortunately that when Mrs Elmer fell ill, neither her GP who initially treated her, nor her family had any idea that her illness may be connected to the Listeria outbreak. This meant that she was not prioritised for a blood test and this delayed her being treated appropriately for Listeriosis. This diagnosis was only made when she was admitted to Tunbridge Wells Hospital, her local hospital in Kent following an emergency admission. It is unknown whether earlier treatment would have changed the outcome but it may have eased Mrs Elmer’s suffering.
5. Consideration needs to be given to how communications should be disseminated following such an outbreak so that as many patients as possible, who had been in the hospital at the relevant time, are made aware and can seek medical assistance if they become 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital trusts to send Listeria isolates
Wider context from the report “1. During the course of the Inquest evidence was given by the representative of Public Health England that there was no legal requirement for Private Laboratories who identify Listeria in food to share the Listeria isolate with PHE or indeed keep this isolate for any period of time. If a problem is subsequently identified by PHE then it makes it particularly difficult to check if particular products have been implicated.
2. Similarly there is no legal requirement of Hospital Trusts to send in Listeria isolates when Listeria has been identified . This therefore does not allow PHE to match particular strains and identify outbreaks which are connected earlier.
3. In both these circumstances this leads to missed opportunities to deal with any outbreak.
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure of private laboratories to share Listeria isolates with PHE
Wider context from the report “1. During the course of the Inquest evidence was given by the representative of Public Health England that there was no legal requirement for Private Laboratories who identify Listeria in food to share the Listeria isolate with PHE or indeed keep this isolate for any period of time. If a problem is subsequently identified by PHE then it makes it particularly difficult to check if particular products have been implicated.
2. Similarly there is no legal requirement of Hospital Trusts to send in Listeria isolates when Listeria has been identified. This therefore does not allow PHE to match particular strains and identify outbreaks which are connected earlier.
3. In both these circumstances this leads to missed opportunities to deal with any outbreak.
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure of private laboratories to retain Listeria isolates
Wider context from the report “1. During the course of the Inquest evidence was given by the representative of Public Health England that there was no legal requirement for Private Laboratories who identify Listeria in food to share the Listeria isolate with PHE or indeed keep this isolate for any period of time . If a problem is subsequently identified by PHE then it makes it particularly difficult to check if particular products have been implicated.
2. Similarly there is no legal requirement of Hospital Trusts to send in Listeria isolates when Listeria has been identified. This therefore does not allow PHE to match particular strains and identify outbreaks which are connected earlier.
3. In both these circumstances this leads to missed opportunities to deal with any outbreak.
” 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 Issue outbreak warnings and public communications through NHS, hospital, government website and media channels, including alerts for high-risk groups.
Verbatim wording from the response “At an IMT meeting on 25 May 2019, the risk assessment summarised that this cluster of cases represented an exposure that occurred between late March and mid-late May 2019, and intelligence on the supply chain indicated that it affected inpatients in 43 National Health Service (NHS) organisations in England, possibly one NHS facility in Wales and one in Scotland, where the sandwich manufacturer had distributed the implicated products. PHE also issued a letter to the supplier of the sandwiches on 25 May 2019 and to all NHS hospitals on 26 May 2020, stating an outbreak of listeriosis on sandwiches served in hospitals by Good Food Chain. The Food Standards Agency (FSA) issued a hazard warning on the implicated food processing facility, Good Food Chain, early in the outbreak. The Good Food Chain voluntarily ceased trading on the 5 June.” Source location 2020-0159-Response-from-Public-Health-England_Redacted.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Write to national microbiological standards bodies to support updated guidance requiring hospital laboratories to refer patient Listeria isolates to PHE.
Verbatim wording from the response “There is a legal requirement under the Health Protection Notification Regulations 2010 (UK) to report cases of listeriosis to PHE. We agree that NHS Trusts should send all the Listeria isolates to the Reference laboratory for rapid detection of incidents. PHE have written to the national microbiological standards on 20 May 2020. They have taken action and the updated SOP (standard operating manual for identification of Listeria) dated June 2020 advises hospital laboratories to refer all isolates from patients to PHE.” Source location 2020-0159-Response-from-Public-Health-England_Redacted.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain and apply a standard protocol for investigating foodborne outbreaks and listeriosis incidents, including screening and whole-genome sequencing.
Verbatim wording from the response “PHE has a standard protocol in place to investigate food borne outbreaks and listeria incidents. Due to the severity of listeriosis in vulnerable patient groups (pregnant, immunocompromised, elderly, chronic illness), all clinically compatible patients are screened for listeriosis by bacterial culture, strains are submitted to PHE for whole genome sequencing to be compared by bioinformatic methods to previous patient, food and environmental isolates. Even a single case with matching listeria genotype with a food and/or environmental sample is investigated further and full investigation carried out in the food facility if indicated.” Source location 2020-0159-Response-from-Public-Health-England_Redacted.pdf
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Food Standards Agency is responsible for implementing food safety measures.
Verbatim wording from the response “PHE is an executive agency and is not directly involved with patient care. The role of PHE is to provide guidance on the implementations to be taken, based on best scientific practices in order to retain good health and prevent deaths. PHE has a mandate to investigate an incident but has no legislative power to implement action on NHS or to implement food safety measures. The latter of which is an FSA mandate.” Source location 2020-0159-Response-from-Public-Health-England_Redacted.pdf
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England, NHS hospitals and local authorities are responsible for communicating outbreak warnings and information to patients, clinicians and the public.
Verbatim wording from the response “PHE agree that communications to the public need to be improved. However, as an executive agency, PHE investigates incidents and outbreaks. Any briefing regarding the incidents is conveyed to NHS England and individual NHS hospitals (which are independent statutory bodies themselves) and the local authorities. They are responsible for communicating, warning and informing their patients, local GPs (via the CCGs) and the public, respectively. PHE can inform the public about national investigations through the gov.uk website. Updates were posted on 7 June, 14 June, 17 June, 26 June and 7 August for this particular incident and high-risk groups were alerted. National and local media were also alerted to these notifications to make the public aware. Advice about medical conditions is provided by NHS England and the public were signposted to NHS website for further medical advice.” Source location 2020-0159-Response-from-Public-Health-England_Redacted.pdf
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation PHE has no legislative power to implement actions in NHS organisations or impose food safety measures.
Verbatim wording from the response “PHE is an executive agency and is not directly involved with patient care. The role of PHE is to provide guidance on the implementations to be taken, based on best scientific practices in order to retain good health and prevent deaths. PHE has a mandate to investigate an incident but has no legislative power to implement action on NHS or to implement food safety measures. The latter of which is an FSA mandate.” Source location 2020-0159-Response-from-Public-Health-England_Redacted.pdf
Open published response
6 Mar 2020 Name not published · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to ensure timely and geographically consistent access to thrombectomy services View source Lack of public awareness of the risk of stroke arising from cocaine use View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Name not published · 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
████████ ingested cocaine, suffered a basilar artery occlusion and posterior stroke, underwent thrombolysis and thrombectomy, and was declared brainstem dead on 13 June 2019. Concerns related to limited public awareness of the stroke risks associated with cocaine use and variation in access to thrombectomy services.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure timely and geographically consistent access to thrombectomy services
Wider context from the report “2. I heard evidence during this inquest that the availability of thrombectomy is currently variable and dependent on geographical location and timing . I am concerned that this variation will mean that future deaths will occur in similar circumstances , unless access to thrombectomy services is improved .
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Lack of public awareness of the risk of stroke arising from cocaine use
Wider context from the report “1. ████████ family raised concerns that the risk of stroke arising from cocaine use was not known to him nor his family members . They were concerned that future deaths could occur in similar circumstances and that there is limited public awareness of such risks . I share these concerns and ask that Public Health England consider this point.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Contribute to the second phase of the independent review of drugs, addressing treatment, prevention and drug-related information.
Verbatim wording from the response “The government has commissioned PHE to contribute to the second phase of the independent review of drugs by Professor ████████ ████████. Phase one of ████████ review, which was published in February this year, recognised the increase in cocaine-related deaths.” Source location Response from Public Health England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure that stroke is included among the listed health risks of cocaine use on the FRANK website.
Verbatim wording from the response “Information about the risks associated with cocaine use is widely available online from a range of sources. This includes the NHS Live Well website and the FRANK website, which is managed by Public Health England (PHE).” Source location Response from Public Health England
Open published response
7 Dec 2019 Matthew Colin FITTEN · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 2 Failure to provide measuring equipment and instructions for accurate daily methadone dosing View source Failure to dispense prescribed methadone in single daily dosage bottles View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Matthew Colin FITTEN · 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
Matthew Fitten was found deceased at home on 17 April 2020, and toxicology identified a toxic quantity of methadone in his blood. During the COVID-19 pandemic, his methadone collection was changed from three times per week to fortnightly, but he received three large bottles without a measuring jug or instructions for accurately measuring his prescribed daily dose. The report identifies concerns that this increased access to methadone and the lack of suitable dosing arrangements contributed to his death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide measuring equipment and instructions for accurate daily methadone dosing
Wider context from the report “During the evidence it was heard that at the start of the Covid19 pandemic PHE guidance was issued to Turning Point (the Suffolk Recovery Network) that individuals on opiate replacement treatment (Methadone) should be moved off short term (daily or tri-weekly) prescription collections to longer term ones.
In Matthew’s case his collection was changed from 3 times per week to fortnightly.
The doctor who made the changes to the prescription stipulated that Matthew’s dose must be in single daily dosage bottles. Matthew had a secure store in his home and was used to taking his Methadone from single daily dosage bottles.
In addition the Turning Point doctor had sent a letter to all of the pharmacy’s that supplied opiate replacement therapies to his patients, explaining that only daily usage bottles should be prescribed.
On the 15th April 2020 Matthew collected his 14-day methadone supply from the Haverhill Pharmacy in Haverhill, Suffolk.
Evidence produced by Matthews father during the inquest itself, clearly showed that Matthew had been issued three bottles of Methadone to cover the 14-day period. These bottles contained 100ml, 156ml and 500ml of Methadone respectively.
In addition, because Matthew’s prescription had been for single dose bottles a separate ‘measuring jug’ had not been prescribed by the Turning Point doctor.
Matthew’s prescribed dose of Methadone was 54ml daily. As such, when Matthew was given the 100ml, 156ml and 500ml Methadone bottles on the 15th April 2020, he was not given anything to accurately measure his daily dose from them.
It is therefore probable, that due to a lack of a measuring jug, Matthew guessed his first dose from the larger Methadone bottles with tragic consequences.
Had Matthew been given daily dose bottles of Methadone as prescribed, or a measuring jug and instructions on how to use it had been provided , on a balance of probability basis his death would not have occurred.
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to dispense prescribed methadone in single daily dosage bottles
Wider context from the report “During the evidence it was heard that at the start of the Covid19 pandemic PHE guidance was issued to Turning Point (the Suffolk Recovery Network) that individuals on opiate replacement treatment (Methadone) should be moved off short term (daily or tri-weekly) prescription collections to longer term ones.
In Matthew’s case his collection was changed from 3 times per week to fortnightly.
The doctor who made the changes to the prescription stipulated that Matthew’s dose must be in single daily dosage bottles. Matthew had a secure store in his home and was used to taking his Methadone from single daily dosage bottles.
In addition the Turning Point doctor had sent a letter to all of the pharmacy’s that supplied opiate replacement therapies to his patients, explaining that only daily usage bottles should be prescribed.
On the 15th April 2020 Matthew collected his 14-day methadone supply from the Haverhill Pharmacy in Haverhill, Suffolk.
Evidence produced by Matthews father during the inquest itself, clearly showed that Matthew had been issued three bottles of Methadone to cover the 14-day period. These bottles contained 100ml, 156ml and 500ml of Methadone respectively.
In addition, because Matthew’s prescription had been for single dose bottles a separate ‘measuring jug’ had not been prescribed by the Turning Point doctor.
Matthew’s prescribed dose of Methadone was 54ml daily. As such, when Matthew was given the 100ml, 156ml and 500ml Methadone bottles on the 15th April 2020, he was not given anything to accurately measure his daily dose from them.
It is therefore probable, that due to a lack of a measuring jug, Matthew guessed his first dose from the larger Methadone bottles with tragic consequences.
Had Matthew been given daily dose bottles of Methadone as prescribed , or a measuring jug and instructions on how to use it had been provided, on a balance of probability basis his death would not have occurred.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reiterate to drug and alcohol treatment providers the need for individualised risk assessments before changing medication dispensing arrangements.
Verbatim wording from the response “To prevent future deaths, PHE has often reiterated to drug and alcohol treatment providers the need for individualised risk assessments before changing medication dispensing arrangements and strengthened these lines in subsequent iterations of its published guidance this year. PHE has also worked closely with the Care Quality Commission (CQC), whose inspectors are actively monitoring registered drug treatment services. The CQC has investigated the changes in practice that the pandemic has required, to make sure that there is no blanket application of these changes.” Source location 2020-0275-Response-from-Public-Health-England-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and publish COVID-19 guidance for drug and alcohol treatment providers addressing infection risks and medication dispensing arrangements.
Verbatim wording from the response “Public Health England’s (PHE's) COVID-19 guidance to the drug and alcohol treatment sector (COVID-19: guidance for commissioners and providers of services for people who use drugs or alcohol) was developed with senior medical, pharmacy and other representatives from the sector, including from Turning Point. The process started from calls with treatment providers on 17 and 18 March 2020 and the guidance was developed until the first iteration was published on 15 April 2020.” Source location 2020-0275-Response-from-Public-Health-England-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen individualised risk-assessment requirements in subsequent iterations of published guidance before changing medication dispensing arrangements.
Verbatim wording from the response “To prevent future deaths, PHE has often reiterated to drug and alcohol treatment providers the need for individualised risk assessments before changing medication dispensing arrangements and strengthened these lines in subsequent iterations of its published guidance this year. PHE has also worked closely with the Care Quality Commission (CQC), whose inspectors are actively monitoring registered drug treatment services. The CQC has investigated the changes in practice that the pandemic has required, to make sure that there is no blanket application of these changes.” Source location 2020-0275-Response-from-Public-Health-England-Redacted
Open published response
22 Nov 2019 MAUREEN MILTON · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 2 Lack of awareness of petrol-based emollient fire risks View source Fire ignition of clothing impregnated with petrol-based emollient cream View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
MAUREEN MILTON · 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 Milton, aged 74, died after her clothing caught fire while she was attempting to light a cigarette with a long match; petrol-based emollient cream on her clothing likely accelerated the fire, and she was pronounced dead at the scene. The principal concern was a lack of awareness among medical professionals, carers, victims and families about the fire risks associated with petrol-based emollients.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of petrol-based emollient fire risks
Wider context from the report “Evidence given by fire investigators was that they are increasingly attending fires involving (mostly) the elderly where there is evidence of petrol based emollient cream in use. The petrol base is found in a significant number of prescribed creams and creams (such as moisturisers) which are readily available over the counter. This cream impregnates clothing and is not washed away during a normal washing programme. In the event of a fire the victim is rapidly engulfed by flames with little chance of survival. The cause of death is generally burns, not inhalation of smoke. The concern is the lack of awareness of this problem by medical professionals, carers, victims and their families. It is felt appropriate heighten awareness of this growing problem amongst health professionals and others who work in the field of prescribing such creams and those caring for patients using petrol based emollients.
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Fire ignition of clothing impregnated with petrol-based emollient cream
Wider context from the report “Evidence given by fire investigators was that they are increasingly attending fires involving (mostly) the elderly where there is evidence of petrol based emollient cream in use. The petrol base is found in a significant number of prescribed creams and creams (such as moisturisers) which are readily available over the counter. This cream impregnates clothing and is not washed away during a normal washing programme. In the event of a fire the victim is rapidly engulfed by flames with little chance of survival. The cause of death is generally burns, not inhalation of smoke. The concern is the lack of awareness of this problem by medical professionals, carers, victims and their families. It is felt appropriate heighten awareness of this growing problem amongst health professionals and others who work in the field of prescribing such creams and those caring for patients using petrol based emollients.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation MHRA is better placed to respond to risks involving petroleum-based emollients and skin creams because they are medicines.
Verbatim wording from the response “We have reviewed the report and Public Health England have no comments to add as the report refers to the risks of petroleum-based emollients/skin creams which have been implicated in fire deaths prescribed to the elderly, as they act as an additional fuel.” Source location 2019-0396-Response-by-Public-Health-England
Open published response
Concerns raised 1 Difficulty of remote assessment of very unwell children and infants using adult-oriented symptom pathways View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Myla DEVIREN · 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
Myla Deviren, who had congenital intestinal malrotation, developed a volvulus and was found unresponsive on 27 August 2015 after calls to NHS 111 and an out-of-hours service. She was taken to hospital, where resuscitation attempts were unsuccessful, and post-mortem examination revealed small bowel infarction from untreated small intestinal volvulus. The principal concerns were failures to recognise the significance of her symptoms and the need for robust systems, training, paediatric specialist support and precautionary ambulance advice when children may be seriously unwell.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Difficulty of remote assessment of very unwell children and infants using adult-oriented symptom pathways
Wider context from the report “Children-particularly small infants do not present like adults when they are very unwell. Nor can they articulate their symptoms in a way that lends itself to prescribed pathway questions and answers and they are not in front of the staff handling the calls who therefore rely on parents for information.
” Open source report
Concerns raised 3 Failure of school healthcare provision to share confidential health information with GP surgeries View source Lack of lower-level assistance for young people with life issues who do not meet CAMHS access criteria View source Failure to share relevant information between health agencies for fully informed healthcare decisions 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
Sam Michael Carl Grant · 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
Sam Michael Carl Grant, aged 16, died at home on 09/11/2018 after being found hanging by his sister. The report raised concerns about limited access to lower-level mental health support, incomplete information-sharing between services, and reduced confidential health-information sharing between the school and GP surgery.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure of school healthcare provision to share confidential health information with GP surgeries
Wider context from the report “1) Sam’s GP referred Sam to CAMHS when he presented to the GP with irritability, anger and a report that he was close to being excluded from school. CAMHS rejected the referral because Sam did not meet their threshold of moderate to severe mental health issues. CAMHS did not suggest any alternative assistance. The GP did follow up with Sam to sign post him to two independent organisations who Sam would have to approach independently for help. The GP made it clear in his evidence that there is a lack of lower level assistance for young people who present with ‘life issues’ such as low mood, irritability and anger issues, but who nonetheless need help and assistance but do not meet the criteria for access to CAMHS services.
2) Sam had been referred to, and was receiving the services of COMPASS having been referred by his School. The GP was not made aware of this engagement and was unable to take this into account at the time when Sam did present himself to the GP. The evidence from COMPASS is that they maintain the confidentiality of patients even minors using their services unless they have express consent to disclose that information from the patient themselves. Without all relevant information neither the GP nor CAMHS was in a position to make a fully informed decision about the Sam’s needs. Sharing of information between relevant health agencies to ensure fully informed decisions are made as regards the healthcare needs of an individual should be a priority.
3) Evidence at the inquest from the GP also indicated that a reduction in healthcare provision at Sam’s school and in particular the removal of a medically qualified person(s) has meant that confidential health information is no longer shared between the school and the GP surgery. The school now only engages First Aiders, who are not medically qualified, and who do not therefore exchange information which in the past has proved essential in flagging concerns between the GP and the School. This is another route which has been closed and which would have allowed a potential flag to have been raised in respect of concerns around Sam and his wellbeing to be shared confidentially between GP and school.
2) Sam had been referred to, and was receiving the services of COMPASS having been referred by his School. The GP was not made aware of this engagement and was unable to take this into account at the time when Sam did present himself to the GP. The evidence from COMPASS is that they maintain the confidentiality of patients even minors using their services unless they have express consent to disclose that information from the patient themselves. Without all relevant information neither the GP nor CAMHS was in a position to make a fully informed decision about the Sam’s needs. Sharing of information between relevant health agencies to ensure fully informed decisions are made as regards the healthcare needs of an individual should be a priority.
3) Evidence at the inquest from the GP also indicated that a reduction in healthcare provision at Sam’s school and in particular the removal of a medically qualified person(s) has meant that confidential health information is no longer shared between the school and the GP surgery. The school now only engages First Aiders, who are not medically qualified, and who do not therefore exchange information which in the past has proved essential in flagging concerns between the GP and the School. This is another route which has been closed and which would have allowed a potential flag to have been raised in respect of concerns around Sam and his wellbeing to be shared confidentially between GP and school.
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Lack of lower-level assistance for young people with life issues who do not meet CAMHS access criteria
Wider context from the report “1) Sam’s GP referred Sam to CAMHS when he presented to the GP with irritability, anger and a report that he was close to being excluded from school. CAMHS rejected the referral because Sam did not meet their threshold of moderate to severe mental health issues. CAMHS did not suggest any alternative assistance. The GP did follow up with Sam to sign post him to two independent organisations who Sam would have to approach independently for help. The GP made it clear in his evidence that there is a lack of lower level assistance for young people who present with ‘life issues’ such as low mood, irritability and anger issues, but who nonetheless need help and assistance but do not meet the criteria for access to CAMHS services .
2) Sam had been referred to, and was receiving the services of COMPASS having been referred by his School. The GP was not made aware of this engagement and was unable to take this into account at the time when Sam did present himself to the GP. The evidence from COMPASS is that they maintain the confidentiality of patients even minors using their services unless they have express consent to disclose that information from the patient themselves. Without all relevant information neither the GP nor CAMHS was in a position to make a fully informed decision about the Sam’s needs. Sharing of information between relevant health agencies to ensure fully informed decisions are made as regards the healthcare needs of an individual should be a priority.
3) Evidence at the inquest from the GP also indicated that a reduction in healthcare provision at Sam’s school and in particular the removal of a medically qualified person(s) has meant that confidential health information is no longer shared between the school and the GP surgery. The school now only engages First Aiders, who are not medically qualified, and who do not therefore exchange information which in the past has proved essential in flagging concerns between the GP and the School. This is another route which has been closed and which would have allowed a potential flag to have been raised in respect of concerns around Sam and his wellbeing to be shared confidentially between GP and school.
2) Sam had been referred to, and was receiving the services of COMPASS having been referred by his School. The GP was not made aware of this engagement and was unable to take this into account at the time when Sam did present himself to the GP. The evidence from COMPASS is that they maintain the confidentiality of patients even minors using their services unless they have express consent to disclose that information from the patient themselves. Without all relevant information neither the GP nor CAMHS was in a position to make a fully informed decision about the Sam’s needs. Sharing of information between relevant health agencies to ensure fully informed decisions are made as regards the healthcare needs of an individual should be a priority.
3) Evidence at the inquest from the GP also indicated that a reduction in healthcare provision at Sam’s school and in particular the removal of a medically qualified person(s) has meant that confidential health information is no longer shared between the school and the GP surgery. The school now only engages First Aiders, who are not medically qualified, and who do not therefore exchange information which in the past has proved essential in flagging concerns between the GP and the School. This is another route which has been closed and which would have allowed a potential flag to have been raised in respect of concerns around Sam and his wellbeing to be shared confidentially between GP and school.
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant information between health agencies for fully informed healthcare decisions
Wider context from the report “1) Sam’s GP referred Sam to CAMHS when he presented to the GP with irritability, anger and a report that he was close to being excluded from school. CAMHS rejected the referral because Sam did not meet their threshold of moderate to severe mental health issues. CAMHS did not suggest any alternative assistance. The GP did follow up with Sam to sign post him to two independent organisations who Sam would have to approach independently for help. The GP made it clear in his evidence that there is a lack of lower level assistance for young people who present with ‘life issues’ such as low mood, irritability and anger issues, but who nonetheless need help and assistance but do not meet the criteria for access to CAMHS services.
2) Sam had been referred to, and was receiving the services of COMPASS having been referred by his School. The GP was not made aware of this engagement and was unable to take this into account at the time when Sam did present himself to the GP. The evidence from COMPASS is that they maintain the confidentiality of patients even minors using their services unless they have express consent to disclose that information from the patient themselves. Without all relevant information neither the GP nor CAMHS was in a position to make a fully informed decision about the Sam’s needs. Sharing of information between relevant health agencies to ensure fully informed decisions are made as regards the healthcare needs of an individual should be a priority.
3) Evidence at the inquest from the GP also indicated that a reduction in healthcare provision at Sam’s school and in particular the removal of a medically qualified person(s) has meant that confidential health information is no longer shared between the school and the GP surgery. The school now only engages First Aiders, who are not medically qualified, and who do not therefore exchange information which in the past has proved essential in flagging concerns between the GP and the School. This is another route which has been closed and which would have allowed a potential flag to have been raised in respect of concerns around Sam and his wellbeing to be shared confidentially between GP and school.
2) Sam had been referred to, and was receiving the services of COMPASS having been referred by his School. The GP was not made aware of this engagement and was unable to take this into account at the time when Sam did present himself to the GP. The evidence from COMPASS is that they maintain the confidentiality of patients even minors using their services unless they have express consent to disclose that information from the patient themselves. Without all relevant information neither the GP nor CAMHS was in a position to make a fully informed decision about the Sam’s needs. Sharing of information between relevant health agencies to ensure fully informed decisions are made as regards the healthcare needs of an individual should be a priority.
3) Evidence at the inquest from the GP also indicated that a reduction in healthcare provision at Sam’s school and in particular the removal of a medically qualified person(s) has meant that confidential health information is no longer shared between the school and the GP surgery. The school now only engages First Aiders, who are not medically qualified, and who do not therefore exchange information which in the past has proved essential in flagging concerns between the GP and the School. This is another route which has been closed and which would have allowed a potential flag to have been raised in respect of concerns around Sam and his wellbeing to be shared confidentially between GP and school.
” Open source report
Concerns raised 3 Failure to update Green Book Guidance View source Failure to effectively communicate key changes in clinical practice and advice View source Reliance on Primary Care practitioners to find key clinical information across multiple linked documents 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
Zona Ethel Tebbs · 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
Zona Ethel Tebbs, an 88-year-old woman, sustained a garden injury, later developed tetanus, and died in hospital on 5 November 2018 from generalised tetanus and acute on chronic myelopathy. The principal concerns were ineffective communication of changes to tetanus-prone wound guidance, failure to update Green Book guidance, and failure to provide immunoglobulin, which exposed her to an increased risk of developing tetanus and death.
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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to update Green Book Guidance
Wider context from the report “(1) Failure to effectively communicate key changes in clinical practice and advice e.g. an amended definition of a tetanus prone wound in the Public Health England email of July 2018 entitled Vaccine Update (attached).
(2) Requiring Primary Care practitioners to click through a number of links and documents to try and unearth key pieces of information carries with it the risk that that information will be overlooked if key issues have not been identified in the covering email.
(3) A failure generally to identify key issues in any updated in medical practice and communicate those effectively to those healthcare professionals involved in delivering such care.
(4) Failure to update Green Book Guidance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively communicate key changes in clinical practice and advice
Wider context from the report “(1) Failure to effectively communicate key changes in clinical practice and advice e.g. an amended definition of a tetanus prone wound in the Public Health England email of July 2018 entitled Vaccine Update (attached).
(2) Requiring Primary Care practitioners to click through a number of links and documents to try and unearth key pieces of information carries with it the risk that that information will be overlooked if key issues have not been identified in the covering email.
(3) A failure generally to identify key issues in any updated in medical practice and communicate those effectively to those healthcare professionals involved in delivering such care.
(4) Failure to update Green Book Guidance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Reliance on Primary Care practitioners to find key clinical information across multiple linked documents
Wider context from the report “(1) Failure to effectively communicate key changes in clinical practice and advice e.g. an amended definition of a tetanus prone wound in the Public Health England email of July 2018 entitled Vaccine Update (attached).
(2) Requiring Primary Care practitioners to click through a number of links and documents to try and unearth key pieces of information carries with it the risk that that information will be overlooked if key issues have not been identified in the covering email.
(3) A failure generally to identify key issues in any updated in medical practice and communicate those effectively to those healthcare professionals involved in delivering such care.
(4) Failure to update Green Book Guidance.
” Open source report
9 Oct 2018 Tom Cribley · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 12 Failure to document important clinical findings View source Insufficient clinical staff training in identifying and treating sepsis View source Failure to escalate monitoring and management after grossly abnormal blood results View source Failure of senior leadership ownership of training programme implementation and review View source Failure to maintain systematic and monitored ongoing sepsis training View source Failure to complete full PIT STOP reviews View source Failure to hand over clinical concerns to relevant clinical staff View source Failure to escalate and convey the severity of deterioration to the Critical Care Team View source Failure to review an initial diagnosis when the patient deteriorates View source Delays in escalating NEWS to medical staff View source Delays in administering antibiotic therapy during clinical deterioration View source Failure to repeat observations hourly in accordance with the NEWS policy View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Tom Cribley · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Tom Cribley attended Aintree hospital on 18 February 2017 with vomiting, diarrhoea and a rash, and was later diagnosed with meningococcal sepsis. The report identifies concerns including failures to document and escalate the rash and deteriorating observations, inadequate handovers and reassessment, delayed recognition of abnormal blood results, and delayed antibiotic treatment. Tom did not recover and died on 20 February 2017.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to document important clinical findings
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage . The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Insufficient clinical staff training in identifying and treating sepsis
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate monitoring and management after grossly abnormal blood results
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results , the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure of senior leadership ownership of training programme implementation and review
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board . This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain systematic and monitored ongoing sepsis training
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness .
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to complete full PIT STOP reviews
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review , the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to hand over clinical concerns to relevant clinical staff
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers , the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate and convey the severity of deterioration to the Critical Care Team
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team , who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to review an initial diagnosis when the patient deteriorates
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate , the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Delays in escalating NEWS to medical staff
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Delays in administering antibiotic therapy during clinical deterioration
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to repeat observations hourly in accordance with the NEWS policy
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy . The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Open source report
22 Nov 2017 Tomas Kelly · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 2 Lack of routine chicken pox vaccination offer for children with Downs Syndrome View source Failure to communicate the increased infection risks associated with Downs Syndrome to parents or carers 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
Tomas Kelly · 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
Tomas Kelly, aged 3, was admitted to hospital after choking and being diagnosed with aspiration pneumonia and a chest infection. After later developing chicken pox, he deteriorated rapidly at home and died in hospital on 22 November 2016; the cause of death was confluent bronchopneumonia. The principal concerns were that his parents may not have been informed about the increased infection risks associated with Down’s Syndrome, and whether children with Down’s Syndrome should routinely be offered chicken pox vaccination.
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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Lack of routine chicken pox vaccination offer for children with Downs Syndrome
Wider context from the report “2. Vaccination against chicken pox
a. The evidence confirmed that it is not the chicken pox per se which creates a risk. Rather it is the immunosupppressant effect of this – creating a risk of more serious infections as a result.
b. We heard from a community paediatrician that, as matters stand, there is no plan to vaccinate all children against chicken pox. This is limited to certain high risk groups only.
c. It is clear that children with Downs Syndrome are at increased risk – both of contracting infection and of the infections being more serious.
d. Careful consideration should be given to including children with Downs Syndrome to the category of children who will be routinely offered this vaccination .
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the increased infection risks associated with Downs Syndrome to parents or carers
Wider context from the report “1. Talking to parents
a. I did not have concerns about the medical professionals being aware of the increased risks associated with infection in children with Downs Syndrome. I heard no evidence of the parents being made aware of this however – either when he was discharged from hospital on 22 October 2016 or when he was seen by his GP on 21 November 2016.
b. Tomas’ parents said they may have sought additional medical assistance if they had known about these risks.
c. Whilst this may be happening to some extent in community paediatrics, it is important for health professionals in acute settings (including primary care) to be advised to share these risks with parents/ carers, so that they can adopt an appropriate threshold for seeking medical assistance.
” Open source report
Concerns raised 4 Failure to provide antibiotic prophylaxis cover for medical procedures in patients after splenectomy View source Failure to provide consistent advice about inoculation, life-long antibiotic prophylaxis and procedural cover after splenectomy View source Failure to record advice about inoculation and life-long antibiotic prophylaxis View source Failure to ensure life-long antibiotic prophylaxis for patients after splenectomy 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
Theresa Mary Thompson · 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
Theresa Mary Thompson died on 9 October 2016 after admission with sepsis caused by a Streptococcus pneumonia infection, following a history of splenectomy and recent ventriculo-peritoneal shunt insertion. Concerns were raised that she was not receiving lifelong antibiotic prophylaxis and had no antibiotic cover for the shunt procedure, and that there was no evidence she had been advised or prescribed antibiotics before or after the procedure.
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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide antibiotic prophylaxis cover for medical procedures in patients after splenectomy
Wider context from the report “At the inquest, the pathologist advised that Streptococcus pneumonia infections were typical for patients having undergone splenectomy. The spleen was an important immune defence organ for this type of bacteria. Usually patients were given a vaccination to prevent this type of disease and life-time antibiotic prophylaxis. Both the Pathologist and Treating clinician at the time of death, expressed concerns to the inquest that Mrs Thompson was not on prophylaxis antibiotics and that she had no antibiotic prophylaxis cover for her recent procedure especially as the Streptococcus infection was Serum type 6C for which there was no currently available pneumococcal vaccines (Reference report from Public Health England, Colindale, The Respiratory and Vaccine Preventable Bacteria Reference Unit (RVPBRU)).
The GP gave evidence that Mrs Thompson had been advised about inoculation and taking life-long antibiotic prophylaxis but at some point had declined (although there were no written records to support his evidence in her medical note). There was no evidence that she was advised or prescribed antibiotics prior to or after her Ventriculo-Peritoneal Shunt procedure in August 2016 at Kings College Hospital.
The family acknowledged that a number of the family had had a splenectomy due to familial Acholuric Jaundice but they were unsure that the family members appreciated the necessity for inoculation or prophylaxis antibiotics. They were concerned that there were mixed messages being given out by the Health Agencies about the use of antibiotics and the need to not overuse antibiotics and this had led to them not being inoculated or accepting life time prophylaxis antibiotics or the necessity of cover during medical procedures (if they had been advised at all).
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to provide consistent advice about inoculation, life-long antibiotic prophylaxis and procedural cover after splenectomy
Wider context from the report “At the inquest, the pathologist advised that Streptococcus pneumonia infections were typical for patients having undergone splenectomy. The spleen was an important immune defence organ for this type of bacteria. Usually patients were given a vaccination to prevent this type of disease and life-time antibiotic prophylaxis. Both the Pathologist and Treating clinician at the time of death, expressed concerns to the inquest that Mrs Thompson was not on prophylaxis antibiotics and that she had no antibiotic prophylaxis cover for her recent procedure especially as the Streptococcus infection was Serum type 6C for which there was no currently available pneumococcal vaccines (Reference report from Public Health England, Colindale, The Respiratory and Vaccine Preventable Bacteria Reference Unit (RVPBRU)).
The GP gave evidence that Mrs Thompson had been advised about inoculation and taking life-long antibiotic prophylaxis but at some point had declined (although there were no written records to support his evidence in her medical note). There was no evidence that she was advised or prescribed antibiotics prior to or after her Ventriculo-Peritoneal Shunt procedure in August 2016 at Kings College Hospital.
The family acknowledged that a number of the family had had a splenectomy due to familial Acholuric Jaundice but they were unsure that the family members appreciated the necessity for inoculation or prophylaxis antibiotics . They were concerned that there were mixed messages being given out by the Health Agencies about the use of antibiotics and the need to not overuse antibiotics and this had led to them not being inoculated or accepting life time prophylaxis antibiotics or the necessity of cover during medical procedures (if they had been advised at all).
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to record advice about inoculation and life-long antibiotic prophylaxis
Wider context from the report “At the inquest, the pathologist advised that Streptococcus pneumonia infections were typical for patients having undergone splenectomy. The spleen was an important immune defence organ for this type of bacteria. Usually patients were given a vaccination to prevent this type of disease and life-time antibiotic prophylaxis. Both the Pathologist and Treating clinician at the time of death, expressed concerns to the inquest that Mrs Thompson was not on prophylaxis antibiotics and that she had no antibiotic prophylaxis cover for her recent procedure especially as the Streptococcus infection was Serum type 6C for which there was no currently available pneumococcal vaccines (Reference report from Public Health England, Colindale, The Respiratory and Vaccine Preventable Bacteria Reference Unit (RVPBRU)).
The GP gave evidence that Mrs Thompson had been advised about inoculation and taking life-long antibiotic prophylaxis but at some point had declined (although there were no written records to support his evidence in her medical note ). There was no evidence that she was advised or prescribed antibiotics prior to or after her Ventriculo-Peritoneal Shunt procedure in August 2016 at Kings College Hospital.
The family acknowledged that a number of the family had had a splenectomy due to familial Acholuric Jaundice but they were unsure that the family members appreciated the necessity for inoculation or prophylaxis antibiotics. They were concerned that there were mixed messages being given out by the Health Agencies about the use of antibiotics and the need to not overuse antibiotics and this had led to them not being inoculated or accepting life time prophylaxis antibiotics or the necessity of cover during medical procedures (if they had been advised at all).
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure life-long antibiotic prophylaxis for patients after splenectomy
Wider context from the report “At the inquest, the pathologist advised that Streptococcus pneumonia infections were typical for patients having undergone splenectomy. The spleen was an important immune defence organ for this type of bacteria. Usually patients were given a vaccination to prevent this type of disease and life-time antibiotic prophylaxis. Both the Pathologist and Treating clinician at the time of death, expressed concerns to the inquest that Mrs Thompson was not on prophylaxis antibiotics and that she had no antibiotic prophylaxis cover for her recent procedure especially as the Streptococcus infection was Serum type 6C for which there was no currently available pneumococcal vaccines (Reference report from Public Health England, Colindale, The Respiratory and Vaccine Preventable Bacteria Reference Unit (RVPBRU)).
The GP gave evidence that Mrs Thompson had been advised about inoculation and taking life-long antibiotic prophylaxis but at some point had declined (although there were no written records to support his evidence in her medical note). There was no evidence that she was advised or prescribed antibiotics prior to or after her Ventriculo-Peritoneal Shunt procedure in August 2016 at Kings College Hospital.
The family acknowledged that a number of the family had had a splenectomy due to familial Acholuric Jaundice but they were unsure that the family members appreciated the necessity for inoculation or prophylaxis antibiotics. They were concerned that there were mixed messages being given out by the Health Agencies about the use of antibiotics and the need to not overuse antibiotics and this had led to them not being inoculated or accepting life time prophylaxis antibiotics or the necessity of cover during medical procedures (if they had been advised at all).
” Open source report
25 Oct 2016 Jane Louise Reason · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Insufficient public education in the use of public access defibrillators View source Inadequate placement of public access defibrillators View source Insufficient availability of public access defibrillators in colleges and schools View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jane Louise Reason · 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
Jane Louise Reason, a lecturer, collapsed at work on 28 April 2016 and was later declared deceased in hospital; the medical cause of death was recorded as hypertensive heart disease. The inquest highlighted the importance of early defibrillation and CPR and raised concern about the availability and public education surrounding public access defibrillators, particularly in colleges and schools.
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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Insufficient public education in the use of public access defibrillators
Wider context from the report “1. Evidence at the inquest confirmed that the greatest chance of survival following an arrhythmic out of cardiac arrest is with early defibrillation and CPR. I heard evidence that there was a need for more public access defibrillators particularly in colleges and school. Further consideration needs to be given to the placement of public access defibrillators and education of the public in their use .
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Inadequate placement of public access defibrillators
Wider context from the report “1. Evidence at the inquest confirmed that the greatest chance of survival following an arrhythmic out of cardiac arrest is with early defibrillation and CPR. I heard evidence that there was a need for more public access defibrillators particularly in colleges and school. Further consideration needs to be given to the placement of public access defibrillators and education of the public in their use.
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of public access defibrillators in colleges and schools
Wider context from the report “1. Evidence at the inquest confirmed that the greatest chance of survival following an arrhythmic out of cardiac arrest is with early defibrillation and CPR. I heard evidence that there was a need for more public access defibrillators particularly in colleges and school . Further consideration needs to be given to the placement of public access defibrillators and education of the public in their use.
” Open source report
22 Oct 2015 Harry George Mellor · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Lack of a reliable system to identify children de-registered from a General Practice View source Lack of a legal requirement to register or re-register children with a General Practitioner View source Failure to ensure a new General Practitioner is identified and notified before a child is de-registered View source Failure to directly inform paediatric and physiotherapy services of a child's de-registration View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Harry George Mellor · 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
Harry George Mellor, a child with chronic health needs, collapsed unexpectedly on 28 October 2014 and died shortly after arriving at the emergency department. The inquest recorded that he had died from pyelonephritis. Concerns included the lack of a reliable system to identify when a child was de-registered from a GP, potential safeguarding risks when no new GP had been identified, and the paediatric and physiotherapy teams not being informed of the de-registration.
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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Lack of a reliable system to identify children de-registered from a General Practice
Wider context from the report “2. There is no reliable system in place to identify when a child has been de-registered from a General Practice
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Lack of a legal requirement to register or re-register children with a General Practitioner
Wider context from the report “1. There is no legal requirement to register or re-register a child with a General Practitioner
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure a new General Practitioner is identified and notified before a child is de-registered
Wider context from the report “3. There are potential safeguarding concerns if a General Practitioner can de-register a child , particularly a child with chronic health needs, before a new General Practitioner has been identified and notified of the proposed de-registration
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to directly inform paediatric and physiotherapy services of a child's de-registration
Wider context from the report “4. The paediatric team and physiotherapy services were not directly informed that Harry was going to be de-registered or had been de-registered
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Determining the process for registering patients in general practice falls outside the respondent’s direct role.
Verbatim wording from the response “PHE does not have a direct role in determining the process for the registration of patients in General Practice. NHS England, as commissioners of primary care services, will be able to comment further on the regulation and procedure for GP registration and where there are concerns about loss of continuity of care, will be able to take action to address them.” Source location PHE-Response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is responsible for commenting on GP registration and addressing concerns about loss of continuity of care.
Verbatim wording from the response “PHE does not have a direct role in determining the process for the registration of patients in General Practice. NHS England, as commissioners of primary care services, will be able to comment further on the regulation and procedure for GP registration and where there are concerns about loss of continuity of care, will be able to take action to address them.” Source location PHE-Response
Open published response
20 Feb 2015 Richard Jeffrey Jones · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 3 Failure to record primary responsibility for patient care during transfers of care View source Failure to share patient information accurately with other agencies involved in care View source Failure to record information obtained from mental health patients, including perceived risk and assessment urgency View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Richard Jeffrey Jones · 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
Richard Jeffrey Jones was at home alone and, during 14 to 15 October 2012, voluntarily ingested a quantity of tramadol that led to loss of consciousness, respiratory depression and aspiration of gastric contents, causing his death. The report raised concerns about recording and sharing information on risk and urgency, and about identifying primary responsibility when care was transferred between mental health services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to record primary responsibility for patient care during transfers of care
Wider context from the report “I am concerned in particular as to the following matters :
a) As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment.
b) As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency.
c) As to who has primary responsibility for the care of that patient and how that is recorded by all those involved, particularly where there is a transfer of care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to share patient information accurately with other agencies involved in care
Wider context from the report “I am concerned in particular as to the following matters :
a) As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment.
b) As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency .
c) As to who has primary responsibility for the care of that patient and how that is recorded by all those involved, particularly where there is a transfer of care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Failure to record information obtained from mental health patients, including perceived risk and assessment urgency
Wider context from the report “I am concerned in particular as to the following matters :
a) As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment .
b) As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency.
c) As to who has primary responsibility for the care of that patient and how that is recorded by all those involved, particularly where there is a transfer of care.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Further advice on the specific concerns cannot be provided because Public Health England is not in a position to advise further.
Verbatim wording from the response “DH will continue their discussions with MoD and NHSE on this issue and these discussions will address the specific concerns you have raised in your report. Unfortunately, PHE are not in a position to advise on this matter further.” Source location 2015-0068-Response-by-Public-Health-England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The mental health providers named in the report are expected to comment on the particular case and address concerns locally.
Verbatim wording from the response “Finally, I have been advised that the mental health providers named in your report are expected to provide comment on the detail of this particular case and to address your concerns from their local perspective.” Source location 2015-0068-Response-by-Public-Health-England
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Department of Health, Ministry of Defence and NHS England will address the specific concerns through their ongoing discussions.
Verbatim wording from the response “I am aware you have also written to the Department of Health (DH), and I understand that DH, the Ministry of Defence (MoD) and NHS England (NHSE) work closely together to ensure that service personnel receive the right health services. These organisations are also aware of the need for effective patient note transfer between the MoD and the NHS.” Source location 2015-0068-Response-by-Public-Health-England
Open published response
3 Nov 2014 SANDRA HAZEL ELIZABETH HIGHAM · Prevention of Future Deaths report London (Inner South)
View report summary
Concerns raised 3 Lack of awareness among the wider medical profession of atrial-oesophageal fistula as an ablation risk View source Difficulty diagnosing atrial-oesophageal fistula in acute medical settings View source Risk of atrial-oesophageal fistula following ablation procedures View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
SANDRA HAZEL ELIZABETH HIGHAM · 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
Sandra Hazel Elizabeth Higham died at St Thomas's Hospital, London, on 7 December 2013 after developing an atrial-oesophageal fistula following an ablation procedure for atrial fibrillation. The principal concerns were that this rare but known complication can be difficult to diagnose because of non-specific symptoms and limited awareness, and that early diagnosis, prompt surgery and prolonged antibiotic therapy may be important for survival.
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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness among the wider medical profession of atrial-oesophageal fistula as an ablation risk
Wider context from the report “(4) According to the literature there are no clear predictors of mortality from an atrial-oesophageal fistula, but early diagnosis, prompt surgical intervention and prolonged antibiotic therapy may be crucial for survival.
(5) Diagnosing an atrial-oesophageal fistula can be difficult, especially in an acute medical setting, given its range of non-specific symptoms and duration of onset, and the lack of awareness within the wider medical profession of such a fistula being a risk of the ablation procedure .
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Difficulty diagnosing atrial-oesophageal fistula in acute medical settings
Wider context from the report “(4) According to the literature there are no clear predictors of mortality from an atrial-oesophageal fistula, but early diagnosis, prompt surgical intervention and prolonged antibiotic therapy may be crucial for survival.
(5) Diagnosing an atrial-oesophageal fistula can be difficult , especially in an acute medical setting, given its range of non-specific symptoms and duration of onset , and the lack of awareness within the wider medical profession of such a fistula being a risk of the ablation procedure.
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Risk of atrial-oesophageal fistula following ablation procedures
Wider context from the report “(2) The development of an atrial-oesophageal fistula is a very rare, but known, risk of the ablation procedure (developing in around 0.01-0.2% of cases of percutaneous ablation and around 1-1.5% of cases of surgical ablation).
(3) If an atrial-oesophageal fistula does develop, it has a very high mortality rate (reported to be 67-100%).
” Open source report
Concerns raised 3 Lack of regulation of the sale of large amounts of toxic or potentially fatal gases View source Risk to public health from toxic or potentially fatal gases View source Lack of Trading Standards powers to take action or prosecute View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sindy Louise Woodhall · 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
Sindy Louise Woodhall had longstanding addictions to alcohol and butane and propane, which she misused regularly. She was found collapsed in the street on 24 October 2013, was taken to hospital, and subsequently died; the concerns included the sale of large amounts of potentially fatal gases to her by retailers aware of her addiction, along with lack of regulation and limited Trading Standards powers.
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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Lack of regulation of the sale of large amounts of toxic or potentially fatal gases
Wider context from the report “1. During the course of the inquest, it transpired that cans of the aforementioned gases were being sold to the deceased by local retailers who were fully aware of her addiction/problems. Whilst morally reprehensible, there was no law to prevent them from selling large amounts of the toxic/potentially fatal gases to the deceased .
2. Lack of regulation.
” 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 Public Health England; that does not assign responsibility.
PFD Monitor interpretation Risk to public health from toxic or potentially fatal gases
Wider context from the report “4. Risk to public health.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Public Health England; that does not assign responsibility.
PFD Monitor interpretation Lack of Trading Standards powers to take action or prosecute
Wider context from the report “3. No powers afforded to Trading Standards to take action/prosecute.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the Department of Health to support restrictions on inappropriate access to volatile substances.
Verbatim wording from the response “We share your concern about abuse of volatile substances (VSA) such as butane and propane and have been working with the Department of Health to support their efforts to restrict inappropriate access to these products. A large number of retailers already restrict access to butane lighter refills and some have committed to restricting the sale of multiple canisters in one transaction. The Association of Convenience Stores (ACS) was asked by the public health minister last year to urge its members to remove accessible displays and restrict sales to one can per customer. ACS reassured the minister that its members already had policies in place to restrict access to butane.” Source location 2014-0292-Response-by-Public-Health-England
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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